Spondylolysis and

Spondylolisthesis in
Children and Adolescents:
I. Diagnosis, Natural
History, and Nonsurgical
Management

Ralph Cavalier, MD Abstract

Martin J. Herman, MD
Emilie V. Cheung, MD
Peter D. Pizzutillo, MD
Dr. Cavalier is Attending Orthopaedic
Surgeon, Summit Sports Medicine and
Orthopaedic Surgery, Brunswick, GA.
Dr. Herman is Associate Professor,
Department of Orthopaedic Surgery,
Drexel University College of Medicine,
St. Christopher’s Hospital for Children,
Philadelphia, PA. Dr. Cheung is Fellow,
Department of Orthopaedic Surgery,
Mayo Clinic, Rochester, MN. Dr.
Pizzutillo is Professor, Department of
Orthopaedic Surgery, Drexel University
College of Medicine, St. Christopher’s
Hospital for Children.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Cavalier, Dr. Herman, Dr. Cheung,
and Dr. Pizzutillo.
Reprint requests: Dr. Herman, St.
Christopher’s Hospital for Children,
Department of Orthopaedic Surgery,
Front Street at Erie Avenue,
Philadelphia, PA 19134-1095.
Spondylolysis and spondylolisthesis are often diagnosed in children
presenting with low back pain. Spondylolysis refers to a defect of
the vertebral pars interarticularis. Spondylolisthesis is the forward
translation of one vertebral segment over the one beneath it. Isth-
mic spondylolysis, isthmic spondylolisthesis, and stress reactions
involving the pars interarticularis are the most common forms seen
in children. Typical presentation is characterized by a history of
activity-related low back pain and the presence of painful spinal
mobility and hamstring tightness without radiculopathy. Plain ra-
diography, computed tomography, and single-photon emission
computed tomography are useful for establishing the diagnosis.
Symptomatic stress reactions of the pars interarticularis or adjacent
vertebral structures are best treated with immobilization of the
spine and activity restriction. Spondylolysis often responds to brief
periods of activity restriction, immobilization, and physiotherapy.
Low-grade spondylolisthesis (≤50% translation) is treated similarly.
The less common dysplastic spondylolisthesis with intact posterior
elements requires greater caution. Symptomatic high-grade spondy-
lolisthesis (>50% translation) responds much less reliably to non-
surgical treatment. The growing child may need to be followed
clinically and radiographically through skeletal maturity. When
pain persists despite nonsurgical interventions, when progressive
vertebral displacement increases, or in the presence of progressive
neurologic deficits, surgical intervention is appropriate.

J Am Acad Orthop Surg 2006;14:417-

424
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
S pondylolysis and spondylolisthe-
sis are common causes of low
back pain in children and adoles-
cents. Upright posture and ambula-
tion appear to be contributing fac-
tors to the development of these
conditions; there are no reported cas-
es in nonambulators.1 Spondylolysis
has been rarely reported in infancy,
but by age 6 years, the reported inci-
dence of 5% approximates that of
the adult population.2-5 Most chil-

Volume 14, Number 7, July 2006 417

Spondylolysis and Spondylolisthesis: I. Diagnosis, Natural History, and Nonsurgical Management
Table 1
Classification Systems for Spondylolisthesis
Wiltse-Newman
I. Dysplastic
II. Isthmic
IIA, Disruption of pars as a
result of stress fracture
IIB, Elongation of pars without
disruption related to repeated,
healed microfractures
IIC, Acute fracture through pars
III. Degenerative
IV. Traumatic
V. Pathologic
dren are asymptomatic. Hereditary
factors appear to predispose some in-
dividuals to the development of
spondylolysis and spondylolisthe-
sis.6,7 Specific sporting activities
with repetitive hyperextension and
rotational loads applied to the lum-
bar spine may result in the develop-
ment of spondylolysis and spondy-
lolisthesis in the young athlete. The
incidence of spondylolysis is as high
as 47% in elite athletes who partic-
ipate in high-risk sports such as div-
ing and gymnastics.8,9
Spondylolisthesis may be associ-
ated with neurologic dysfunction in
patients with congenital dysplasia of
the lumbosacral facets and sacrum.
These congenital changes allow an-
terior translation of the L5 vertebral
body with intact posterior elements
that can compress the L5 and sacral
nerve roots.
Spondylolysis is the term used to
describe an anatomic defect of the
pars interarticularis without dis-
placement of the vertebral body.
When plain radiographs or comput-
ed tomography (CT) reveal sclerosis
with incomplete bone disruption at
418
Marchetti-Bartolozzi
Developmental
High dysplastic
With lysis
With elongation
Low dysplastic
With lysis
With elongation
Acquired
Traumatic
Acute fracture
Stress fracture
Postsurgery
Direct surgery
Indirect surgery
Pathologic
Local pathology
Systemic pathology
Degenerative
Primary
Secondary
the pars, adjacent lamina, or pedicle,
the term stress reaction is most ap-
propriately applied. Magnetic reso-
nance imaging (MRI) will demon-
strate intraosseous edema in the
affected areas in these patients.
When the defect is characterized by
a radiolucent gap with sclerosis of
the adjacent bone edges, it is termed
a spondylolytic or isthmic defect.
Spondylolisthesis describes the
forward translation of one vertebra
relative to the next caudal vertebral
segment. Spondylolysis occurs most
commonly in the fifth lumbar verte-
bra but may occur at more cephalad
lumbar levels. Patients with L4
spondylolysis are more frequently
symptomatic.10 In children and ado-
lescents, however, spondylolisthesis
most commonly occurs at the L5-S1
motion segment.
Classification
The Wiltse-Newman classification
(Table 1) is the most widely used
classification of spondylolisthesis.11
Of the five types, only types I and II
apply commonly to the child and ad-
Journal of the American Academy of Orthopaedic Surgeons
olescent. Type I, the dysplastic type,
defines spondylolisthesis secondary
to congenital abnormalities of the
lumbosacral articulation, including
maloriented or hypoplastic facets
and sacral deficiency. The pars is
poorly developed, which allows for
elongation or eventual separation
and forward slippage of L5 on the
sacrum with repetitive loading over
time. This type is less common,
comprising 14% to 21% of cases in
large series.12,13
Type II, the isthmic type, defines
spondylolisthesis that results from
defects of the pars interarticularis.
This group is subdivided into three
subtypes. Type IIA, the most com-
mon subtype, is caused by fatigue
failure of the pars from repetitive
loading, resulting in a complete ra-
diolucent defect. Type IIB is caused
by an elongated pars secondary to re-
peated microfractures that heal.
This type can be difficult to distin-
guish radiographically from the dys-
plastic type. Type IIC refers to a pars
fracture that results from an acute
injury. Wiltse hypothesized that
isthmic defects are the result of
chronic loading of a pars interarticu-
laris that is genetically predisposed
to fatigue failure.14
Marchetti and Bartolozzi15 pro-
posed an alternative classification
system with two broad categories—
developmental and acquired. The de-
velopmental category defines spondy-
lolisthesis resulting from an inherited
dysplasia of the pars, lumbar facets,
disks, and vertebral endplates, com-
bining the dysplastic and isthmic cat-
egories of Wiltse-Newman. Acquired
spondylolysis and spondylolisthesis
define failure of the pars secondary to
repetitive spinal loading related to
specific activities. An expanded ver-
sion of this classification was later
proposed15 ( Table 1). Although some
aspects of this detailed classification
are more easily applied to the child
and adolescent than is the Wiltse-
Newman scheme, the Marchetti-
Bartolozzi classification has not yet
achieved universal acceptance. De-

scriptive terms such as dysplastic,
congenital, sclerotic, spondylolytic,
developmental, acquired, traumatic,
stress fracture, and stress reaction
have resulted in substantial confusion
in taxonomy.
Natural History
Stress reactions of the pars, lamina,
and pedicle have been documented
in athletes who participate in high-
risk sports such as gymnastics, div-
ing, football, and rowing.9 These in-
juries are the result of repetitive
loading of the lumbar spine in exten-
sion and rotation, may be unilateral
or bilateral, and occur most com-
monly at L5. With immobilization,
stress injuries may heal, particularly
when the stress reaction is unilater-
al and has not yet resulted in cortical
disruption.16 When left untreated,
healing becomes less predictable,
and well-defined lucent defects may
develop.
In dysplastic spondylolisthesis
(Wiltse-Newman type I), the L5 ver-
tebra, with intact posterior elements,
slips forward on the sacrum. The re-
sulting lumbar stenosis may cause
L5 nerve radiculopathy as well as
bowel and bladder dysfunction from
compression of sacral nerve roots.
Children and adolescents with dys-
plastic spondylolisthesis are more
like to develop neurologic injury and
carry greater risk of progressive
deformity than do patients with
isthmic spondylolisthesis (Wiltse-
Newman type II). McPhee et al17 re-
ported a markedly higher frequency
of progression in the dysplastic type
(32%) than in the isthmic type (4%).
Furthermore, patients with dysplas-
tic spondylolisthesis are notably
more likely to require surgical treat-
ment.18,19
Isthmic spondylolysis and
spondylolisthesis, the most com-
monly occurring form in children
and adolescents, has an incidence of
4.4% at age 6 years, increasing to 6%
by age 18 years.3 In family studies of
individuals with isthmic spondylol-
Volume 14, Number 7, July 2006
ysis and spondylolisthesis, Wiltse6
and Albanese and Pizzutillo7 noted
that 26% and 22%, respectively, of
first-degree relatives demonstrated
radiographically similar changes.
Most affected individuals were un-
aware of the existing spinal changes
and were asymptomatic. Although
most patients with an isthmic
spondylolysis present with some de-
gree of slip, <4% of children and ad-
olescents demonstrate slip progres-
sion through skeletal maturity and
into adulthood.16,17 Children who are
diagnosed before their adolescent
growth spurt, girls, and those pre-
senting with >50% slip are most
likely to progress.12 Hamstring
spasm is the most frequently associ-
ated neurologic abnormality. Lum-
bar radiculopathy and bowel or blad-
der symptoms are rare but may
occur in individuals with severe
isthmic spondylolisthesis.
Harris and Weinstein20 studied
the long-term outcome in patients
with Meyerding grades III or IV
spondylolisthesis (≥51% slip) and
found that 36% of the patients treat-
ed nonsurgically were asymptomat-
ic, 55% had occasional back pain,
and 45% had neurologic symptoms;
none of the patients was inconti-
nent. At an average follow-up of 18
years, all patients were leading ac-
tive lives with only minor adjust-
ments in lifestyle.
Beutler et al21 reported on the nat-
ural history of spondylolysis and
spondylolisthesis with a 45-year
follow-up. No patients with unilat-
eral defects progressed to slippage
over the course of the study. Patients
with bilateral L5 pars defects and
low-grade (Meyerding grade I or II,
≤50%) slips followed a clinical
course similar to that of the general
population. Marked slowing of slip
progression was observed with each
decade, and no patient reached a
40% slip. No correlation was found
between slip progression and low
back pain. Furthermore, there was
no significant difference in Medical
Outcomes Study 36-Item Short
Ralph Cavalier, MD, et al
Form scores between the study pop-
ulation and the age-matched general
population.
In most studies, no distinction
has been made between the dysplas-
tic and isthmic types of spondylolis-
thesis. Also, most of the reported
studies are retrospective. In addition,
patients with spondylolysis and
spondylolisthesis have often been
considered together in natural histo-
ry studies.
Clinical Assessment
History and Physical
Examination
The child or adolescent typically
presents with low back pain or, occa-
sionally, pain that radiates to the
buttock or posterior thigh. Although
acute injury may precipitate the on-
set of pain, insidious onset is more
common. In addition to document-
ing a detailed history of the patient’s
complaints and their relation to ac-
tivity, a record of specific physical
activities and sports participation is
helpful. Radicular symptoms and
disturbance of bowel or bladder
function rarely occur with spondy-
lolysis or low-grade spondylolisthe-
sis, but they may be reported by pa-
tients with high-grade (Meyerding
grade III or IV) slip. A history of night
pain is not typical; when present, it
may suggest the presence of an oc-
cult neoplasm.
A thorough orthopaedic and neu-
rologic evaluation is mandatory for
all children and adolescents present-
ing with back pain. Gait should be
observed with the patient wearing
underwear or a bathing suit. A short-
ened stride length with flexion at the
hips and knees secondary to ham-
string contracture may be seen in pa-
tients with advanced degrees of
spondylolisthesis (Figure 1).
Coronal spinal alignment is ob-
served for scoliosis, but more defin-
itive evaluation of scoliosis is de-
ferred until pain and muscle spasm
have resolved. A flattened lumbar
lordosis is commonly observed in
419
Spondylolysis and Spondylolisthesis: I. Diagnosis, Natural History, and Nonsurgical Management

Figure 1 The standard posteroanterior radio-

A, A 9-year-old girl with grade IV dysplastic (Wiltse type I) spondylolisthesis of L5-
S1. Note the position of flexion of her hips and knees. B, Popliteal angle
measurement of 55° secondary to contracture of hamstring muscles. C, Standing
lateral radiograph of the lumbosacral spine of the same patient, illustrating high-
grade dysplastic spondylolisthesis with severe lumbosacral kyphosis (arrows).
patients with painful spondylolysis.
The sacrum appears vertically ori-
ented, and a visible or palpable step-
off at the spinous processes of the in-
volved levels may be observed in
patients with advanced slip. The
spinous processes and lumbodorsal
fascia, paraspinal muscles, and sa-
croiliac joints are palpated for ten-
derness. Lumbar flexion and exten-
sion are often limited, and lumbar
hyperextension frequently will
elicit pain.
Neurologic examination should
include lumbar sensory and motor
root testing as well as evaluation of
deep tendon reflexes at the knees
and ankles and of abdominal reflex-
es. A rectal examination is indicated
in patients with bowel or bladder
dysfunction to assess anal sphincter
tone and reflex contraction. Straight
leg–raise testing to assess nerve root
irritation and popliteal angle mea-
surements to assess hamstring
spasm and contracture complete the
examination.
Diagnostic Studies
Standing posteroanterior and lat-
eral radiographs of the thoracolum-
bar spine, with supine oblique views
of the lumbosacral spine, are most
useful to assess the child or adoles-
cent with back pain and potential
spondylolysis or spondylolisthesis.
graphic view allows evaluation of
coexisting scoliosis that may be sec-
ondary to paraspinal spasm, wheth-
er idiopathic or olisthetic (ie, the re-
sult of asymmetric forward vertebral
translation at the level of the
spondylolisthesis). The standing lat-
eral view is useful for identifying
spondylolytic defects and document-
ing the degree of spondylolisthesis.
Supine oblique and spot lateral ra-
diographic views of the lumbosacral
junction improve the likelihood of
diagnosing stress reactions and
spondylolytic defects (Figure 2).
The Meyerding classification
quantifies the amount of forward
translation based on the standing
lateral radiograph22 (Figure 3, A).
Measurement of the slip angle quan-
tifies the degree of lumbosacral ky-
phosis that has occurred in associa-
tion with this anterior translation.
The slip angle is the angle subtend-
ed by the intersection of a line drawn
along the superior endplate of L5 and
the perpendicular of a line drawn
along the posterior cortex of the
sacrum (Figure 3, B). In the past, the
inferior limb of the angle was con-
structed by drawing a line parallel to
the superior border of S1. This has
proved to be unreliable because of
the rounding of the superior sacrum
that occurs secondary to the slip. A
slip angle >50° is associated with
greater risk of slip progression, insta-
bility, and development of postoper-
ative pseudarthrosis.12
Single-photon emission CT
(SPECT) of the lumbosacral spine is
the most effective method for de-
tecting spondylolysis when plain ra-
diographs are normal and the patient
history and physical examination
are suggestive of the diagnosis.23-25
Increased radionuclide uptake in an
intact pars, lamina, or pedicle is con-
sistent with a stress reaction (Fig-
ure 4). A relative decrease in tracer
uptake on serial SPECT scans has
been correlated with improvement
of clinical symptoms and signs in pa-
tients treated for symptomatic

420 Journal of the American Academy of Orthopaedic Surgeons

 Ralph Cavalier, MD, et al

Figure 2

Standing lateral (A) and supine oblique (B) radiographs demonstrating spondylolytic defect of the pars interarticularis of L5
(circle, arrow). C, Axial CT image through the L5 vertebra of the same patient, demonstrating the bilateral spondylolytic defects
of the pars interarticularis. Note the sclerotic margins.

Figure 3

A, The Meyerding classification is used to quantify the degree of spondylolisthesis. Grade I is 0% to 25% slip, grade II is
26% to 50% slip, grade III is 51% to 75% slip, and grade IV is 75% to 99% slip. A = width of the superior endplate of S1,
a = distance between the posterior edge of the inferior endplate of L5 and the posterior edge of the superior endplate of S1.
B, Slip angle A quantifies the degree of lumbosacral kyphosis. A value >50° correlates with a significantly increased risk of
progression of spondylolisthesis. (Adapted with permission from Herman MJ, Pizzutillo PD, Cavalier R: Spondylolysis and
spondylolisthesis in the child and adolescent athlete. Orthop Clin North Am 2003;34:461-467.)

Volume 14, Number 7, July 2006 421

Spondylolysis and Spondylolisthesis: I. Diagnosis, Natural History, and Nonsurgical Management
Figure 4
Axial image of a SPECT scan of the
lumbar spine of a 13-year-old boy with
a 2-month history of activity-related
low back pain. Increased tracer uptake
is seen in both pars regions (arrows).
Plain radiographs appeared normal.
spondylolysis.26
Thin-section CT, performed with
a reverse gantry angle, is the best mo-
dality for defining the bony anatomy
of spondylolysis and spondylolisthe-
sis.27 Stress reactions, diagnosed by
SPECT scan, and spondylolytic de-
fects may be definitively evaluated
by thin-section CT scan for the de-
gree of cortical disruption, lysis, and
sclerosis at the pars, lamina, or pedi-
cle (Figure 5). Progressive healing of
stress reactions may be documented
by serial CT scan evaluation. CT is
also useful for identification of the
nidus of an osteoid osteoma, which
may cause back pain and is associ-
ated with focal increased uptake on
SPECT. Two- and three-dimensional
CT reconstruction of the spine in pa-
tients with severe spondylolisthesis
is useful to clarify the pathoanatomy
of the region for preoperative plan-
ning.
MRI is indicated when neurolog-
ic symptoms and signs are present in
conjunction with spondylolysis and
spondylolisthesis. Nerve root com-
pression, lumbar disk abnormalities,
spinal cord anomalies, and neoplasm
of the spinal cord or vertebral spinal
column are other sources of low
back pain that are best assessed with
MRI. The role of MRI as a primary
422
Figure 5
A 15-year-old diver presented with upper lumbar back pain of several months’
duration. A, Anteroposterior radiograph of the lumbar spine showing sclerosis of
the L2 pedicle (arrows). B, Axial CT image through the L2 vertebra demonstrating
dense sclerosis in the area of the left pedicle, which is indicative of stress reaction.
After 8 weeks of restricted activities and full-time bracing, the patient’s symptoms
resolved and he returned to diving after a short course of physical therapy.
diagnostic tool in young patients ly detection may improve clinical
with stress reactions or symptomat- outcome.16 Early treatment with
ic spondylolytic defects is not well brace immobilization has achieved
defined. A high rate of false-positive results superior to those of activity
studies and a low positive predictive restriction alone. Early brace treat-
value suggest that other modalities ment also has been shown to be
may be more effective in diagnosing more effective than bracing after an
these entities.28 initial trial period of activity restric-
tion.26,29
Nonsurgical Full-time immobilization in a
Management thoracolumbosacral orthosis (TLSO),
Stress Reaction with or without a thigh extension, or
Spondylotic stress fractures of the in a one-legged pantaloon spica cast
pars interarticularis without cortical for a period of 6 to 12 weeks is indi-
disruption were reported in 47% of cated for the child or adolescent with
100 adolescent athletes assessed by a stress reaction of the pars. Immobi-
Micheli and Wood.9 This sympto- lization may be discontinued once
matic stress reaction of the pars has pain-free lumbar extension and rota-
the potential to heal.9 Lesions may tion can be demonstrated and
present with unilateral or bilateral follow-up evaluation with repeat CT
involvement of the pars, adjacent documents progressive bony healing.
lamina, or pedicle; in the presence of After discontinuation of immobiliza-
normal radiographs, these lesions tion and a period of physiotherapy,
are diagnosed by SPECT and CT. Os- activities are gradually reintroduced.
seous healing potential is greater in If bony healing is absent on
unilateral than bilateral lesions, and follow-up CT but symptoms have re-
prompt treatment as a result of ear- solved, a fibrous union has occurred.
Journal of the American Academy of Orthopaedic Surgeons

Fibrous union of a pars defect does
not indicate instability, and it often
leads to a good clinical result with
resumption of sporting activities.16,26
Surgery is indicated when patients
do not respond clinically despite a
minimum of 6 months of nonsurgi-
cal treatment.
Spondylolysis With a
Spondylolytic Defect
(Isthmic Spondylolysis)
The goals of treatment of the
young patient with a symptomatic
spondylolytic defect are alleviation
of pain and improvement of spinal
mobility—not bony healing.16 In this
clinical scenario, a thorough search
for other sources of pain must be
conducted because many of these ra-
diographic lesions are asymptomat-
ic. For most symptomatic children
and adolescents, a period of restrict-
ed activity and physiotherapy will
relieve symptoms and allow a safe
return to activities. The need for
brace treatment is infrequent and is
reserved for patients who do not re-
spond to rest and physical therapy.
An antilordotic TLSO or soft spinal
corset, which limits the extremes of
spinal motion, is effective in reduc-
ing pain and facilitating progression
to physiotherapy.30-32 In this popula-
tion, the duration of brace treatment
rarely exceeds 6 to 8 weeks. Clinical
observation of diminished pain, im-
proved spinal mobility, and de-
creased hamstring spasm confirm
the efficacy of treatment. Activities
may be resumed once symptoms
have resolved after an appropriate
period of physiotherapy.
Physical therapy incorporating a
“specific exercise” treatment ap-
proach has been found to be more ef-
fective than other commonly pre-
scribed general therapy programs.
O’Sullivan et al33 evaluated 44 pa-
tients with radiographic diagnosis of
spondylolysis or spondylolisthesis;
patients were assigned randomly to
two treatment groups. Those in one
group were taught specific strength-
ening exercises to target the deep ab-
Volume 14, Number 7, July 2006
dominal muscles (internal oblique
and transversus abdominus) and the
lumbar multifidus (proximal to the
pars defect). These muscles sur-
rounding the lumbar spine have the
primary role of contributing to dy-
namic segmental stability. At 30-
month follow-up, patients in the
specific exercise group demonstrated
marked reduction in pain and dis-
ability compared with the control
group, who underwent more general
physiotherapy treatment. Also rou-
tinely prescribed was stretching of
tight lumbodorsal fascia and ham-
string muscles.
Serial examination and radio-
graphs are indicated for children who
have recurrence of symptoms or un-
dergo change in clinical appearance.
Spondylolisthesis
In two studies of children and ad-
olescents with symptomatic low-
grade spondylolisthesis, two thirds
in one study32 and all patients in the
second study34 responded to nonsur-
gical measures, including activity re-
striction, physiotherapy, and brace
treatment. When pain, spinal mobil-
ity, and hamstring spasm are im-
proved, the patient may return to
full activities. Low-grade isthmic
spondylolisthesis rarely progresses,
regardless of patient age or activity
level, and it has a benign clinical
course in the majority of patients. In
their report on the natural history of
symptomatic low-grade spondylolis-
thesis, Frennered et al35 found that
only 2 of 47 patients demonstrated
progression of slip. Accordingly, we
routinely advise parents to maintain
awareness of the spondylolisthesis;
they should not, however, restrict
the child’s activity, expect an in-
crease in any deformity, or antici-
pate a higher likelihood of develop-
ment of incapacitating pain.
In contrast, children and adoles-
cents with low-grade dysplastic
spondylolisthesis are at greater risk
for progression, development of neu-
rologic deficit, and need for surgical
intervention. Thus, we recommend
Ralph Cavalier, MD, et al
serial physical examination and ra-
diographs for the asymptomatic
child with low-grade dysplastic
spondylolisthesis at 6- to 9-month
intervals through skeletal maturity.
Children and adolescents with
symptomatic high-grade spondy-
lolisthesis, regardless of type, re-
spond less reliably to nonsurgical
measures. Symptomatic relief can
be expected in <10% of cases. Con-
sequently, surgical management is
recommended for children and ado-
lescents with symptomatic high-
grade spondylolisthesis.32 There is
no evidence to support prophylactic
fusion for asymptomatic high-grade
isthmic spondylolisthesis, nor is it
indicated on the basis of long-term
evaluation of individuals with high-
grade spondylolisthesis.20
Indications for Surgical
Management
Surgical treatment is indicated for the
child with persistent pain resulting
from a nonhealing stress fracture of
the pars, a spondylolytic defect, or
low-grade spondylolisthesis despite a
minimum of 6 months of nonsurgi-
cal treatment. A careful diagnostic
search for discogenic, abdominal, or
pelvic sources of low back pain is
mandatory because a spondylolytic
defect may be an incidental radio-
graphic finding. Surgery is also in-
dicated in young patients with
progressive dysplastic spondylolisthe-
sis, those presenting with neurologic
deficit, and symptomatic children
presenting with a high-grade slip.
Summary
Spondylolysis and spondylolisthesis
are common causes of back pain in
the child or adolescent. The inci-
dence of spondylolysis and spondy-
lolisthesis is particularly high in ath-
letes who participate in sports that
place excessive stress on the lumbar
spine. Careful clinical and diagnostic
evaluation is important to properly
diagnose and effectively treat pa-
423
Spondylolysis and Spondylolisthesis: I. Diagnosis, Natural History, and Nonsurgical Management
tients with specific types of spondy-
lolysis and spondylolisthesis. Most
children and adolescents with
spondylolysis and low-grade spondy-
lolisthesis may be successfully
treated by nonsurgical methods with
expected return to full activity. Sur-
gical treatment is necessary for indi-
viduals with persistent symptoms
despite nonsurgical treatment and
those with neurologic impairment.
“Spondylolysis and Spondylolis-
thesis in Children and Adoles-
cents: II. Surgical Management”
will appear in the next issue of the
Journal of the American Academy
of Orthopaedic Surgeons.
References
Evidence-based Medicine: There are
no level I or II randomized controlled
studies referenced. Level III/IV case-
controlled or case series are reported.
Citation numbers printed in bold
type indicate references published
within the past 5 years.
1. Rosenberg NJ, Bargar WL, Friedman B:
The incidence of spondylolysis and
spondylolisthesis in nonambulatory
patients. Spine 1981;6:35-38.
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