Conservative treatment of lumbar spondylolysis in childhood and adolescence

Hysterical conversion paralysis in an adolescent boy with lumbar spondylolysis

We describe a case of recurrent hysterical paralysis triggered by low back pain because of lumbar spondylolysis. A 16-year-old male soccer player was referred to our institution with five previous episodes of acute paralysis triggered by severe low back pain. We performed direct surgical repair of the terminal-stage bilateral spondylolysis at L4 using a hook-rod system. His chronic low back pain was completely resolved, and no further episodes of hysterical paralysis have occurred after surgery. Spine surgeons should be aware of possible hysterical conversion paralysis when there is discrepancy between radiological and neurological findings.

State-of-the-art management of low back pain in athletes: Instructional lecture

In this paper, we describe "state of the art" on the diagnosis and treatment for low back pain in athletes. Lumbar motion that induces specific pain would be a clue to the exact diagnosis. In the flexion pain group, lumbar herniated nucleus pulposus is the most common disorder. Discogenic pain and type 1 Modic endplate inflammation may also cause flexion pain; however, the diagnosis is sometimes difficult. In children and adolescents, apophyseal ring fracture is prevalent. In the extension pain group, lumbar spondylolysis is very common, especially in pediatric athletes. In adults, facet pain due to overloading would be the pathology, while low back pain with trunk rotation is not common. However, throwing athletes, such as pitchers and hammer throwers, may experience this kind of pain; facet arthritis contralateral to the throwing arm would be the origin of the pain. Low back pain on lumbar lateral bending is rare, but we experienced some cases in golfers in whom type 1 Modic change at the lateral corner was the source of pain. In this article, we explained strategies for state-of-the-art diagnosis and minimally invasive treatment.

Radiographic and functional outcome of posterolateral lumbosacral fusion for low grade isthmic spondylolisthesis in children and adolescents

Aims

We reviewed 34 consecutive patients (18 female-16 male) with isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis who underwent in situ posterolateral arthodesis between the L5 transverse processes and the sacral ala with the use of iliac crest autograft. Ten patients had an associated scoliosis which required surgical correction at a later stage only in two patients with idiopathic curves unrelated to the spondylolisthesis.

Methods

No patient underwent spinal decompression or instrumentation placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative blood loss 200 ml (150 to 340). There was one wound infection treated with antibiotics but no other complication. Radiological assessment included standing posteroanterior and lateral, Ferguson and lateral flexion/extension views, as well as CT scans.

Results

A solid posterolateral fusion was confirmed in all patients at mean latest follow-up of 4.7 years (3.4 to 9.8) beyond skeletal maturity into early adult life. Fusion of the isthmic lesion was documented in nine patients bilaterally and eight patients unilaterally. The poor fusion rate across the spondylolysis has not affected the excellent functional results of the procedure, which in our series depended on achieving a stable lumbosacral junction.

Conclusion

Quality of life assessment demonstrated significant improvement in all functional scores and high patient satisfaction with 28 patients returning to previous sports activities at an elite competitive level. Take home message: Posterolateral arthrodesis in situ with autologous iliac crest bone without instrumentation has achieved a solid fusion between the L5 transverse processes and the sacral ala in patients with grade I to II isthmic lumbosacral spondylolisthesis and this has produced excellent clinical outcomes and high patient satisfaction. Cite this article: Bone Joint J 2016;98-B:88–96.

Low Back Pain in Athletes

CONTEXT

Low Back Pain (LBP) in athletes is common and has a broad spectrum of differential diagnoses that must be taken in to account when a clinician approaches the patient with LBP. The physicians should take into account spinal and extra spinal causes of low back pain in athletes.

EVIDENCE ACQUISTION

A literature review was performed for the years 1951 through 2013. Keywords used were Low Back Pain and Athletes. We searched MEDLINE, EMBASE, OVID, PUBMED, the Cochrane Library, ELSEVIER, and the references of reviewed articles, for English-language of Low Back Pain in Athletes.

RESULTS

The two most common causes of LBP arising from spine in athletes are degenerative disc disease and spondylolysis with or without listhesis. Although most athletes, respond well to conservative treatment, surgical treatment is indicated when conservative treatment failes.

CONCLUSIONS

The major concern in athletes with LBP is return to play and previous level of their activity after treatment. There is insufficient evidence regarding this issue in literature to define the optimal time of return to play following treatment.

Characteristics of lumbar spondylolysis in elementary school age children

PURPOSE

Lumbar spondylolysis, a stress fracture of the pars interarticularis in the lumbar spine, is often precipitated by trauma, but there may be a congenital predisposition to this condition. There have been few studies on spondylolysis in young children, despite their suitability for studies on congenital defects. The aim of this study was to identify the clinical features of lumbar spondylolysis in elementary school age children in order to elucidate its pathogenesis.

METHODS

Thirty lumbar spondylolysis patients (23 boys, 7 girls, including a pair of twins; mean age 9.5 years, age range 5-12 years) were studied. Patient data on history of athletic activity, symptoms at first consultation, and radiological findings such as spinal level, stage of the stress fracture, and skeletal age were collected.

RESULTS

Among the 30 patients, 27 (21 boys, 6 girls) had L5 spondylolysis (90.0 %). Only 2 patients had no history of athletic activity at the first consultation. All patients, except for 2 whose diagnosis was incidental, complained of low back pain. In the 27 patients with L5 spondylolysis, 17 (63.0 %) had terminal-stage fracture and 25 (92.6 %) had spina bifida occulta (SBO) involving the S1 lamina. Sixteen of the 27 (59.3 %) had SBO involving the affected lamina (L5) and S1 lamina. In contrast, the 3 patients with L3 or L4 spondylolysis had no evidence of SBO. With respect to skeletal age, 23 of the 27 L5 spondylolysis patients (85.2 %) were in the cartilaginous stage while the remaining 4 patients were in the apophyseal stage.

CONCLUSION

Lumbar spondylolysis in elementary school age children was commonly a terminal-stage bone defect at L5, which was not necessarily related to history of athletic activity and was sometimes asymptomatic. It was often associated with SBO, indicating a possible congenital predisposition. These findings may provide further insight into the pathogenesis of lumbar spondylolysis.

Current Evidence Regarding the Etiology, Prevalence, Natural History, and Prognosis of Pediatric Lumbar Spondylolysis: A Report from the Scoliosis Research Society Evidence-Based Medicine Committee

STUDY DESIGN

Structured literature review.

OBJECTIVES

To assess the current state of evidence as a first step in the development of practice guidelines for pediatric spondylolysis.

SUMMARY OF BACKGROUND DATA

Progress in published medical knowledge, changes in societal expectations, and developments in health care economics have led medical organizations to develop evidence-based documents and products.

METHODS

A comprehensive literature search for pediatric spondylolysis was performed with the assistance of a medical librarian. The authors reviewed citations and abstracts. Abstracts were reviewed for exclusions and data from included studies were analyzed by committee. A total of 44 articles provided the best available evidence for the questions of etiology, prevalence, natural history, and prognosis: 9 were graded as level I evidence, 23 were level II, 3 were level III, and 9 were level IV. No level V studies were included in the final list.

RESULTS

There is good evidence that pediatric lumbar spondylolysis is an acquired fracture of the pars interarticularis that can occur unilaterally or bilaterally. Evidence shows that when chronic, bilateral pars defects develop, 43% to 74% of patients will progress to grade 1 or 2 spondylolisthesis. In addition, unilateral, incomplete, and early lesions can obtain bony union. With or without bony union or spondylolisthesis, short-term symptom resolution is the norm. Long-term prognosis is less clear, but there is fair evidence that most patients will have lumbar symptoms compared with the general population. There is also fair evidence that some patients will develop significant symptoms as adults and will undergo surgical treatment. There is insufficient knowledge to predict which patients will continue to do well in the long term with conservative or no treatment and which patients will develop symptoms significant enough to warrant early intervention.

CONCLUSIONS

The current medical literature provides fair to good evidence for clinically relevant questions regarding the etiology, prevalence, natural history, and prognosis of pediatric spondylolysis.

Current Evidence Regarding the Surgical and Nonsurgical Treatment of Pediatric Lumbar Spondylolysis: A Report from the Scoliosis Research Society Evidence-Based Medicine Committee

STUDY DESIGN

Structured literature review.

OBJECTIVES

The Scoliosis Research Society requested an assessment of the current state of peer-reviewed evidence regarding pediatric spondylolysis with the goal of identifying both what is really known and what research remains essential to further understanding.

SUMMARY OF BACKGROUND DATA

Spondylolysis is common among children and adolescents and no formal synthesis of the published literature regarding treatment has been previously performed.

METHODS

A comprehensive literature search was performed. The researchers reviewed abstracts and analyzed by committee data from included studies. From 947 initial citations with abstract, 383 articles underwent full text review. The best available evidence for clinical questions regarding surgical and nonsurgical treatment was provided by 58 included studies. None of the studies were graded as level I or level II evidence. Two of the studies were graded as level III evidence. Fifty-six of the studies were graded as level IV evidence. No level V (expert opinion) studies were included in the final list.

RESULTS

Although natural history studies suggest a benign, relatively asymptomatic course for spondylolysis in most patients, both nonsurgical and surgical treatment series suggest that a substantial number of patients present with pain and activity limitations attributed to spondylolysis. Pain resolution and return to activity are common with both nonsurgical and surgical treatment (80% to 85%, respectively). Although it is implied that most surgically treated patients have failed nonsurgical treatment, the specific treatment modalities and duration required before failure is declared are not well defined. There is insufficient evidence to know which patients will benefit from specific treatment modalities (both nonsurgical and surgical).

CONCLUSIONS

Because of the preponderance of uncontrolled case series and the lack of comparative studies, only low-quality evidence is available to guide the treatment of pediatric spondylolysis.

Lumbar spondylolysis and spondylolytic spondylolisthesis: who should be have surgery? An algorithmic approach

Lumbar spondylolysis and spondylolisthesis are common spinal disorders that most of the times are incidental findings or respond favorably to conservative treatment. In a small percentage of the patients, surgical intervention becomes necessary. Because too much attention has been paid to novel surgical techniques and new modern spinal implants, some of fundamental concepts have been forgotten. Identifying that small but important number of patients with lumbar spondylolysis or spondylolisthesis who would really benefit from lumbar surgery is one of those forgotten concepts. In this paper, we have developed an algorithmic approach to determine who is a good candidate for surgery due to lumbar spondylolysis or spondylolisthesis.

Lumbar spondylolysis in juveniles from the same family: a report of three cases and a review of the literature

Spondylolysis is reported as a stress fracture of the pars interarticularis with a strong hereditary basis. Three cases of lumbar spondylolysis in juveniles from the same family are reported, and the genetics of the condition are reviewed. The first boy, a 13-year-old soccer player, was diagnosed with terminal stage L5 bilateral spondylolysis with grade 1 slippage. The second boy, a 10-year-old baseball player, had terminal stage right side unilateral spondylolysis. The third boy, also a 10-year-old baseball player, was diagnosed with early stage bilateral L5 spondylolysis. The second and third boys are identical twins, and all three cases exhibited concomitant spina bifida occulta. Lumbar spondylolysis has a strong hereditary basis and is reported to be an autosomal dominant condition.

V-rod technique for direct repair surgery of pediatric lumbar spondylolysis combined with posterior apophyseal ring fracture

We report a pediatric baseball player having both a fracture of the posterior ring apophysis and spondylolysis. He was presented to a primary care physician complaining of back pain and leg pain. Despite conservative treatment for 3 months, the pain did not subside. He was referred to our clinic, and surgical intervention was carried out. First, a bony fragment of the caudal L5 apophyseal ring was removed following fenestration at the L5-S interlaminal space, bilaterally: and decompression of the bilateral S1 nerve roots was confirmed. Next, pseudoarthrosis of the L5 pars was refreshed and pedicle screws were inserted bilaterally. A v-shaped rod was inserted beneath the L5 spinous process, which stabilized the pars defects. After the surgery, back pain and leg pain completely disappeared. In conclusion, the v-rod technique is appropriate for the spondylolysis direct repair surgery, especially, in case the loose lamina would have a partial laminotomy.

Comparison of a fluoroscopic 3-dimensional imaging system and conventional CT in detection of pars fractures in the cadaveric lumbar spine

STUDY DESIGN

Cadaveric Study.

OBJECTIVE

To compare a fluoroscopic imaging system with computed tomography (CT) and radiographs in detection of spondylolysis and radiation exposure in a cadaver model.

SUMMARY OF BACKGROUND DATA

Lumbar spondylolysis is defined as a defect or fracture of the pars interarticularis and occurs with or without anterior spondylolisthesis. CT scan is the gold standard imaging study for spondylolysis but is limited by the supine position, which may cause reduction of anterolisthesis and by ionizing radiation, which limits the frequency of follow-up scans.

METHODS

Thirteen intact cadaveric lumbar spine segments with 26 pars were randomized to be left intact or to undergo simulated fracture using a 1.3 mm oscillating microsurgical saw. Fifteen pars underwent simulated fracture and 11 pars were left intact. Lumbar spine segments were imaged using plain radiographs, multiplanar fluoroscopic imaging, and conventional CT scan. The images were interpreted by 3 observers blinded to the number and location of defects. Radiation exposure and doses were recorded from all imaging units.

RESULTS

Average radiation doses were 0.0025 mSv for each radiograph, 0.23 mSv (low dose) and 0.47 mSv (high dose) for fluoroscopic imaging, and 1.5 mSv for conventional CT imaging (pediatric dose setting). Evaluation of radiographs for spondylolysis had sensitivity of 98% and specificity of 97%. Evaluation using low-dose fluoroscopic images, high-dose fluoroscopic images, and CT scan images correctly identified the status of all pars based on multiplanar images; sensitivity and specificity were 100%. Kappa analysis demonstrated a value of 0.89 for radiographic interpretation indicating excellent agreement. Kappa values describing agreement for image interpretation for fluoroscopic imaging and CT scan were equal to 1.0, representing perfect agreement.

CONCLUSIONS

Three-dimensional fluoroscopic imaging provides comparable diagnostic imaging with CT scan in an experimental cadaveric model of spondylolysis using up to 85% less radiation than conventional CT scan.

Multilevel direct repair surgery for three-level lumbar spondylolysis

A 45-year-old man presented to our clinic requesting evaluation for surgical treatment of chronic low back pain of more than 20 years duration. He was diagnosed with 3-level lumbar spondylolysis at L3-5. Direct repair using the pedicle screw and hook-rod system was conducted for all three levels. After the surgery, his low back pain completely disappeared. Six months later, he felt discomfort and heard a metallic sound as he twisted his trunk. Computed tomography and radiography indicated that the hook head for L3 and the screw head for L4 were interfering with each other, causing the sound. We confirmed bony union at L3 and removed the L3 system. Surgeons should be aware of such complications if direct repair using a pedicle screw and hook-rod system is conducted for multilevel spondylolysis.

Diagnosis of radiographically occult lumbar spondylolysis in young athletes by magnetic resonance imaging

BACKGROUND

The early stages of spondylolysis are extremely difficult to diagnose on plain radiography. Although several studies have examined changes in active spondylolysis on magnetic resonance imaging (MRI), no studies to date have determined the onset frequency of active spondylolysis detectable on MRI but occult on plain radiography. Moreover, the clinical features of active spondylolysis described in the literature do not facilitate the differentiation of this condition from other causes of low back pain.

PURPOSE

This study aimed to evaluate the usefulness of MRI in diagnosing active spondylolysis early and in determining the prevalence of active spondylolysis in cases where findings were not detected on plain radiography. In addition, specific clinical features to aid in the early detection of active spondylolysis were evaluated.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were 200 consecutive young athletes (144 boys and 56 girls; mean age, 14.1 ± 1.5 y) with low back pain. All patients were examined by plain radiography (188 with negative findings and 12 with unclear findings of spondylolysis) and MRI. Computed tomography (CT) was performed only for patients with high intensity changes of the pedicle observed on MRI. The presence or absence of low back pain was examined during lumbar spine extension and flexion. The Kemp test on the right and left sides and percussion of the vertebral spinous process were also performed.

RESULTS

Ninety-seven (48.5%) patients showed evidence of active spondylolysis on MRI, findings that had been missed by plain radiography. These pars defects were organized into the following categories based on CT findings: nonlysis stage, 52; very early stage, 37; late early stage, 22; progressive stage, 10; and terminal stage, 0. No significant physical examination factors were identified that could assist in the early detection of active spondylolysis.

CONCLUSION

The MRI results suggest a high rate of active spondylolysis in young athletes with low back pain who test negative for spondylolysis on plain radiography. Magnetic resonance imaging appears to be useful in the early diagnosis of active spondylolysis, especially as we found no significant physical examination factors that could assist in early detection.

Preoperative templating before spinal fusion using a fluoroscopic multiplanar imaging system is as accurate as CT scan and uses substantially less radiation

BACKGROUND

Many surgeons utilize preoperative multiplanar imaging for surgical planning before fusion surgery using pedicle screw instrumentation. Computed tomographic (CT) scan is often used but limited by non-weight-bearing images and high-ionizing radiation. The purpose of this study was to compare pedicle length and width measurements using a multiplanar fluoroscopic imaging system and CT with gross measurements to validate the accuracy of multiplanar fluoroscopic imaging and compare relative radiation exposure between techniques.

METHODS

Thirteen intact cadaveric lumbar spine segments were imaged using multiplanar fluoroscopic imaging and conventional CT scan using a low-dose pediatric protocol. At each level and each imaging modality, the 26 pedicles were measured digitally for width and pedicle screw length in accordance with typical presurgical planning procedures. All images were independently measured by 3 observers. After measurement, the specimens were sectioned using a microsurgical saw to facilitate anatomic measurements using calipers. Measurements of the multiplanar fluoroscopic imaging and CT were compared with direct anatomic measurements to quantitate and compare measurement accuracy of CT and fluoroscopic imaging. At the time of image acquisition, radiation exposure from each modality was quantified to allow for comparison of radiation exposures.

RESULTS

CT and multiplanar fluoroscopy had similar agreement with gross measurements with respect to pedicle width and length, with κ values for comparison of CT and fluoroscopy with gross measurements falling between 0.61 and 0.73. Both modalities underestimated pedicle width (by 1.9 mm for both modalities) and length (5.5 mm for CT, 6.6 mm for fluoroscopy). Interobserver reliability was higher for fluoroscopy versus CT. High-dose fluoroscopic imaging used 31% of the radiation exposure for CT.

CONCLUSIONS

Multiplanar fluoroscopic imaging provides comparable diagnostic preoperative planning to CT scan in an experimental cadaveric model. The use of multiplanar fluoroscopic imaging resulted in between 69% and 85% less radiation exposure than conventional CT scan using pediatric settings.

CLINICAL EVIDENCE

This study demonstrates similar results from simulated preoperative templating using fluoroscopic imaging compared with CT scan but with less radiation exposure.

A remarkable case of hypertrophic pseudoarthrosis of the pars interarticularis in a young American football professional player

Lumbar spondylolysis is a defect of the pars interarticularis regarded as a stress fracture. The bone stump around the pars defect usually appears atrophic and is fibrously united or filled with fibro cartilaginous mass, similar to long bone pseudoarthrosis. Lumbar spondylolysis sometimes causes bone growth resembling that of an osteophyte in osteoarthritis, and in elderly patients, the ragged edges result in radiculopathy around the defect. However, lumbar spondylolysis is rarely reported to cause hypertrophic changes resulting in spinal canal stenosis in young patients. In this report, we present an unprecedented radiological finding of distinctive hypertrophic change around the pars defect, which occurred in a young professional football player.

Spondylolysis is frequently missed by MRI in adolescents with back pain

PURPOSE

Magnetic resonance imaging (MRI) is often used in the evaluation of lower back pain in adolescents. The purpose of our study is to report on the frequency of MRI missing spondylolysis in adolescents with back pain in a pediatric orthopaedic practice.

METHODS

A retrospective review of all patients with a diagnosis of spondylolysis who presented from January 2000 to March 2010 was performed. All patients were evaluated at a single institution by the senior author. Inclusion criteria were patients with spondylolysis confirmed on computed tomography (CT) or plain film that also received an MRI.

RESULTS

Eleven patients with spondylolysis had an MRI performed. The mean age of the study patients was 14.2 years (range 10-17). The diagnosis of spondylolysis was missed in the MRI radiology reading in 7 out of 11 (64 %) studies.

CONCLUSIONS

MRI missed a spondylolysis in over half of the adolescents in this consecutive series. In patients with a history or physical findings suggestive of spondylolysis, such as localized pain of the lumbar spine with back extension, further radiographic evaluation should be considered, even if an MRI is negative.

LEVEL OF EVIDENCE

III, retrospective review.

Repair of pars defects by segmental transverse wiring for athletes with symptomatic spondylolysis: relationship between bony union and postoperative symptoms

STUDY DESIGN

Retrospective study of surgery for spondylolysis patients.

OBJECTIVE

To assess clinical outcome of bony union using multislice computed tomography after segmental wiring fixation.

SUMMARY OF BACKGROUND DATA

How bony union affects surgical outcome of spondylolysis repair is unclear.

METHODS

Forty-four athletes with symptomatic spondylolysis (33 men and 11 women; mean age, 24.2 ± 5.4 years) who underwent segmental wiring fixation were evaluated retrospectively at a mean follow-up of 85 ± 17 months. The level of spondylolysis was L5 in 42 cases, and both L4 and L5 in 2 cases, giving a total of 46 operative levels of vertebrae. Bony union using axial and sagittal reconstruction images of computed tomography, the Japanese Orthopaedic Association (JOA) score for back pain, and complications were reviewed. State of bony union was classified as bilateral union, unilateral union, or nonunion. The total score and the improvement ratio of the JOA score were compared among the 3 groups.

RESULTS

Bilateral bony union was obtained in 29 cases (31 of 46 vertebrae, 67.4%). Six cases (13%) showed unilateral union, and 9 cases (19.6%) showed nonunion. JOA score increased significantly after surgery in all groups, average improvement rate was 78.9% in the bilateral group, 63.6% in the unilateral group, and 29.8% in the nonunion group; differences among the 3 groups were significant (P < 0.05). JOA score was significantly higher in the bilateral group than in the other 2 groups.

CONCLUSION

Although symptoms were significantly ameliorated in all groups, the bilateral group showed the greatest improvement ratio in JOA score showing bony union to be an important factor in clinical outcome. However, there were a few exceptional cases with contradictory clinical and radiological outcomes. Thus, further studies are required to gain a better understanding of the other multiple factors affecting clinical outcome after spondylolysis repair.

Conservative treatment for pediatric lumbar spondylolysis to achieve bone healing using a hard brace: what type and how long?: Clinical article

OBJECT

Various kinds of trunk braces have been used to achieve bone healing in cases of pediatric lumbar spondylolysis. However, the optimal brace for achieving bone healing is unclear. The purpose of the present study was to determine in what types of spondylolysis bone healing can be achieved and how long it takes.

METHODS

In this prospective study, 63 pars interarticularis defects (spondylolysis) among 37 patients who were younger than 18 years (mean 13.5 ± 2.7 years) were treated using a hard brace. The youngest patient was 8 years old. Based on the results of CT scanning, the lyses were classified into 3 categories: early, progressive, and terminal defects. Progressive defects were further divided into 2 types according to STIR MRI findings: those with high signal intensity at the adjacent pedicle and those with low signal intensity (that is, a normal appearance). A hard brace, such as a molded plastic thoracolumbosacral orthosis, was used to immobilize the trunk. Approximately every 3 months, CT scanning was performed to evaluate bone healing until approximately 6 months.

RESULTS

The union rates were 94%, 64%, 27%, and 0% for the early, progressive with high signal intensity, progressive with low signal intensity, and terminal defects, respectively. It was noted that no terminal defect was healed using conservative treatment. The mean time to healing among the defects that showed bone healing was 3.2, 5.4, and 5.7 months for the early, progressive with high signal intensity, and progressive with low signal intensity groups, respectively.

CONCLUSIONS

Patients with early-stage defects are the best candidates for conservative treatment with a hard brace because more than 90% of such cases can be healed in 3 months.

Treatment options for low back pain in athletes

CONTEXT

Low back pain is one of the most common medical presentations in the general population. It is a common source of pain in athletes, leading to significant time missed and disability. The general categories of treatment for low back pain are medications and therapies.

EVIDENCE ACQUISITION

Relevant studies were identified through a literature search of MEDLINE and the Cochrane Database from 1990 to 2010. A manual review of reference lists of identified sources was also performed.

RESULTS

It is not clear whether athletes experience low back pain more often than the general public. Because of a aucity of trials with athlete-specific populations, recommendations on treatments must be made from reviews of treatments for the general population. Several large systemic reviews and Cochrane reviews have compiled evidence on different modalities for low back pain. Superficial heat, spinal manipulation, nonsteroidal anti-inflammatory medications, and skeletal muscle relaxants have the strongest evidence of benefit.

CONCLUSIONS

Despite the high prevalence of low back pain and the significant burden to the athletes, there are few clearly superior treatment modalities. Superficial heat and spinal manipulation therapy are the most strongly supported evidence-based therapies. Nonsteroidal anti-inflammatory medications and skeletal muscle relaxants have benefit in the initial management of low back pain; however, both have considerable side effects that must be considered. Athletes can return to play once they have recovered full range of motion and have the strength to prevent further injury.

Painful lumbar spondylolysis among pediatric sports players: a pilot MRI study

INTRODUCTION

For children and adolescents who are very active athletes, fresh lumbar spondylolysis is the main pathologic cause of lower back pain (LBP). However, regarding the terminal-stage spondylolysis (pars defect), there have been few studies to clarify the pathomechanism of LBP. The purpose of this study is to clarify the cause of LBP associated with pars defects in athletes. This is the first report showing a possible pathomechanism of LBP in active athletes with painful pars defect.

METHOD

Six pediatric athletes (5 boys and 1 girl) below 18 years old with painful bilateral lumbar spondylolysis were evaluated. In all cases, spondylolysis was identified as terminal stage (pseudoarthrosis) on CT scan. To evaluate the inflammation around the pars defects, short time inversion recovery (STIR) MRI was performed along with the sagittal section. Fluid collection, which is an indicator of inflammatory events, was evaluated in 12 pars defects as well as in 12 cranial and caudal adjoining facet joints.

RESULTS

Inflammation (i.e., fluid collection) was observed in all 12 pars defects in six subjects at the pseudoarthrotic pars defects. In terms of facet joints, 7 of 12 (58%) pars defects showed fluid collection at the cranial and/or caudal adjoining joints on STIR MRI.

CONCLUSION

The present study showed that inflammation was always present at the pars defects and in some cases at the adjoining facet joints. Thus, it is not difficult to understand how, during sports activity, inflammation may first occur at the pseudoarthrotic site and then spread to the adjoining facet joints. This mechanism could cause LBP associated with terminal-stage (pseudoarthrotics) spondylolysis in athletes.

Spondylolysis in the adolescent athlete

PURPOSE OF REVIEW

Spondylolysis is a common cause for back pain in the adolescent athlete. Increased awareness of the presentation of this subset of patients can aid in optimal outcomes. This paper aims to review the typical presentation of spondylolysis in the adolescent with specific focus on the adolescent athlete. We review current controversies in diagnosis and management and aim to provide a thorough review to aid the pediatrician in making clinical decisions for this subset of patients.

RECENT FINDINGS

The optimal algorithm for diagnostic imaging is controversial. Single positron emission computerized tomography can provide good sensitivity but poor specificity for spondylolysis. Computerized tomography can be useful as a follow-up exam to visualize the bony anatomy and osseous healing but has the concern of high radiation exposure. MRI may be a useful tool for diagnosis and follow-up examination, which may have significant advantages over traditional imaging techniques. Brace use is controversial and most likely functions as an adjunct for limiting motion to promote activity restrictions.

SUMMARY

Spondylolysis in the adolescent athlete is a common problem. MRI is a good study for diagnosis, although further studies need to be done in order to show its advantages over traditional diagnostic methods. Brace wear is encouraged as a method for promoting activity modification, although its efficacy in promoting healing and success in treating spondylolysis is controversial.

Spondylolysis originates in the ventral aspect of the pars interarticularis: a clinical and biomechanical study

Lumbar spondylolysis is a stress fracture of the pars interarticularis. We have evaluated the site of origin of the fracture clinically and biomechanically. Ten adolescents with incomplete stress fractures of the pars (four bilateral) were included in our study. There were seven boys and three girls aged between 11 and 17 years. The site of the fracture was confirmed by axial and sagittal reconstructed CT. The maximum principal tensile stresses and their locations in the L5 pars during lumbar movement were calculated using a three-dimensional finite-element model of the L3-S1 segment. In all ten patients the fracture line was seen only at the caudal-ventral aspect of the pars and did not spread completely to the craniodorsal aspect. According to the finite-element analysis, the higher stresses were found at the caudal-ventral aspect in all loading modes. In extension, the stress was twofold higher in the ventral than in the dorsal aspect. Our radiological and biomechanical results were in agreement with our clinical observations.

Causes of radiculopathy in young athletes with spondylolysis

BACKGROUND

The main clinical symptom of lumbar spondylolysis is lower back pain. Radiculopathy rarely occurs without vertebral slippage. Hypothesis Spondylolysis in young athletes can cause lumbar radiculopathy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Ten patients (7 males and 3 females) were included in this study. The age of the patients ranged from 12 to 27 years. We employed plain radiography, computed tomography, magnetic resonance imaging, and selective radiculography if needed.

RESULTS

The pathomechanism was classified into nonspondylolytic radiculopathy (3 cases) and spondylolytic radiculopathy (7 cases). In the nonspondylolytic group, 1 patient had a juxta-facet cyst at L4-5 and 2 patients had a herniated nucleus pulposus. In the other group, spondylolytic-related factors caused radiculopathy, and spondylolysis was in the early or progressive stage in all 7 patients. Radiologic findings indicated that radiculopathy was caused by extraosseous hematoma or edema in the vicinity of the fracture site. The radiculopathy disappeared within a month of nonoperative management, and radiologic abnormalities disappeared 3 to 6 months later.

CONCLUSION

Radiculopathy can occur together with lumbar spondylolysis without slippage in young athletes. We propose extra-osseous hematoma or edema at the site of spondylolysis as the unique pathomechanism causing radiculopathy in young athletes. Radiculopathy is rare in athletes with spondylolysis. Magnetic resonance imaging is a useful tool to clarify the pathologic changes that induce the radiculopathy for both spondylolytic and nonspondylolytic factors.