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Surgery is indicated for skeletally immature patients with greater than 30-50% slippage (with or without symptoms) because they are at greater risk for progression, in the event of progressive neurologic deficit, or in those with pain persisting for more than 6-12 months that has not been relieved with rest and immobilization with any degree of slip.Spondylolysis or low-grade spondylolisthesis may be managed nonoperatively.
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.
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.
This consists of exercises to strengthen the abdominal muscles (eg, William flexion-type exercises) and flexibility programs to stretch the spinal extensor muscles, hamstrings, and lumbodorsal fascia.
Avoidance of heavy-duty labor or activities with repetitive lumbar extension is necessary to allow healing to occur.
Patients with grade 2 slippage are generally instructed to avoid hyperextension loading of the spine after symptoms resolve with conservative treatment.
Younger patients require more careful observation, even if the initial symptoms resolve, because of their greater risk for progression.
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.