eMedicine Specialties > Sports Medicine > Spine
Lumbosacral Spondylolysis: Treatment & Medication
Updated: Jun 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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 interarticularis11 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.
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.
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 defect11 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
Consultations
Consult neurosurgeons, orthopedic surgeons, neurologists, and physiatrists as indicated.
Other Treatment
Lumbar corsets and neoprene belts are also used.11
Medication
Tylenol (acetaminophen) and NSAIDs are the mainstays of pain control in those with lumbosacral spondylolysis (lumbar spondylolysis). Moreover, a short course of narcotic analgesics can help those who are in significant acute pain initially.
Muscle relaxants are overprescribed and have not been demonstrated to be of significant help in this condition.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.
For the relief of moderate to severe pain, a short course of a narcotic analgesic may be warranted. Opiates exert their effects by binding to different opioid receptors throughout the body, which produces a wide range of effects such as analgesia, euphoria, constipation, and respiratory depression.
Acetaminophen (Tylenol, Feverall, Aspirin-Free Anacin)
Effective analgesic-antipyretic but only has weak anti-inflammatory effects. Inhibits prostaglandin synthetase. Well absorbed from gastrointestinal tract. Peak concentrations in serum are reached within 2 h.
Adult
500-1000 mg q4h PO prn for pain
Pediatric
10-15 mg/kg q4h PO prn for pain; not to exceed adult dose
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G6PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose.
Acetaminophen and codeine (Tylenol #3)
Indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose PO based on codeine content q4-6h or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
The toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics.
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase the hepatotoxicity of acetaminophen.
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates, because this substitution may result in acute opiate withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction.
Hepatotoxicity with acetaminophen is possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses that exceed the recommended maximum dose.
Hydrocodone and acetaminophen (Lortab, Lorcet-HD, Vicodin, Norcet)
Drug combination indicated for moderate to severe pain. Available in different strengths.
Adult
1-2 tab PO q4-6h; not to exceed 4 g/d of acetaminophen
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants.
Documented hypersensitivity to hydrocodone, acetaminophen or components; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates, because this substitution may result in acute opiate withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction; tolerance or drug dependence may result from prolonged use
Hydrocodone and ibuprofen (Vicoprofen)
Drug combination indicated for short-term (<10 d) relief of moderate to severe acute pain.
Adult
1-2 tab PO q4-6h prn pain; not to exceed 5 tab/d
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; third trimester of pregnancy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; duration of action may increase in elderly patients
Propoxyphene and acetaminophen (Darvocet-N100, Wygesic)
Drug combination indicated for mild to moderate pain.
Adult
1-2 tab PO q4h prn; not to exceed 600 mg/d
Pediatric
Not established
May increase serum concentrations of MAOIs, tricyclic antidepressants, carbamazepine, phenobarbital, and warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates, because this substitution may result in acute opiate withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Naproxen (Anaprox, Naprelan, Naprosyn, Aleve)
For the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of COX, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Ibuprofen (Motrin, Ibuprin, Advil)
NSAIDS exert their main therapeutic effect on pain and inflammation principally by inhibition of prostaglandin synthesis.
Adult
400 mg q4-6h prn mild to moderate pain
Pediatric
10 mg/kg q6h
May decrease the antihypertensive effect of angiotensin-converting enzyme (ACE) inhibitors; can reduce the natriuretic effect of furosemide and thiazides in some patients; reduces lithium clearance
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use of NSAIDS is not recommended during pregnancy, labor, and delivery and in nursing mothers; use of NSAIDS may result in or aggravate gastrointestinal adverse effects and bleeding and cause hypersensitivity reactions.
Mefenamic acid (Ponstel)
Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
500 mg PO initially then 250 mg q6h prn for not more than 1 wk
Pediatric
<14 years: Not established
>14 years: Administer as in adults.
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May have adverse effects in fetus; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Orudis, Oruvail, Actron)
For the relief of mild to moderate pain and inflammation.
Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease.
Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution and closely observe the patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults.
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may increase celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in patients with compromised cardiac function, hypertension, and conditions predisposing to fluid retention; caution in patients with severe heart failure and hyponatremia because circulatory hemodynamics may deteriorate; NSAIDs may mask the usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
Muscle Relaxants
Muscle relaxants are overprescribed and have not been demonstrated to be of significant help in cases of lumbosacral spondylolysis (lumbar spondylolysis).
Methocarbamol/aspirin (Robaxisal)
Used mainly as adjunctive treatment of muscle spasm associated with acute painful musculoskeletal conditions. Causes musculoskeletal relaxation by decreasing impulse transmission from the spinal cord to the muscle.
Adult
2 tabs PO qid
Pediatric
<12 years: Not established
>12 years: 2 tabs PO qid
Increased toxicity with CNS depressants; aspirin blunts the antihypertensive effect of ACE inhibitors
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in patients with underlying bleeding and platelet disorders (increases risk of bleeding), peptic ulcer disease, and renal dysfunction.
More on Lumbosacral Spondylolysis |
| Overview: Lumbosacral Spondylolysis |
| Differential Diagnoses & Workup: Lumbosacral Spondylolysis |
 Treatment & Medication: Lumbosacral Spondylolysis |
| Follow-up: Lumbosacral Spondylolysis |
| Multimedia: Lumbosacral Spondylolysis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
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Further Reading
Related eMedicine Topics
- Lumbar Spondylolysis and Spondylolisthesis [in the Physical Medicine and Rehabilitation section]
- Mechanical Low Back Pain [in the Physical Medicine and Rehabilitation section]
- Pars Interarticularis Injury
- Pathophysiology of Chronic Back Pain [in the Neurology section]
Clinical Trials
- D-Cycloserine in the Management of Chronic Low Back Pain
- Effect of Interventions in Return to Work for Patients With Neck and Low Back Pain
- Manual and Manipulative Therapy for Low Back Pain
- Prospective Clinical Evaluation of the New Aegis Plate for Anterior Interbody Fusions
- Traditional Acupuncture and Myofascial Trigger Point Dry Needling and Acupressure for Chronic Low Back Pain
National Guidelines Clearinghouse
- ACR Appropriateness Criteria® low back pain. American College of Radiology - Medical Specialty Society. 1996 (revised 2005). 7 pages. [NGC Update Pending] NGC:004786
- Adult low back pain. Institute for Clinical Systems Improvement - Private Nonprofit Organization. 1994 Jun (revised 2006 Sep). 65 pages. [NGC Update Pending] NGC:005287
- Diagnosis and treatment of degenerative lumbar spondylolisthesis. North American Spine Society - Medical Specialty Society. 2008. 133 pages. NGC:006568
- Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: fusion in patients with stenosis and spondylolisthesis. American Association of Neurological Surgeons - Medical Specialty Society. Congress of Neurological Surgeons - Professional Association. 2005 Jun. 7 pages. NGC:005370
- Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 12: pedicle screw fixation as an adjunct to posterolateral fusion for low-back pain. American Association of Neurological Surgeons - Medical Specialty Society. Congress of Neurological Surgeons - Professional Association. 2005 Jun. 7 pages. NGC:005373
Keywords
lumbosacral spondylolysis, lower back pain, low back pain, lumbar spondylolysis, spondylosis, pars interarticularis defect, spondylolisthesis
