Fatigue fracture of the vertebra (spondylolysis at the pars interarticularis) is initially approached with nonoperative care. When that first-line strategy does not achieve the required clinical response, a structured surgical protocol becomes the indicated next step.

Previous Line — Failure Condition

Conservative (nonoperative) management — comprising activity restriction, a progressive structured physical therapy program, NSAIDs, and in selected cases spinal injections or external bracing — did not achieve the required outcome: symptomatic improvement within approximately six weeks, with resolution of pain and normalised range of motion of the lumbar spine.

Next-Line Approach (partial overview)

After failure of conservative care, the protocol involves direct surgical repair of the spondylolysis. Multiple operative techniques exist; which technique applies, and under what conditions, is set out in the full structured regimen.

References

DOI: 10.1155/2020/9235958

In the small percentage of young patients who fail conservative treatments, direct surgical repair of the spondylolysis has been shown to be highly effective.
In 1968, Kimura described bone grafting without internal fixation for the treatment of spondylolytic defects.
In the same time period, Scott detailed a wiring technique to augment the bone grafting of the lytic defect.
In 1970, Buck described a technique of placing a lag screw across the lytic defect to internally reduce the fracture.
Modern minimally invasive techniques for direct spondylolysis repair may have superior clinical outcomes over conventional open techniques and may be considered in cases where conservative management has failed.

View source ↗

Fatigue Fracture of Vertebra — Surgical Protocol After Conservative Management Has Failed

References