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Lumbosacral Spondylolysis Treatment & Management

  • Author: Achilles Litao, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Nov 17, 2015
 

Acute Phase

Rehabilitation Program

Physical Therapy

The approach to the treatment of lumbosacral spondylolysis (lumbar spondylolysis) is based on the stage of the bony lesion as guided by radiography and nuclear medicine or SPECT scanning investigations, as well as symptomatology.[11, 29] The complete healing of the bony lesion is the ultimate goal in treating patients with lumbosacral spondylolysis (lumbar spondylolysis).

Acute phase

Some patients present with a spondylolytic defect on plain radiography and also have positive findings on bone scanning. This can represent a recent-onset defect on the pars interarticularis[11] or a healing spondylolysis. Bracing and rest are the cornerstones of treatment for this type of lesion.[29] Pain control and avoiding sports are also part of the acute phase or rehabilitation.

Transcutaneous electrical nerve stimulation (TENS) has had widespread use as a therapeutic adjunct to the pharmacologic management of pain, but its effectiveness in chronic low back pain remains controversial. Khadilkar et al selected 4 randomized controlled clinical trials that met their selection criteria and that compared TENS to placebo for the management of chronic low back pain.[30] The investigators found conflicting evidence in 2 trials regarding whether TENS had any benefit in reducing back pain intensity, whereas 2 trials showed consistent evidence that TENS did not improve back-specific functional status.[30]

In addition, Khadilkar et al found conflicting results in 2 studies regarding generic health status: 1 study showed no improvement on the modified Sickness Impact Profile, whereas another study showed significant improvements on several, but not all subsections of the Short Form-36 (SF-36) Health Survey.[30] Moreover, multiple physical outcome measures lacked statistically significant improvement relative to placebo. The investigators concluded that at present, the evidence does not support the use of TENS in the routine management of chronic low back pain.[30]

Acupuncture has also had widespread use in the management of pain, with conflicting results. Yuan et al conducted a systematic review of randomized controlled trials to explore the evidence for the effectiveness of acupuncture for nonspecific low back pain.[31] Twenty-three trials with 6359 patients met the investigators' inclusion criteria and classified into 5 types of comparisons, 6 of which were of high quality.

Yuan et al found moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief.[31] In addition, the investigators found strong evidence that acupuncture can be a useful supplement to other forms of conventional therapy for nonspecific low back pain, but further investigation is needed. Yuan et al concluded that acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated in the European Guidelines for the treatment of chronic low back pain.[31]

Cherkin et al studied the importance of needle placement and skin penetration in eliciting acupuncture effects for 638 adult patients with mechanical chronic low back pain.[32] The patients were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care, receiving 10 treatments over a 7-week period as administered by experienced acupuncturists.

The investigators reported that individuals receiving real or simulated acupuncture (60%) were more likely than those receiving usual care (39%) to experience clinically meaningful improvements on the dysfunction scale (P < 0.001).[32] Cherkin et al found that although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appeared to be unimportant in eliciting therapeutic benefits—which raises the question of whether acupuncture or simulated acupuncture provides physiologically important stimulation or whether it represents placebo or nonspecific effects.

Physical therapy

A Boston overlapping brace is used to immobilize the pelvis for prevention of hyperextension and is worn in 0° lordosis for 23 hours per day and for as long as the patient is totally symptom free for a minimum of 3 months, after which a repeat bone scan is performed. Hamstring stretching and lumbar flexibility motions are performed in the brace. Most patients are said to have normal findings on scanning within 3-9 months.[11] Aquatic rehabilitation can also be performed in the acute phase.

Exercise programs have also been used in the treatment of chronic low back pain. Sertpoyraz et al compared the effectiveness of an isokinetic exercise program with a standard exercise regimen in 40 patients with chronic low back pain using the parameters of pain, mobility, disability, psychologic status, and muscle strength.[33] The investigators found both isokinetic and standard exercise resulted in significant improvement compared with the baseline that persisted until the end of the first month. However, comparison of both exercise groups at the end of the treatment and at the first month after treatment showed no significant difference. Sertpoyraz et al concluded that isokinetic and standard exercise are equally effective in the treatment of low back pain; however, in terms of ease of use and cost, standard exercise programs were the preferred option for exercise.[33]

Consultations

Consult neurosurgeons, orthopedic surgeons, neurologists, and physiatrists as indicated.

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Recovery Phase

Rehabilitation Program

Physical Therapy

Recovery phase

The goals of the recovery phase are the resolution of pain and the healing of the pars defect with either bony union or painless fibrous union if bony union is not possible.

Physical therapy

This phase of rehabilitation consists of a progressively shallower aquatic rehabilitation location so that graded gravitational forces are applied to the spine. Also, lumbar flexibility out of the brace as symptoms resolve is helpful, but inciting activities must still be avoided. Flexibility and strengthening of the paraspinal, iliopsoas, and abdominal muscles along with endurance training of the back (necessitated by deconditioning) are all especially important. One may advance to full participation in a brace as symptoms resolve.

Consultations

Consult neurosurgeons, orthopedic surgeons, neurologists, and physiatrists as indicated.

Other Treatment (Injection, manipulation, etc.)

Electromagnetic field therapy for persistent nonunion may be used in this phase.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

Maintenance phase

The single best predictor for a new injury during athletic activity is a history of a previous injury. Patients showing a spondylolytic defect on plain radiography but whose bone scanning result is negative are regarded as having an inactive spondylolytic defect[11] or a pseudoarthrosis or old unhealed fracture.[29]

Physical therapy

Continue bracing for up to 6-9 months is indicated as necessary to heal the pars. These patients benefit from physical therapy that puts emphasis in deep abdominal muscles, specifically the internal oblique and transversus abdominis and the lumbar multifidus,[34] in addition to flexibility exercises for the hamstrings and lower back. Hyperextension movements are to be avoided. One may need SPECT bone scanning or CT scanning to monitor healing.

Surgical Intervention

Some investigators advocate surgery to prevent spondylolisthesis.[29, 35, 36]

Consultations

Consult neurosurgeons, orthopedic surgeons, neurologists, and physiatrists as indicated.

Other Treatment

Lumbar corsets and neoprene belts are also used.[11]

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Contributor Information and Disclosures
Author

Achilles Litao, MD Staff Physician, Department of Internal Medicine, Lincoln Medical and Mental Health Center, Cornell University

Achilles Litao, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Andrew D Perron, MD Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

John Munyak, MD Associate Program Director, Director of Sports Medicine Education, Department of Emergency Medicine, Lincoln Medical and Mental Health Center

Disclosure: Nothing to disclose.

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Radiograph of L4 defect in the pars interarticularis.
Computed tomography scan demonstrating defects in the left and right pars interarticularis.
Long TR (T2-weighted) fat suppressed sagittal magnetic resonance image shows increased signal in the pars interarticularis on the left at L5 (same patient in Images 3-4). This is an acute stress reaction.
Sagittal short TR (T1-weighted) magnetic resonance image shows decreased signal in the pars interarticularis on the left at L5 (same patient in Images 3-4).
Lateral radiograph of the lumbar spine shows spondylolysis at L5 with spondylolisthesis at L5 through S1. On this single view, it is not possible to determine if these pars defects are unilateral or bilateral. Oblique views may help resolve this issue.
Sagittally reconstructed computed tomography scan of the lumbar spine shows a defect of the pars interarticularis on the left at L5.
Lumbar oblique radiograph showing the "Scotty dog." A pars defect is seen at L5.
 
 
 
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