Surgery is indicated if the slippage is greater than 50% or in cases of refractory symptoms or progressive neurologic deficit.
Best results are observed in those with a lytic defect between L1 and L4. Disc degeneration as seen on MRI is a relative contraindication.
Slippage of greater than 2 mm decreases the likelihood of successful repair.
Options for operative management include direct repair of the spondylolytic defect, fusion in situ, reduction and fusion, and vertebrectomy.
Ideally, repair of a pars defect is for young patients with spondylolysis but no spondylolisthesis.
Once asymptomatic, patients with grade 1 or less slippage may resume their activities as desired (as long as they remain pain free).
Continue to emphasize avoidance of aggravating factors, particularly those activities that involve repetitive hyperextension of the back.The desire to participate in a contact sport should not be the sole indication for a fusion.Decompression and fusion are typically performed in cases of dural sac compression with the presence of bowel or bladder dysfunction or significant motor deficits.In an asymptomatic child with slippage up to 25% (grade 1), initially observe with radiographs every 4-6 months if younger than age 10 years, semiannually until age 15 years, then annually until the end of growth.No limitation of activities is required, but the patient is advised to avoid occupations that entail heavy labor.The postoperative rate of permanent neurologic deficits is high (25-30%), although many are preexistent.This does not appear to be balanced by improved results; fusion in situ has achieved similar clinical outcomes with a lower complication rate.Avoidance of heavy labor or any repetitive hyperextension continues to be important.An occupational therapist can assist by completing an ergonomic evaluation and assessing subsequent workstation modifications if needed to avoid unnecessary loading of the patient's lumbosacral spine.An occupational therapist can be very beneficial for those individuals who need instructions and compensatory strategies for activities of daily living.Restriction from sports and other activities that require repetitive hyperextension may be sufficient treatment in young athletes.