Nonoperative Bracing and Physical Therapy Protocol for Acute Spondylolysis in Adolescent Athletes: High Rates of Clinical Resolution and Factors Associated With Recurrent Acute Spondylolysis and Chronic Spondylolysis in 179 Patients

Study Design: Retrospective case series. Objective: To evaluate the clinical outcomes and variables associated with recurrent acute spondylolysis and progression to chronic spondylolysis in a cohort of adolescent athletes who were treated nonoperatively for acute spondylolysis with a protocol of rest, bracing, and physical therapy (PT). Background: The optimal nonoperative treatment algorithm for spondylolysis in adolescent athletes remains unclear. Patients and Methods: Acute spondylolysis was defined as a stress reaction/defined pars interarticularis fracture with edema on MRI from February 2016 to August 2024. All patients were treated nonoperatively with a period of rest, bracing, and PT. Outcomes included clinical resolution of pain, recurrence of pain, recurrent acute spondylolysis, progression to chronic spondylolysis, and surgical intervention. Multivariable logistic regression identified variables associated with recurrent acute spondylolysis and progression to chronic spondylolysis, respectively. Results: One hundred seventy-nine adolescents (mean: 14.4 ± 1.6 y) with acute spondylolysis were treated with rest, bracing for 11.0 ± 2.3 weeks, and PT initiation at 5.9 ± 1.6 weeks into treatment. Clinical resolution was achieved in 79% at first follow-up (mean: 6.8 ± 2.2 wk) and 96% by the second follow-up (13.9 ± 3.6 wk). Seventy-eight (44%) had recurrent pain; 19 (10.6%) developed recurrent acute spondylolysis, and 15 (8.4%) progressed to chronic spondylolysis. Five (2.8%) patients required surgical intervention (4 L5/S1 fusions, 1 pars fixation). An additional week of bracing was associated with 22% decreased odds (OR: 0.78, P = 0.019) of recurrent acute spondylolysis. Multilevel spondylolysis (OR: 8.21, P = 0.038), persistent pain at second follow-up (OR: 10.65, P = 0.009), and each week delay in initiating PT (OR: 1.43, P = 0.013) were associated with higher odds of recurrent acute spondylolysis. Persistent pain at the first follow-up visit was associated with higher odds (OR: 4.95, P = 0.005) of progression to chronic spondylolysis. Conclusion: Our findings demonstrate the success of our spondylolysis protocol involving 12 weeks of bracing with initiation of physical therapy at four to six weeks following rest, and identify specific variables associated with nonresolving acute spondylolysis.