The effectiveness of surgical versus conservative treatment for symptomatic unilateral spondylolysis of the lumbar spine in athletes: a systematic review

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Executive summaryBackgroundSpondylolysis is a common cause of low back pain in athletes. Historically, spondylolysis injuries were thought to be mostly bilateral; however advances in lumbar spine imaging have shown that in certain athlete groups, unilateral spondylolysis is highly prevalent. It remains unclear whether athletes with unilateral spondylolysis who undergo surgical repair are able to return to sports as effectively or faster than if they had conservative treatment.ObjectivesTo determine the effectiveness of surgical fixation performed after a trial period of conservative management, compared to the effectiveness of conservative management only for unilateral spondylolysis in athletes.Inclusion criteriaTypes of participantsAthletes with symptomatic unilateral spondylolysis of the lumbar spine.Types of intervention(s)Surgical interventions which attempted a direct repair of the pars interarticularis, compared to conservative management.Types of studiesExperimental and epidemiological study designs were considered for inclusion. The majority of the studies reviewed consisted of descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies.Types of outcomesThe primary outcome of interest in this review was the ability to return to sport. The effectiveness of surgery on pain and overall function were secondary outcomes of interest.Search strategyA three-step search strategy that aimed to find both published and unpublished studies was utilized. The search was limited to studies published in the English language between 1 January 1970 and 1 September 2013.Methodological qualityThe studies were critically appraised using one of the standardized critical appraisal instruments from The Joanna Briggs Institute.Data collectionDetails describing each study and results on effectiveness in promoting the outcomes of interest were extracted from papers included in the review using the standardized data extraction tool from The Joanna Briggs Institute.Data synthesisDue to heterogeneity in the included studies, the results for similar outcome measures were not pooled in statistical meta-analysis. A narrative and tabular format was used to synthesize the results of identified and included studies.ResultsFive studies reporting results for the outcomes of interest were critically appraised and included in the review. One study was a quasi-experimental design, while the other four were case series studies. Due to the paucity of data, studies were included regardless of whether their participants were exclusively athletes with unilateral spondylolysis or adults (athletes and non-athletes) with unilateral and bilateral spondylolysis. Sub-group analysis was used to distinguish the findings for the main participant group of interest, namely athletes with unilateral spondylolysis.ConclusionsThe limited evidence on the effectiveness of surgical treatment versus conservative treatment for unilateral spondylolysis in athletes does not allow any conclusions to be drawn about the relative effectiveness of surgery versus conservative treatment for facilitating rapid return to sport or a high level of post injury sporting level/performance. It does suggest, however, that for adult athletes for whom conservative treatment has not been successful, surgery is likely to enable return to sport, reduce pain and promote overall function.Implication for practiceAdult athletes who have failed conservative treatment who suffer pain and compromised functionality (including inability to play regular sport) can consider surgery to reduce their pain, increase their function and enable return to sport (Grade B). It does however remain unclear as to what level of sport they will be able to return to post surgery (Grade B).Implications for researchA prospective case series design focused specifically on unilateral spondylolysis is required. Future research needs to be more specific in identifying athletes and the specific sports they participate in. More clarity is a also required when describing return to sport as an outcome measure.

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