A teenager initially consulted a physician at the age of 14 years for low back pain attributed to a trauma. He had progressively been involved in competitive sport (ice hockey) since the age of 6 without any major concern. The physical evaluation showed a step-off, a painful limitation of the active extension of the lumbar spine and some hamstring tightness. Standard radiographs demonstrated an L5 bilateral spondylolysis with Grade I spondylolisthesis (Fig. 12.1A), while functional radiographs in hyperflexion and hyperextension demonstrated minor translation of L5. A conservative management option was chosen after discussion with a pediatric orthopaedic surgeon, with a good functional outcome and return to the patient’s previous level of sports activity. Lumbar radiographs taken 3 years later did not show any progression of the vertebral slip (Fig. 12.1B). The subject is currently aged 23 and still playing ice hockey in a team, without any specific medical attention since the last radiographs.

The treatment of spondylolysis and spondylolisthesis can be conservative or surgical, but the therapeutic objectives remain similar. The three main treatment objectives recognized
are bone healing, pain relief, and optimization of physical function (7). However, in their review, Herman et al. emphasize that bracing a young patient with spondylolysis is not directed at healing the defect, but that the real goal of immobilization is just alleviating symptoms (8). A similar point of view can be found in Wimberly and Lauerman’s review of the topic (9). Various modalities of conservative management can be identified in the literature, from no treatment and observation, to activity modification, physical therapy, bracing, casting (5,10) or electrical stimulation (11). In all cases, information relies mainly on case reports, series of cases or cohort studies, and we failed to identified any single randomized controlled trial in these age groups. As stated before, most authors do not recommend active therapy in the case of an asymptomatic patient. According to Logroscino et al., physical activity should not be restricted in asymptomatic patients with spondylolysis, while patients with Grade 1 olisthesis should be advised to restrict sports and activities that place an increased strain on the unstable vertebra (2). However, based on their impressive longitudinal study’s data, Fredrickson et al. allow full participation in sports (3). They do recommend, however, that the asymptomatic patient be informed of the existence of the lesion and told to seek medical attention if symptoms develop. Most authors agree on the beneficial effects of physical therapy, treatment that remains widely prescribed even if the demonstration of its efficiency is still lacking. A systematic review of physiotherapy for spondylolysis and olisthesis has recently been published (12). The fact that only 2 of 52 studies could finally be included in the analysis indicates the poor methodologic quality of this literature, and unfortunately neither included children or teenagers in their population. Therefore, there is an obvious lack of evidence to advise for or against physiotherapy as treatment, even if it appears reasonable (12). As a physical therapy modality, external electrical stimulation deserves a special note. Stasinopoulos has carefully reviewed the literature (11) and found that only two articles, which may be considered case reports, described the effects of such treatment in adolescents. One of these articles, describing two adolescent athletes, seems particularly promising. However, in terms of evidence, these findings are again too limited to advise for or against a generalized utilization of external electrical stimulation in this indication (11). Similarly, if
external immobilization may seem an obvious mode of treatment, the timing, the role, and the best type of device continue to be a matter of debate and unresolved. In one of the original papers by Wiltse et al. (13), healing of the defects under conservative management was described in 12 cases. However, bracing ranged from no immobilization at all to a knees-to-nipples cast for 2 months. Even in the recent literature, the role and best type of external immobilization continue to be debated (1). In their review article, Herman et al. recommend for the treatment of spondylolysis immobilization in a thoracolumbosacral orthosis (TLSO) with a single-leg thigh extension or an antilordotic TLSO for a period of 6 to 12 weeks, casting being reserved for the noncompliant athlete. The period of immobilization should be adapted to bone healing, with bracing for longer than 6 months not indicated. Also, they do recommend the prescription of a rehabilitation program and a progressive return to sports activities over a 6- to 8-week period after the immobilization (8). Finally, the use of immobilization in a lightweight plaster or plastic jacket has been advocated by Hensinger for the preoperative evaluation (14).