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Spondylolysis Surgery Options

I just wanted to post some of the things I've learned from going through this process that I would like to share with people who are suffering from chronic pain due to spondylolysis. Theres so much misinformation and incomplete anecdotes online that I thought I'd try and put it all out there.

For reference, I am a 21 year old division 1 college pole vaulter training at the highest levels you can think of (~6 hrs of exercise a day). I'm a spondy sufferer, and had a trauma to my spondy by a 17 foot fall during training onto concrete which unmasked the pain unilaterally (i have bilateral L4 pars fractures). I continued to compete on the pain for about 5 months until it got so bad I couldn't walk. This was really dumb on my part, but when you're a serious athlete your trained to live with pain if you want to win. I've been navigating the medical system trying to get a complete knowledge of treatment and surgery for my condition since the conclusion of my track career. I've read A LOT.

heres what i have:

First... non-surgical treatment is very effective. Most cases, healed fractures or not, people can lead very normal lives carrying around these pars fractures. If you're just discovering this condition now, chances are you are in an acute phase and rest + physical therapy + NSAIDs will likely get you back to normal (you've probably had them for years). Once your body adjusts and finds a comfortable way to deal with the fractures, you will probably not notice them again unless you continue vigorous hyperextension or suffer from a trauma. (As a Division 1 Pole Vaulter, I encountered both a trauma, and continued use symptoms)

Acute phases usually last anywhere from a few weeks to even a year. Most non surgical protocol follows minimum 6 months conservative therapy, sometimes in a back brace (although it is questionable if bracing is even effective). Follow what the doctor says EXACTLY. Even if you start to feel better, chances are that you will re-aggrivate your fracture before the lesion can heal or calcify/stabilize. Don't give it a few weeks and then get back at it. Yes its tough to take so much time off, but this is your SPINE we're talking about here. The rest of your life, you will need to maintain active core strength, low body weight, and you can never smoke. Otherwise you risk some slippage and a spinal fusion down the road. Just keep up on rehab. Its sort of a blessing in disguise because you will need to keep fit forever.

So you've exhausted every possible non-surgical option. You've probably been in a lot of pain now, for a long time. Pain can wear you away. The hardest part of back injury is avoiding depression and isolation that chronic pain causes. Its really easy to let pain interfere with your life, and its really hard to have pain sitting in the back of your mind at all times. Don't fear. Surgery is NOT the end of you. most people make spirited recoveries from surgery. this isn't the 40's where spine fusion meant a year of bedrest and body casting. this is the new millenium. skilled orthopedists perform these proceedures ALL THE TIME. A good doctor may do several in a single day. they've seen a LOT. spondylolysis is SO common and spine surgeons give many many people pain free (or nearly painless) lives back. Often, with minimally invasive techniques, recovery is rapid. Its easy to get caught up reading horror stories online, especially on forums like these where people who faced complications are online posting often. theres a reason you rarely read about successful surgery online-- those patients often move on with their lives and barely remember they had surgery. they are rarely in enough long term pain to warrant posts about it online.

The trauma I sustained chipped a bit of my bone on the corner into the fracture site and so conservative therapy did not work on me. I began to explore surgery.

You have two options when it come to surgery. I'm talking spondylolysis here, NOT spondylolisthesis or any denerative disc disease. good ol' spondy. the kind where you have a painful pars defect (fracture) with nearly no slippage.

The first

Laminectomy + spinal fusion

This procedure is the classic. This is the gold standard that nearly every doctor out there uses. Its reliable, there are often few complications, and it's been performed a thousand times before. The drawback is that you reduce your range of motion significantly and it puts extra stress on the spine/ discs above and below the fusion. the recovery is significant and no cake walk, and a couple decades down the road you'll probably have other types of pain from biomechanical changes to your back. I don't want to dissuade anybody from undergoing this procedure but it's a good idea to hold off on spinal fusion surgery for as long as you can comfortably do so. On the other hand, if you have severe pain, it's time to bite the bullet and get fixed up. Surgery is often a "quality-of-life" saving event for patients. Its a last option, but an option none-the-less. Don't hold out just because it's surgery. Unfortunately, if you have degenerating discs or any -lysthesis (slip) with your spondy... this is the only procedure you can do.

The second

Pars repair surgery

If you have no disc degeneration, no slippage, chronic pars fractures, and your pain is coming from the defect itself.... then you CAN get it repaired. Some doctors will tell you this is only done in pediatrics, but adults with no slip have successful repairs done too. There are a few types, notably the buck's screw technique, which requires a really practiced hand at placing the screws properly. Only get a bucks repair from a surgeon who has a LOT of experience with it. It is technically more challenging then the other procedures even though internal fixation is very stable. another type is some form of pedicle screws and laminar hook constructs. This is a much easier procedure to have done and is technically easier for the surgeon working on you. this provides great stabilization while the repair heals and is generally the most used option for repair surgery (you may not even need a back brace when you have this one done).

The repair works by deriding the scar tissue in the defect, scoring the fracture to get blood flowing out again, packing it with bone graft, and SOMETIMES surgeons will use BMP (bone morphic protein) to stimulate bone consolidation. Techniques are different with different surgeons but when done correctly, there is often over 90% success rate with fracture healing. Once the fractures heal, the pars is restabilized, and the instrumentation remains there forever.

Pars repair surgery is RARELY the first surgery mentioned to you when you start meeting with doctors for opinions. I met with two doctors who told me pray for 6 months and if the pains persists, fusion. I even inquired once about repair to the surgeon who told me, "some people have tried to bolt a screw across the fracture, but those usually break". Finally I decided to pony up the bill for consultation with a world class spinal surgeon at a certain brand name hospital in new york city that performs "special surgeries" (I don't wanna get moderated). It was REALLY worth the trip into NYC and the 1,000 dollars I spent on it. When you think about major surgery, start saving those pennies because you want to have it done right by an expert. He told me he performs repairs all the time, he has huge success rates, and fibrous union at a minimum when bony union fails. He showed me xrays and CT scans of sample patients with my condition and explained to me the surgery and healing process. He treated me well... even offered contact info for people who underwent the procedure if I wanted to ask them questions. He said that he wouldn't even think about a spinal fusion unless conservative therapy AND direct repair both fail... which is rare. Some people even elect to have this surgery despite their pain being manageable because it can help prevent slippage and fusion down the road and save your discs. This is a safe and reliable procedure. Find a doctor that does it.

Word of wisdom... get MANY professional opinions. as many as you can afford or insurance will allow.

I'm gonna keep giving it time and therapy before I go under the knife. Maybe if I can get my core strength even better, surgery may go better. I'm going to make a decision by december so I'll post my surgery and recovery here when I go through it. It helps to see how others are dealing with it.

Back pain is SCARY. unhealed fractures are SCARY. but keep in mind that you have options. you will most likely find a way to pain relief.

I hope this helps for people going through this process. I know that I could have used a little clarity when it happened to me. Hope this is useful.

Good luck to everyone out there suffering from back pain. G-d bless and major support from me here.



  • jellyhalljjellyhall Posts: 4,344
    edited 08/23/2013 - 1:51 PM
    You have obviously learned a lot about your spondylolysis and that really helps when it comes to talking to and asking questions of the surgeons.

    I really wish you luck and hope that you will find that physical therapy will improve things for you.
    I did my upmost to avoid surgery for my grade 2 spondylolisthesis but had to give in when my life was being seriously limited and the pain just kept growing.

    My condition wasn't diagnosed until I was in my 50s which really surprised the doctors as I had carried 3 pregnancies which apparently is know to be very painful as the weight of the bump pulls the slip forward further compressing the nerves. This generally leads to a diagnosis. I just thought that pregnant women had back pain and sciatica!

    I had a lot of degeneration of my discs and bony spurs and hypertrophic facet joints. I have problems with the whole of my spine, including the thoracic level; degeneration throughout. The levels either side of my L4/5 which was treated surgically with a laminectomy and fusion (PLIF) were not good at the time of surgery. I went on to have a neck fusion of C3/4 and C4/5 and the rest of my neck is a mess.

    Who knows which came first, the spine degeneration of the spondylolisthesis? Having read your post, I do wonder if my spondylolysis had been diagnosed and treated with a Pars repair surgery years earlier, the rest of my spine might be in better shape now. I will never know!

    I would add that my fusion surgery to the lumbar spine was successful in giving me great relief of the awful bilateral sciatica and lower back pain. I wish I hadn't tried to avoid it for over 2 years and had just gone ahead with it and avoided so much pain.

    I wish you luck and hope that you will let us know how you get on. There are not many stories here about patients who have had the Pars defect repair surgery.

  • chandlerpvcchandlerpv Posts: 10
    edited 11/16/2013 - 8:24 AM
    Update to this post. I will be having the spondylolysis repair surgery next week. I will post another post detailing my pre-operative findings, what qualified me for the procedure, and what the procedure entails. For reference, I am significantly better already than I was a few months ago, but I can feel the instability and if I were to try and be active in any way, I would be back to square 1, so this is to potential keep me in the game! I also have mild radiculopathy in one leg only that only exists if I am active or after I lift anything heavy.

    After the surgery, I will try to give a small, weekly update on the progress and on the outcomes. I think this will be helpful for anyone contemplating the same procedure so they know what they can expect. I have yet to see any accounts of this procedure online... so this may be the first. Everybody is different though, so what happens to me may be significantly different then another person, so take everything with a grain of salt.

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  • chandlerpvcchandlerpv Posts: 10
    edited 12/10/2013 - 9:06 AM
    I'm back on here and thought I'd give an update from my surgery.

    I'm 2 weeks post-op now and already feeling an incredible amount better.

    Before the surgery I was having really bad sciatica in my left leg (I didn't know how bad it actually was until it was gone after surgery). The back pain was almost completely gone but would return on one side if I walked too far or if I did anything active. I made the mistake of dancing with my girlfriend one time and had some pretty bad pain after that experience. Ultimately, the pain was tolerable. The biggest detriment in my life was just the leg pain and the mental anguish of not being able to be active ever again. I conferred with my surgeon who told me that I had 1mm of slippage if he was being generous with the measurement, healthy disks with only mild bulging that comes along with age, and bilateral pars defects at L4. This signaled that the pars fractures were stress fractures from an active D1 sports career and not from degeneration of the spine at that level. He told me that If I could live with the pain it was fine, but the risk is that the extra mobility of that vertebrae wears away the disk and begins rapid degeneration. In my 30s I would likely face a spinal fusion anyways.

    I went with the surgery after nearly 11 months of pain and failed physical therapy and this is a summary of what happened.

    During the surgery, the surgeon removed a 3-4cm diameter mass of scar tissue that had built up from the constant bleeding and hypermobility of the area and my injury. This mass had grown and entrapped my nerve root causing the leg pain. Luckily my leg pain was not a mechanical pressure of the bone but a steady pressure of accrued scar tissue. They could not see this tissue on the MRI because it would only fall into the nerve space when I stood up or lay on my stomach, not when I laid on my back like during the MRI imaging. He removed the mass and freed the nerve. The rest of the procedure was standard. Two screws into the vertebrae to anchor the hooks, bone graft from the hip, shaved the bone down to get fresh bone bleeding again, dropped the screws down and clamped the lamina back on, and finally exited. I was shown x-rays of the instrumentation after surgery. the incision was about 5 inches long. It was done "minimally invasively" (whatever that means, it was still incredibly invasive)

    I woke up feeling okay because I was heavily sedated. I was urged to start walking 24 hours later with the help of a walker. I had a self-delivering morphine drip that could be administered every 10 minutes. After about 36 hours I was switched to oral main meds, I was discharged after 3 days. I got behind on the meds once when the nurse decided he'd rather keep me sleeping then wake me u and ask me to take them and, for the first time in my life, experienced a true 10 on the pain scale. So bad I couldn't breathe, I had panic attacks, and I was screaming for pain medication. It was truly terrible. I honestly couldn't believe that type of pain existed. Luckily, I was back on the horse with stronger meds and a more regular schedule after that. It was generally painful, like any major surgery, but really not that bad when the meds were working their magic.

    I was instructed on how to live life at home (with the help of loving family) and have been making leaps and bounds toward full recovery since I got home. I stopped taking the oral pain medication by day 5 because the pain was bearable and I didn't want to get addicted. I documented every pill I took for the sake of medical records and in case I needed evidence for future medical situations. I can't bend, lift, or twist in any way shape or form until my doctor approves it. I have only a soft back brace because the internal instrumentation is strong enough to avoid a hard cast. Now two weeks out I am in basically no surgical pain, my wound is almost completely healed (save a bit of scabbing on one part of it that is holding on for dear life). I stand a little better, I can feel the support of the instrumentation, and the only pain I have is the odd and ends of what I assume is healing. I get a bit of a dull throb that lasts an hour or two on occasion and then goes away without me doing anything. I am walking with strength again, I am having no trouble with daily life, I'm showering on my own and getting dressed on my own, I really am very happy with life right now because that dang leg pain is FINALLY gone. Hallelujah!

    I'm only two weeks out, and honestly.. if I didn't get any better, this is already better than before surgery. I know the surgical pain will completely heal, I hope the bone grafts take and the pars repair is successful, but bone healing takes a long time, so I won't know for another couple months. But the biggest improvement is the relief of it all. I know that resting, laying down, and inactivity aren't just crutches for pain management but instead productive time off as I slowly make a recovery. I am so happy. I can stand and cook food, I can sit down, I can walk around the house, I can use the toilet, I can put my clothes on, I can live every bit of a normal life... and NONE of it increases my pain. I just hope that I can keep getting better. I am so impressed that modern medicine can do this.

    I already know this surgery was the right decision. I would absolutely recommend it to anybody who is considering it and I'm only two weeks out. I've had knee surgery, hand surgery, my appendix out, and a hernia repaired so I have a good surgical history to compare this pain to. I can say it is a lot harder of a recovery and the surgery is far more painful, but the recovery thus far has been just as fast and just a successful (so far). I kept reading so many horror stories about back surgeries on these message boards for months on months and was so scared to have surgery and now I'm already upset that I waited so long out of fear. I could have had this repaired months ago and I would be back to running and exercising again by this time, but I waited out of that fear. Knowing what I know now about the pain, recovery, and success rates, the only thing I would have changed was doing it MUCH earlier. The spondylolysis repair surgery is, in my personal/ non-professional opinion, the best decision I have made in my life so far. If you are covered for it, REALLY consider it.

    I'm going to give another post at my 6 week follow up and let you all know where I am at that point. I'm supposed to start physical therapy then... so thats the plan now.

    My advice. Ask your surgeon about this surgery. If he/she doesn't know about it, or they haven't performed it, find a surgeon who has. At least if they tell you it's not an option, then there's a medical reason they can't do it, not just inexperience. Please please please understand this is a MUCH different surgery than a spinal fusions and really can't be put into the same category. If you have a kid, or are still young and healthy, this is the right call. I already know it was the right decision for me. Now I just have to force myself to follow the doctors orders for recovery. I'm STRICTLY adhering to protocol. I'm going to do everything in my power to make sure this works.
  • Wow, what a LONG 6 weeks it has been. Very hard recovery so far. The biggest hurdle is the mental anguish and the anxiety of guessing at the causes of all the various types of pains and the innate fear that the recovery is not going as planned. I had a lot of ups and downs, good days and bad days, days with meds and days without meds, and a heck of a lot of worst case scenario planning. Long story short, I thought everything had gone terribly wrong because I felt a lot of pain when I twisted a bit early on, turns out I'm radiographically fine.

    Got to the appointment. Looks like everything is progressing as expected. No signs of any hardware failure or breakage on the xray, no signs of movement or instability, but also no outright healing yet. takes 3-6 months for bony union to show up on an x-ray and he said that the stage I'm at now is completely normal for my type of surgery. He could still see the bone grafts in the x-ray and told me I was in the soft/hard callous phase of the process. I'm so tight in the hamstrings that I couldn't even straighten my leg at the exam. Since I haven't bent, lifted, or twisted in almost 7 weeks, I'm SO stiff. I still have a bit of hot/sharp pain in the muscles and around the incision, which should clear up with physical therapy. I'm also still tender to the touch. Sometimes I get bad pain, but not nearly as often. Most of my pain feels like really bad arthritic pain, which should fade away with time and healing.

    Nest phase is the start of physical therapy. I'm getting on a stationary bike and doing aqua-therapy, and I'm going to be getting range of motion back and core strengthening in the neutral spine position. I can bend now, but still cannot twist far, or lift heavy objects. I'm not going to get to do that until the bones have healed and grafted (just to be safe).

    At this point (at least with me) I still have a significant amount of discomfort. I'm just a tad worse off than I expected (my expectations were high though), but I'm staying positive and moving forward. I believe that I'm better off now than I was before surgery, if only because I was truly struggling before surgery. I can envision that if I keep improving from this point forward, it will all have been worth it. I'm supposed to improve steadily over the next year, so I've got to imagine that I'll end up okay. I'm not pediatric (thinning hair already... yikes!), so bouncing back after a few weeks is unlikely, but I'm also not geriatric, so my body is responding fairly well. That being said, the first 6 weeks or so are really, really rough. Don't expect to make it back to daily life so easily. It's not a spinal fusion, but it's still a big spine surgery. Lot of hardware, long recovery. Make friends with your bed and your TV. expect scary pain and anxiety. but you'll get through it all

  • I thought I'd check in and give a status update, let people looking into the procedure here know where they can expect to be at 12-13 weeks following the procedure.

    Right around 3 months, I feel like I've just begun to turn the corner. It seems like I have practically no pain, or only very very mild soreness emanating from the bones themselves.. I really got back to walking again and made myself get moving as much as I could, which was physically and mentally difficult. It still flairs up when I sit for long periods of time, which reminds me I still have a few more months before I can expect to get back to my active life. I'm significantly more mobile at 3 months than I was at 6 weeks. Only 2 weeks ago, I was thinking I would never get better, but then I woke up and started to feel okay again. I will not presume about my radiological bone-union status, because I don't have another follow up with the surgeon until 6 mo post op, but I imagine I am moving along at the typical rate of recovery.

    I do still have a significant amount of muscle pain, only on one side. I think it's because the surgeon spent 3 hours on one side cleaning up the nerves and such and only 30 min on the other, so the muscles had a lot more damage. I had a palpable bulge in the muscle which has finally disappeared and left behind immense soreness and sporadic muscle spasms. (some of those spasms will really floor you!!) There are so many odds and ends, aches and pains along the way it would be impossible to try and list them here. Still not nearly ready for anything major yet, but I'll get there eventually. I have faith. Maybe I can expect to run again in a few more months.. Here's to hoping!

    Anyways, I'm just here to clear up the information and misinformation out there about this procedure. It was absolutely the right decision for me to have this done. My surgeon said I'll start feeling better right around the time the weather turns.. I'll be sure to give an 18 week and 6 month update. Hopefully I can report to here a radiological union at my 6mo follow up!!

    Any questions, feel free to post to me! God bless, good luck, get well soon

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  • My son is three months post op today. ( L4 bilateral bucks fusion and graft ) Is still wearing his brace, we see his doctor end of March, so will find out how to go about weaning him off the brace then. He has had no pain for a month, he has walked every day about a kilometre or 2.

    i am wondering how chandlerpv is now as his surgery was about a month before my sons.

  • It is great to hear how well your son is doing now after 3 months.
    I didn't ever have a brace (or collar with my neck fusion). They don't seem to use them much here in the UK.
    I have heard that wearing one can cause the muscles to become very weak.
    I wonder if your son will have physiotherapy to strengthen his muscles again.
    The walking every day will have helped him. My physiotherapist said that walking was the absolutely best thing I could do to help my recovery.

    My surgery for L4/5 was 4 years ago tomorrow. I am so much better than before surgery. Definately a good decision to have the fusion.

    I hope your son will continue to do well and will be able to get on with enjoying his life again. :-)

  • Hi everybody,

    You can expect another post next week after my 5 1/2 month follow up apt. I will know a lot more then.. I'm steadily improving.

    If you're hanging on to see my outcome, feel free to shoot me a message. I'll happily get back to you!

  • Hi everyone,

    I had a follow up a few weeks ago (5 mo 1 wk post op), but have been busy graduating college (!!!) and traveling. Sorry to post this off the timeline I offered.

    At my 5 mo post op apt, I had plain X-rays done. The surgeon said there was excellent bone growth and, sure enough, I could see it myself on the X-ray. He showed me the progression from day one, 6 weeks, and "6 months" (yes, it was a lot earlier than 6 months, but close enough for him). It went from full gap, to blurry gap with whitish filling, and to what looks like completely solid bone with no gap visible. He said, "success!".

    I still had a pretty significant amount of pain and was worried about the inconsistency of plain radiographs to assess fracture healing. I had read that x-rays can often be misleading or wrong. While pain had been steadily improving, I was still far from feeling good (average 3/10, sometimes as high as 5/10). Per my request, and his recommendation, I asked to have a follow up CT scan done, which was performed that same day. Results were returned 4 days later via phone call. If it was healed, the pain was likely the instrumentation (I'm a slender guy) and could be removed at my discretion.

    The doc said that they did a CT scan with less than 1mm slices is each direction. An independent radiologist observed the results. The fractures had united with solid bone between 25-50%. That is, the fractures had bone bridging, mostly on the outside layers of the bone, less than half way on both sides. Obviously, I was very very concerned. The surgeon assured me that now that bone had immobilized the fracture ends, bone would continue to fill the remaining parts. "union" had occurred, but consolidation had not fully completed.

    Since the appointment (1 months time), I have continued to improve in pain. I'm now 2 on average and no significant increases of pain with walking or activity. I imagine things are still improving per usual. I ache a lot, but the incredible sharp, debilitating, pain is pretty much gone. I have no nerve pain, I can walk around like a normal person without limping or anything, I can lift modestly heavy objects (~50lbs). I got in the pool and did a bit of light treading water and breast stroke swimming and felt GREAT. Another few more months and, hopefully, I'll be out of the woods. The day I am able to run pain free, I will consider this a true success. I've been cleared for light jogging, and to let "pain be my guide" for return to activities. I've decided to not return to activity quite yet until I feel much better. I'm waiting for completely pain free life before I start getting back in shape. No rush considering how horrible this last year and a half has been. I don't want to risk anything. I've got a long life, and no reason to push it.

    One interesting thing to note. I can actually feel the stability. I don't know if this is my imagination or not, but I can feel that there is a bit of rigidity in my lower back that feels sturdy and strong. I don't think I've ever felt this sensation before. I've had these fractures for potentially years and years... so this is an eerie feeling. hopefully it's a good sign!!

    as always, questions will be answered. feel free to message me!

    Another follow up in the late summer. Hopefully with more good news

  • chanlderPV, I would like to hear more about your recovery. My daughter is 15 with bilateral pars fractures at her L4. She recently started getting leg pain. We are waiting on the results from the MRI that was done last week. She was diagnoses with the pars fractures a year ago and had pain for 7 months before the diagnosis. She too kept playing through the pain as we were told it was a hip issue, not a back issue. I am very curious to know more about your journey.

    Thank you!
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