The radiological investigation of lumbar spondylolysis

L5 spondylolysis: Anatomical study comparing healed and unhealed lesions

The anatomy and pathogenesis of spondylolysis has been widely studied; however, the microanatomy of spondylolysis of the lumbar vertebra has not been well described. Therefore, we aim to better elucidate this anatomy. Twenty dry bone specimens of healed and unhealed spondylolysis of the L5 vertebra were collected from human skeletal remains. Twelve L5 vertebrae were examples of unhealed spondylolysis and eight specimens exhibited a healed (i.e., bony fusion of the lesion) spondylolysis lesion. The specimens underwent macro and microanatomical analysis followed by CT and microCT imaging. Finally, selected healed and unhealed lesions were submitted for histological analysis using Mason Trichrome staining. The pars interarticularis of two L5 vertebrae without signs of healed/unhealed spondylolysis were evaluated histologically as controls. Of the 12 unhealed L5 pars defects, three were unilateral on left side. Of the eight healed pars defects, all were unilateral and seven of these were on left sides. One unilateral pars defect also had spina bifida occulta. Both on imaging and histological analysis, healed pars defects were only so superficially and not at deeper levels. Histologically, unhealed edges were made up of dense cortical bone while healed edges were made up primarily of trabecular bone. Based on our anatomical findings, the so-called healed spondylolysis lesions, although externally fused, are not thoroughly fused internally. Moreover, the anterior and posterior edges of the unhealed spondylosysis lesions are irregular and show signs of long-term disarticulation. Taken together, these data suggest that such 'healed' lesions might not be as stable as the normal L5 pars interarticularis.

Diagnostic performance of SPECT in lumbar spondylolysis: a systematic review and meta-analysis

AIM

To evaluate the diagnostic value and clinical applicability of single-photon-emission computed tomography (SPECT) for lumbar spondylolysis using meta-analysis.

MATERIALS AND METHODS

Stata 12.0, was used to test the heterogeneity, and the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and other effect sizes were collected to generate the summary receiver operating characteristic (SROC) curve for comprehensive evaluation. Meta-regression analysis was used to explore the source of heterogeneity, and subgroup analysis was performed. Funnel plots, Fagan's line diagrams, and likelihood ratio dot plots were drawn to evaluate publication bias and clinical applicability.

RESULTS

Eight studies involving 785 patients were included. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, odds ratio, and area under the SROC curve of SPECT for the diagnosis of lumbar spondylolysis were 0.85 (95% confidence interval [CI]: 0.70 0.93), 0.92 (95% CI: 0.60 0.99), 11.01 (95% CI: 1.61 75.18), 0.17 (95% CI: 0.08 0.35), 0.92 (95% CI: 0.90 0.94). Meta-regression analysis showed that the sources of heterogeneity were region and age. Subgroup analysis showed that the specificity of the child and adolescent subgroup was significantly higher than that of the middle-aged and elderly subgroups. Deek's funnel plots showed no significant publication bias. The pooled effect of the likelihood ratio dot plot for diagnosis is in the upper-right quadrant.

CONCLUSION

As a diagnostic tool for spondylolysis, SPECT has a high degree of specificity, moderate sensitivity, and relatively high diagnostic effectiveness. It can be used as an auxiliary sign in the diagnosis and treatment of lumbar spondylolysis.

New technique and case report: Robot-assisted intralaminar screw fixation of spondylolysis in an adolescent

Introduction

Management of spondylolysis in adolescents is generally successful with conservative management. Uncommonly, surgical fixation is necessary for refractory cases. Direct repair with intralaminar screws is one commonly utilized technique. Recently, less invasive spinal procedures are becoming viable with the enabling of technologies, including robotics.

Case description

A 14-year-old baseball player and surfer presented with low back pain, diagnosed by MRI as bony edema and stress fractures of the posterior spinal elements. After 18 months, the pain was unresponsive to rest, physical therapy, and bracing. There was no radicular pain or neurologic symptoms. Computed tomography (CT) revealed bilateral, chronic nonhealing pars defects at L5. He underwent outpatient, robot-assisted percutaneous intralaminar fixation with hydroxyapatite-coated screws through a 2 cm skin incision.

Outcome

On postoperative day 1, the patient reported relief of his preoperative pain and he was ambulating without difficulty. At 2 weeks follow-up, the patient was completely pain free and surfing. At 2 months follow-up, low-dose CT demonstrated partial incorporation of the hydroxyapatite-coated screws, and the patient returned to sports. At 6 months follow-up, the patient had no pain and was swinging his baseball bat with full force. Low-dose CT revealed complete healing of the defects with full incorporation of the hydroxyapatite-coated screws.

Conclusions

A novel minimally invasive robotic percutaneous approach for direct spondylolysis repair using hydroxyapatite-coated screws is a potential surgical treatment option for non-healing pars defects in adolescent patients.

Clinical Practice Patterns of Isthmic Spondylolysis in Young Athletes: A Survey of Pediatric Research in Sports Medicine Members

ABSTRACT

Isthmic spondylolysis is a common cause of back pain in young athletes. The condition presents to numerous medical providers who employ a variety of different practices in diagnosis and management. The purpose of this study was twofold: to review the literature of diagnosis and management of the young athlete with isthmic spondylolysis and to survey Pediatric Research in Sports Medicine (PRiSM) members during the 2021 PRiSM Annual Meeting on practice patterns of diagnosis and management of the young athlete with isthmic spondylolysis. The response rate was 27%. Per respondents: 24% obtain oblique radiographs; 90% use magnetic resonance imaging as the advanced imaging modality; 60% treat with bracing; 57% recommend rest prior to physical therapy (PT); 53% prescribe return to sport activity restrictions. Although there are similarities in the diagnosis of isthmic spondylolysis in young athletes, this survey confirmed variability in management, especially bracing, timing of PT and return to sport activity restrictions.

Spondylolisthesis

Spondylolisthesis refers to the anterior, lateral, or posterior slippage of a superior vertebral disc over the adjacent inferior disc, and is often separated into categories based on the causative etiology. Spondylolisthesis is often asymptomatic but may present with low back pain and neurogenic claudication which is worsened with spinal extension and activity. A detailed history and physical exam, along with appropriate imaging tests are useful in making the diagnosis. Conservative therapy is first-line and includes pain management with physical therapy. Patients who fail conservative therapy may consider surgical decompression, stabilization, and fusion. This review aims to discuss the epidemiology, pathophysiology, presentation, and treatment options of spondylolisthesis.

Diagnosis and Management of Spondylolysis and Spondylolisthesis in Children

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Spondylolysis is defined as a defect of the pars interarticularis, and spondylolisthesis is defined as a slippage of a vertebra relative to the immediately caudal vertebra.

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Most cases of spondylolysis and low-grade spondylolisthesis can be treated nonoperatively. Depending on a patient's age, nonoperative treatment may include a thoracolumbosacral orthosis (TLSO), physical therapy, and activity modification. Bracing and physical therapy have been found to be more effective than activity modification alone.

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Patients with dysplastic spondylolisthesis are at higher risk for progression and should be monitored with serial radiographs every 6 to 9 months.

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Operative management is recommended for symptomatic patients with failure of at least 6 months of nonoperative management or patients with high-grade spondylolisthesis.

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Surgical techniques include pars defect repair, reduction, and fusion, which may include posterior-only, anterior-only, or circumferential fusion.

Utility of Physical Examination Findings for Predicting Low-Back Pain in Adolescent Patients with Early-Stage Spondylolysis: A Retrospective Comparative Cohort Study

Introduction

This study aimed to elucidate low-back pain (LBP) characteristics, i.e., its qualities, extent, and location, in patients with early-stage spondylolysis (ESS).

Methods

We recruited patients (≤18 years old) who presented with acute LBP lasting up to 1 month. Patients were divided into ESS and nonspecific LBP (NS-LBP) groups based on their magnetic resonance imaging findings; patients showing no pathological findings that might explain the cause of LBP were classified as NS-LBP. All patients were evaluated using the following tests: hyperextension and hyperflexion (pain provocation tests in a standing position), pain quality (sharp/dull), pain extent (fingertip-sized area/palm-sized area), and pain location (left and/or right pain in side [side]/central pain [center]). We have also compared outcomes between the ESS and NS-LBP groups in terms of gender and physical symptoms.

Results

Of 101 patients, 53 were determined to have ESS (ESS group: mean age: 14.3 years old; 43 males/10 females), whereas 48 had no pathological findings explaining the LBP origin [NS-LBP group (mean age, 14.4 years old; 31 males/17 females)]. Chi-squared test has identified gender (male), a negative result on hyperflexion test, pain extent (fingertip-sized area), and pain location (side) to be significantly associated with ESS. Among these, regression analysis revealed that male gender and LBP located on the side were significantly associated with ESS (p<0.05).

Conclusions

Although the hyperextension test is generally considered useful for ESS, we demonstrated that its association is not deemed significant. Our results indicate that male gender, a negative result of the hyperflexion test, fingertip-sized pain area, and LBP on the side may be specific characteristics of ESS. Of these physical signs, male gender and LBP located on the side are characteristic factors suggesting ESS presence.

The Management of Acute Lumbar Stress Reactions of the Pedicle and Pars in Professional Athletes Playing Collision Sports

Acute stress reactions in the lumbar spine most commonly occur in athletes at the pars interarticularis followed by the pedicle. These reactions occur as a result of repetitive microtrauma from supraphysiological loads applied to the lumbar spine. Characteristic motions such as trunk extension and twisting are also thought to play a role and may be sport-specific. Other risk factors include increased lumbar lordosis, hamstring and thoracolumbar fascia tightness, and abdominal weakness. On physical examination, pain is typically reproduced with lumbar hyperextension. Currently, magnetic resonance imaging or nuclear imaging remain the most sensitive imaging modalities for identifying acute lesions. In the elite athlete, management of these conditions can be challenging, particularly in those playing collision sports such as American football, hockey, or rugby. Nonoperative treatment is the treatment of choice with rehabilitation programs focused on pain-free positioning and progressive strengthening. Operative treatment is rare, but may be warranted for patients symptomatic for >12 months. Specialized diagnosis protocols as well as treatment and return to play guidelines from 4 physicians treating elite athletes playing collision sports are presented and reviewed.

CONSIDERATION OF SPORT DEMANDS FOR AN 18-YEAR-OLD LACROSSE PLAYER WITH RECALCITRANT SYMPTOMATIC SPONDYLOLYSIS: A CASE REPORT

Background and Purpose

Spondylolysis is an anatomical defect or fracture of the pars interarticularis and encompasses almost half of all cases of low back pain in adolescent athletes. Most athletes return to sport with conservative treatment, but it is possible that consideration of sport demands may further improve rate of successful return. When surgery is performed, complication rate is high, so all conservative measures should be explored before considering surgical intervention. The purpose of this case report is to present a program where demands of sport were considered and allowed successful return to sport for a subject with recalcitrant symptomatic spondylolysis that had failed to respond to prior treatment.

Case Description

An 18-year-old lacrosse player with a history of recalcitrant symptomatic spondylolysis that failed three courses of conservative treatment and had been unsuccessful in returning to sport. A multi-phase program with a focus on multi-planar and full kinetic chain activities that addressed the nature of the sport demands is described, along with improvements in pain level, strength, range of motion, and subjective outcome scores.

Outcomes

The subject was able to successfully return to sport after 10 weeks of physical therapy and complete the remaining few months of his lacrosse season without reinjury. Range of motion and strength testing was markedly improved upon discharge. The subject's Modified Oswestry Disability Index improved from 16% to 0% and his pain level did not rise above 2/10 with any sport activity upon return.

Discussion/Conclusions

Although return to sport rates following spondylolysis in young athletes is high, this case report demonstrates that a consideration of sport demands may increase return to sport rates in athletes that do not respond to standard care and prevent surgical intervention.

Level of Evidence

Level 4, single case report.

Diagnostic Accuracy of Magnetic Resonance Imaging and Computed Tomography Scan in Young Athletes With Spondylolysis

The objective of this study was to determine diagnostic accuracy of magnetic resonance imaging (MRI) and computed tomography (CT) scans in young athletes diagnosed with spondylolysis. A cross-sectional study was used. Twenty-two young athletes (14.7 ± 1.5 years) were diagnosed as spondylolysis based on a single-photon emission CT. Following the diagnosis, participants underwent MRI and CT scan imaging tests on the same day. The sensitivity and false-negative rate of the MRI and CT scans were analyzed. MRI test confirmed 13 (+) and 9 (-) results while CT test showed 17 (+) and 5 (-) results. The sensitivity and false-negative rate of MRI were, respectively, 59.1% (95% confidence interval [CI] = 36.7% to 78.5%) and 40.9% (95% CI = 21.5% to 63.3%). Furthermore, the sensitivity and false-negative rate of CT scan were 77.3% (95% CI = 54.2% to 91.3%) and 22.7% (95% CI = 0.09% to 45.8%). Our results indicated that CT scan is a more accurate imaging modality to diagnose spondylolysis compared with MRI in young athletes.

Lumbar Hyperextension in Baseball Pitching: A Potential Cause of Spondylolysis

Symptomatic spondylolysis/spondylolisthesis is thought to be caused by repetitive lumbar extension. About 8.9% of baseball pitchers that experience back pain will be diagnosed with spondylolysis. Therefore, this study aims to identify and quantify lumbar extension experienced during baseball pitching. It was hypothesized that young pitchers would exhibit less lumbar extension than older pitchers. A total of 187 healthy pitchers were divided into 3 age groups: youth, adolescent, and college. Kinematic data were collected at 250 Hz using a 3-D motion capture system. Lumbar motion was calculated as the difference between upper thoracic motion and pelvic motion over the pitching cycle. Lumbar "hyperextension" was defined as ≥20° past neutral. College pitchers had significantly greater lumbar extension compared with youth and adolescent pitchers at the point of maximum external rotation of the glenohumeral joint during the pitch cycle (-25° [13°], P = .04). For all age groups, lumbar hyperextension was present during the first 66% of the pitch cycle. Most pitchers spent 45% of pitch cycle in ≥30° of lumbar extension. Understanding that lumbar extension and hyperextension are components of the complex, multiplanar motions of the spine associated with baseball pitching can potentially help in both the prevention and management of symptomatic spondylolysis/spondylolisthesis.

Contralateral Spondylolysis and Fracture of the Lumbar Pedicle in a Young Athlete

STUDY DESIGN

Clinical case report of unilateral pedicular stress fracture with a contralateral spondylolysis in a male high-school athlete presenting with low back pain.

OBJECTIVE

To report this uncommon cause of low back pain in an adolescent athlete, and review the relevant literature.

SUMMARY OF BACKGROUND DATA

The incidence of spondylolysis in the Caucasian population was found to be about 3% to 6%. This number is probably higher in the athletic adolescent age group, with reports ranging from 8% to 15%. Spondylolysis may be associated with pedicle fracture, usually on the contralateral side. This is an uncommon phenomenon that is not well described in the adolescent age group.

METHODS

A 16-year-old male athlete presents with low back pain and limitation in sports as well as in daily activities. Clinical evaluation was suspicious for, and radiographic evaluation revealed left-sided L5 spondylolysis as well as contralateral L5 pedicle fracture. Conservative management included Boston Overlapping brace, external electrical stimulation, modification of activities, and a comprehensive physical therapy program.

RESULTS

Radiological evaluation revealed persistent left L5 pars defect and advanced healing of the contralateral pedicle fracture. The patient achieved complete pain relief and returned to varsity level sporting activity.

CONCLUSION

Complete radiographic and clinical healing of the pedicle defect was observed, with return competitive varsity-level football without symptoms.

LEVEL OF EVIDENCE

5.

Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence

The epidemiology of lumbar degenerative spondylolisthesis (DS) remains controversial. We performed a systematic review with the aim of gaining a better understanding of the prevalence of DS in the general population. The results showed that the prevalence of DS is very gender- and age-specific. Few women and men develop DS before they are 50 years old. After 50 years of age, both women and men begin to develop DS, with women having a faster rate of development than men. For elderly Chinese (≥ 65 years, mean age: 72.5 years), large population-based studies MsOS (Hong Kong, females: n = 2000) and MrOS (Hong Kong, males: n = 2000) showed DS prevalence was 25.0% in women and 19.1% in men. The female:male (F:M) prevalence ratio was 1.3:1. The published data for MsOS (USA) and MrOS (USA) studies seem to show that elderly Caucasian Americans have a higher DS prevalence, being approximately 60-70% higher than elderly Chinese; however, the F:M prevalence ratio was similar to the elderly Chinese population. Patient data showed that female patients more often received surgical treatment than male and preliminary data showed the ratio of female to male patients receiving surgical treatment did not differ between Northeast Asians (Chinese, Japanese, and Korean), Europeans, and American Caucasians, being around 2:1 in the elderly population. The existing data also suggest that menopause may be a contributing factor for the accelerated development of DS in postmenopausal women. The translational potential of this article: A better understanding of epidemiology of lumbar degenerative spondylolisthesis can support patient consultation and treatment planning.

Replacement of Vertebral Lamina (Laminoplasty) in Surgery for Lumbar Isthmic Spondylolisthesis: 5-Year Follow-Up Results

Study Design

A review of clinical and radiological outcomes of lumbar laminoplasty (LL) for the treatment of isthmic spondylolisthesis (ISL).

Purpose

The single session performance of posterior lumbar interbody fusion with allograft in the anterior column and providing the realignment of the vertebrae was presented as a preliminary report earlier.

Overview of Literature

Long-term surgical outcome of cervical laminoplasty in patients has been reported. But, outcome of LL in patients is unclear.

Methods

The long-term (5 years) year follow-up results of the LL technique are reported in this retrospective study. All patients underwent preoperative and postoperative direct X-ray, computed tomography, and magnetic resonance imaging. The patients that did not respond to conservative treatment were operated. Twenty-one (52.5%) female and 19 (47.5%) male patients were included.

Results

Mean age was 43,5 years (ranges, 22–57 years). The most common symptoms were low back pain (89%), pelvic and leg pain (69%) and reduction in walking distance (65%). A total of 180 pedicle screws were inserted in 40 patients; posterior lumbar interbody fusion and laminoplasty with reduction was performed in 20 patients for L4–L5, 12 patients for L5–S1, 4 patients for L3–L4–L5 and 4 patients for L4–L5-S1. Ten (25%) patients with ILL had accompanying spinal stenosis. The difference between preoperative and postoperative sagittal plane rotation and dislocation degrees and disc space heights were statistically significant in all patients (p<0.05). Solid grade 4 fusion was observed in 38 patients; in only 2 patients grade 2 pseudoarthrosis developed (5%), but these patients were asymptomatic. Visual analog scale, Prolo economical and functional scale was examined with an average follow-up 5.5 years.

Conclusions

LL technique has the advantages of shorter duration of operation, lack of graft donor site complications, protection of posterior column osseoligamentous structures and achievement of high fusion rates in one session.

Confidence in Assessment of Lumbar Spondylolysis Using Three-Dimensional Volumetric T2-Weighted MRI Compared With Limited Field of View, Decreased-Dose CT

Background:

Limited z-axis–coverage computed tomography (CT) to evaluate for pediatric lumbar spondylolysis, altering the technique such that the dose to the patient is comparable or lower than radiographs, is currently used at our institution. The objective of the study was to determine whether volumetric 3-dimensional fast spin echo magnetic resonance imaging (3D MRI) can provide equal or greater diagnostic accuracy compared with limited CT in the diagnosis of pediatric lumbar spondylolysis without ionizing radiation.

Hypothesis:

Volumetric 3D MRI can provide equal or greater diagnostic accuracy compared with low-dose CT for pediatric lumbar spondylolysis without ionizing radiation.

Study Design:

Clinical review.

Level of Evidence:

Level 2.

Methods:

Three pediatric neuroradiologists evaluated 2-dimensional (2D) MRI, 2D + 3D MRI, and limited CT examinations in 42 pediatric patients who obtained imaging for low back pain and suspected spondylolysis. As there is no gold standard for the diagnosis of spondylolysis besides surgery, interobserver agreement and degree of confidence were compared to determine which modality is preferable.

Results:

Decreased-dose CT provided a greater level of agreement than 2D MRI and 2D + 3D MRI. The kappa for rater agreement with 2D MRI, 2D + 3D MRI, and CT was 0.19, 0.32, and 1.0, respectively. All raters agreed in 31%, 40%, and 100% of cases with 2D MRI, 2D + 3D MRI, and CT. Lack of confidence was significantly lower with CT (0%) than with 2D MRI (30%) and 2D + 3D MRI (25%).

Conclusion:

For diagnosing spondylolysis, radiologist agreement and confidence trended toward improvement with the addition of a volumetric 3D MRI sequence to standard 2D MRI sequences compared with 2D MRI alone; however, agreement and confidence remain significantly greater using decreased-dose CT when compared with either MRI acquisition.

Clinical Relevance:

Decreased-dose CT of the lumbar spine remains the optimal examination to confirm a high suspicion of spondylolysis, with dose essentially equivalent to radiographs. If clinical symptoms are not classic for spondylolysis, 2D MRI is still very good at detecting spondylolysis while remaining sensitive for detection of alternative diagnoses such as disc abnormalities and pars stress reaction. The data suggest that standard 2D MRI sequences should not be entirely replaced by a volumetric T2-weighted 3D sequence (despite promising features of rapid acquisition time, increased spatial resolution, and reconstruction capability).

Posterior Dynamic Stabilization With Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel Surgery

STUDY DESIGN

A retrospective study to evaluate the clinical outcomes of a novel surgical method for treating patients with lumbar spondylolysis.

OBJECTIVE

The aim of this study was to investigate the effectiveness of posterior ISOBAR TTL stabilization of the lumbar spine with direct pars repair using Wiltse approach for the treatment of lumbar spondylolysis with or without slight spondylolisthesis and discuss the indications of this surgery.

SUMMARY OF BACKGROUND DATA

Surgical treatment of lumbar spondylolysis has yielded relatively good results. However, there are still many limitations of the current surgical methods, including, adjacent level degeneration, restricted indications, and soft tissue damage.

METHODS

Between August 2010 and January 2013, 13 (9 males and 4 females; mean age: 28.2 yrs), patients with lumbar spondylolysis with or without slight spondylolisthesis underwent posterior ISOBAR TTL stabilization of the lumbar spine, with direct pars repair via Wiltse approach. All patients were followed up for at least 24 months at outpatient visits or telephonically. Pre-operative and postoperative radiological assessments included anteroposterior, lateral and flexion extension radiographs, 3-dimensional reconstruction computed tomography (CT), and magnetic resonance imaging (MRI). Data pertaining to intraoperative blood loss, duration of operation, visual analog score (VAS), Oswestry disability index (ODI) scores, and other assessments were collected.

RESULTS

The median follow-up duration was 36 months (range, 24-53 months). Surgery was successful in all patients with no complications; bony fusion of pars was confirmed on CT scan at postoperative 2 years. Significant pain relief was achieved in all patients including those with discogenic pain, those >30 years of age, and those with severe disc degeneration (P < 0.01).

CONCLUSION

We evaluated a new surgical technique for the treatment of patients with spondylolysis with or without slight spondylolisthesis. Besides the good clinical results, the indications for this new surgery are much wider and can potentially overcome the limitations of earlier techniques.

LEVEL OF EVIDENCE

4.

CT outperforms radiographs at a comparable radiation dose in the assessment for spondylolysis

BACKGROUND

Lumbar spondylolysis, a unilateral or bilateral fracture at pars interarticularis, is a common cause of low back pain in children. The initial imaging study in the diagnosis of lumbar spondylolysis has historically been lumbar spine radiographs; however, radiographs can be equivocal or false-negative. Definitive diagnosis can be achieved with computed tomography (CT), but its use has been limited due to the dose of ionizing radiation to the patient.

OBJECTIVE

By limiting the z-axis coverage to the relevant anatomy and optimizing the CT protocol, we are able to provide a definitive diagnosis of fractures of the pars interarticularis at comparable or lower radiation dose than commonly performed lumbar spine radiographs. As there is no gold standard for the diagnosis of spondylolysis besides surgery, we compared interobserver agreement and degree of confidence to determine which modality is preferable.

MATERIALS AND METHODS

Sixty-two patients with low back pain ages 5-18 years were assessed for the presence of spondylolyis. Forty-seven patients were evaluated by radiography and 15 patients were evaluated by limited field-of-view CT. Both radiographic and CT examinations were assessed anonymously in random order for the presence or absence of spondylolyisis by six raters. Agreement was assessed among raters using a Fleiss Kappa statistic for multiple raters.

RESULTS

CT provided a significantly higher level of agreement among raters than radiographs (P < 0.001). The overall Kappa for rater agreement with radiographs was 0.24, 0.34 and 0.40 for 2, 3 or 4 views, respectively, and 0.88 with CT.

CONCLUSION

Interobserver agreement is significantly greater using limited z-axis coverage CT when compared with radiographs. Radiologist confidence improved significantly with CT compared to radiographs regardless of the number of views.

Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review

The aim of this paper was to systematically review the diagnostic ability of clinical tests to detect lumbar spondylolysis and spondylolisthesis. A systematic literature search of six databases, with no language restrictions, from 1950 to 2014 was concluded on February 1, 2014. Clinical tests were required to be compared against imaging reference standards and report, or allow computation, of common diagnostic values. The systematic search yielded a total of 5164 articles with 57 retained for full-text examination, from which 4 met the full inclusion criteria for the review. Study heterogeneity precluded a meta-analysis of included studies. Fifteen different clinical tests were evaluated for their ability to diagnose lumbar spondylolisthesis and one test for its ability to diagnose lumbar spondylolysis. The one-legged hyperextension test demonstrated low to moderate sensitivity (50%-73%) and low specificity (17%-32%) to diagnose lumbar spondylolysis, while the lumbar spinous process palpation test was the optimal diagnostic test for lumbar spondylolisthesis; returning high specificity (87%-100%) and moderate to high sensitivity (60-88) values. Lumbar spondylolysis and spondylolisthesis are identifiable causes of LBP in athletes. There appears to be utility to lumbar spinous process palpation for the diagnosis of lumbar spondylolisthesis, however the one-legged hyperextension test has virtually no value in diagnosing patients with spondylolysis.

Low back pain in the adolescent athlete

Clinicians must have knowledge of the growth and development of the adolescent spine and the subsequent injury patterns and other spinal conditions common in the adolescent athlete. The management and treatment of spinal injuries in adolescent athletes require a coordinated effort between the clinician, patients, parents/guardians, coaches, therapists, and athletic trainers. Treatment should not only help alleviate the current symptoms but also address flexibility and muscle imbalances to prevent future injuries by recognizing and addressing risk factors. Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength.

Back pain in children and adolescents

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

Frequency of spondylolysis and chronic low back pain in young soccer players

Objective: To demonstrate the safety of soccer for adolescents in terms of chronic lesions of the lumbar spine, particularly spondylolysis. Methods: 54 young players underwent a pre-season assessment. The athletes were submitted to radiography of the lumbosacral spine. Players complaining of chronic low back pain were later submitted to more specific tests. Results: only 1 athlete (1.85 % of our sample) had complaints of chronic low back pain. In this case, the radiograph showed olisthesis grade I spondylolysis at the L5 level. Conclusion: Soccer proved to be a very safe sport in terms of the risk of developing chronic lesions of the lumbosacral spine. However, the actual incidence of spondylolysis in these athletes was not determined because only plain radiographs were used in this study.

Lumbar injuries of the pediatric population

Primary musculoskeletal etiologies, such as stress fractures, strains, facet arthropathy, and sacroiliac joint dysfunction, are more common causes of pediatric pain than systemic diseases, both in the office setting and the emergency room. Systemic features, young age, and atypical pain should clue physicians to causes other than a primary musculoskeletal cause and prompt an intensive search for other conditions.

Do oblique views add value in the diagnosis of spondylolysis in adolescents?

BACKGROUND

Anteroposterior, lateral, and right and left oblique lumbar spine radiographs are often a standard part of the evaluation of children who are clinically suspected of having spondylolysis. Recent concerns regarding radiation exposure and costs have brought the value of oblique radiographs into question. The purpose of the present study was to determine the diagnostic value of oblique views in the diagnosis of spondylolysis.

METHODS

Radiographs of fifty adolescents with L5 spondylolysis without spondylolisthesis and fifty controls were retrospectively reviewed. All controls were confirmed not to have spondylolysis on the basis of computed tomographic scanning, magnetic resonance imaging, or bone scanning. Anteroposterior, lateral, and right and left oblique radiographs of the lumbar spine were arranged into two sets of slides: one showing four views (anteroposterior, lateral, right oblique, and left oblique) and one showing two views (anteroposterior and lateral only). The slides were randomly presented to four pediatric spine surgeons for diagnosis, with four-view slides being presented first, followed by two-view slides. The slides for twenty random patients were later reanalyzed in order to calculate of intra-rater agreement. A power analysis demonstrated that this study was adequately powered. Inter-rater and intra-rater agreement were assessed on the basis of the percentage of overall agreement and intraclass correlation coefficients (ICCs). PCXMC software was used to generate effective radiation doses. Study charges were determined from radiology billing data.

RESULTS

There was no significant difference in sensitivity and specificity between four-view and two-view radiographs in the diagnosis of spondylolysis. The sensitivity was 0.59 for two-view studies and 0.53 for four-view studies (p = 0.33). The specificity was 0.96 for two-view studies and 0.94 for four-view studies (p = 0.60). Inter-rater agreement, intra-rater agreement, and agreement with gold-standard ICC values were in the moderate range and also demonstrated no significant differences. Percent overall agreement was 78% for four-view studies and 82% for two-view studies. The radiation effective dose was 1.26 mSv for four-view studies and 0.72 mSv for two-view studies (difference, 0.54 mSv). The charge for four-view studies was $145 more than that for two-view studies.

CONCLUSIONS

There is no difference in sensitivity and specificity between four-view and two-view studies. Although oblique views have long been considered standard practice by some, our data could not identify a diagnostic benefit that might outweigh the additional cost and radiation exposure.

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.

L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus

INTRODUCTION

Spondylolysis is most commonly observed in the lumbar spine, particularly L5, and is associated with spondylolisthesis, or anterior "slippage" of a vertebra in relation to an adjacent vertebra. Isthmic spondylolisthesis is the result of a pars interarticularis defect and will be the only type of spondylolisthesis addressed in this review.

CONCLUSIONS

Spondylolysis and spondylolisthesis represent a relatively common cause of low back pain, especially in young athletes, and a less common cause of neurologic compromise. When discovered in a symptomatic patient with corroborating imaging findings, early intervention provides an excellent prognosis. Herein, we review the anatomy and pathology of spondylosis and spondylolisthesis of the L5 vertebra.

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.

Ossicles of lumbar articular facets: normal variant or spondylolytic variant?

PURPOSE

The objective of this study was to establish the prevalence and significance of ossicles of lumbar articular facets (OLAF) in young athletes with backache diagnosed by multi-detector computed tomography (MDCT).

MATERIALS AND METHODS

The MDCT examinations of the lumbar spine carried out for suspected spondylolysis on 46 consecutive symptomatic young athletes presenting to a sports injury clinic over a 1-year period were retrospectively reviewed. OLAF study included detailed correlation with the structural and morphological stress features of the posterior neural arches. This was then compared with a control group composed of 39 patients.

RESULTS

Twenty-three OLAF were identified in 15 patients. Eleven of the 15 patients with ossicles had posterior element stress changes (PEST)/pars defects. In the control group, two OLAF were identified in two patients, one demonstrating PEST changes.

CONCLUSION

The high prevalence of OLAF in young symptomatic athletes compared with the asymptomatic control group is indicative of stress fractures. The non-united articular process fractures should be regarded as part of the spectrum of stress-induced changes in the posterior neural arch in the same way as spondylolysis. MDCT with volumetric acquisition and multi-planar reformation is the most reliable investigation in the diagnosis of OLAF.

KEY POINTS

1) This CT study supports a traumatic aetiology for lumbar articular facets ossicles. 2) OLAF represent part of a spectrum of stress-induced changes in the posterior neural arch. 3) OLAF are associated with typical spondylolysis. 4) OLAF can be overlooked on reverse gantry angle computed tomography (RG-CT). 5) OLAF may account for some of the discrepancy between radionuclide and RG-CT studies.

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.

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.

The imaging and management of nonconsecutive pars interarticularis defects: a case report and review of literature

BACKGROUND CONTEXT

Lumbar spondylolysis is a well-recognized condition occurring in adolescents because of repetitive overuse in sports. Multiple-level spondylolysis involving consecutive lower lumbar segments are rare. Several authors have reported failure of conservative treatment in the management of multiple-level pars fractures.

STUDY DESIGN

A case report and review of previous literature is presented.

OBJECTIVE

The objectives of this case report were to present a rare case of pars fracture involving nonconsecutive segments and discuss image findings and treatment.

METHODS

The patent's history, clinical examination, computed tomography (CT), magnetic resonance imaging (MRI) findings, and treatment are reported. We also discuss the pathogenesis, various treatment options, and review the literature.

RESULTS

We present the fourth case of bilateral pars fractures involving nonconsecutive lower lumbar spine segments of L3 and L5, in a 16-year-old young adolescent footballer who presented with 4-month history of constant low back pain. After 1 year of conservative management, the more acute fractures at L3 showed complete bony union, symptomatic pain relief, and return to full sporting activity.

CONCLUSION

We report a rare case of bilateral pars fractures involving nonconsecutive segments. Multiplane reconstruction of CT images and MRI are very useful in planning treatment and follow-up. Conservative management may be used to treat multilevel nonconsecutive pars fractures.

Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report

OBJECTIVE

This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic.

CLINICAL FEATURES

The 43-year-old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis.

INTERVENTION AND OUTCOME

A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire.

CONCLUSIONS

Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

Lumbar spine spondylolysis in the adult population: using computed tomography to evaluate the possibility of adult onset lumbar spondylosis as a cause of back pain

OBJECTIVE

To determine if new onset of low back pain in adults could be secondary to lumbar spondylolysis by establishing the age-related prevalence in the general population by examining patients undergoing computed tomography (CT) for reasons unrelated to back pain.

MATERIALS AND METHODS

The records of 2,555 patients who had undergone abdominal and pelvic CT in 2008 were reviewed electronically. In order to determine a true representation of the general population, we reviewed all indications for CT, excluding patients with a primary complaint of low back pain as the primary indication for imaging. Equal numbers of patients were separated into age groups by decade to ensure an even distribution of ages for statistical analysis. Patients older than 70 years were grouped together to provide case numbers comparable to those of the other decades. Logistic regression analysis was performed to evaluate the significance of the results. Three board-certified radiologists, including two musculoskeletal fellows and a radiology resident, retrospectively evaluated CT scans for lumbar spondylolysis, including unilateral and bilateral defects.

RESULTS

Of the 2,555 cases evaluated, there were 203 positive cases of defects of the lumbar pars interarticularis. This corresponded to an overall prevalence of 8.0%. Prevalence per decade was fairly evenly distributed and ranged from 7.0%( ages 30-39 years) to 9.2% (ages 70 years and above). Prevalence of ages 20-49 years was 7.9%, and that of ages 50 years and older was 8.0%. Male to female ratio was 1.5:1. Logistic regression showed no significant increase in spondylolysis based on age.

CONCLUSION

No significant increase in the prevalence of lumbar spondylolysis was demonstrated in patients older than 20 years. This suggests that the development of symptomatic lumbar pars defects do not occur in this population and should not be considered as a rare but potentially treatable cause of new onset low back pain in adults. This study demonstrated an overall prevalence of pars defects of 8.0% in our population. As demonstrated in previous studies, the male to female ratio of 1.5:1 was a statistically significant difference.

The value of SPECT in the detection of stress injury to the pars interarticularis in patients with low back pain

The medical cost associated with back pain in the United States is considerable and growing. Although the differential diagnosis of back pain is broad, epidemiological studies suggest a correlation between adult and adolescent complaints. Injury of the pars interarticularis is one of the most common identifiable causes of ongoing low back pain in adolescent athletes. It constitutes a spectrum of disease ranging from bone stress to spondylolysis and spondylolisthesis. Bone stress may be the earliest sign of disease. Repetitive bone stress causes bone remodeling and may result in spondylolysis, a non-displaced fracture of the pars interarticularis. A fracture of the pars interarticularis may ultimately become unstable leading to spondylolisthesis. Results in the literature support the use of bone scintigraphy to diagnose bone stress in patients with suspected spondylolysis. Single photon emission computed tomography (SPECT) provides more contrast than planar bone scintigraphy, increases the sensitivity and improves anatomic localization of skeletal lesions without exposing the patient to additional radiation. It also provides an opportunity for better correlation with other imaging modalities, when necessary. As such, the addition of SPECT to standard planar bone scintigraphy can result in a more accurate diagnosis and a better chance for efficient patient care. It is our expectation that by improving our ability to correctly diagnose bone stress in patients with suspected injury of the posterior elements, the long-term cost of managing this condition will be lowered.

Prevalence of vertebral pars defects (spondylolysis) in a population with osteogenesis imperfecta

STUDY DESIGN

We performed a retrospective study of spinal roentgenograms of a large cohort of patients suffering from osteogenesis imperfecta.

OBJECTIVE

To determine the prevalence of vertebral pars defects (spondylolysis) in patients with osteogenesis imperfecta.

SUMMARY OF BACKGROUND DATA

Patients suffering from osteogenesis imperfecta are known to be prone to pathologic fractures. Pathologic fractures due to microtraumas, repetitive activities, and posture acting together on a congenitally weakened pars interarticularis may lead to vertebral pars defects. The prevalence of vertebral pars defects in patients with osteogenesis imperfecta has never been studied before to our knowledge.

METHODS

We performed a retrospective study of posterior-anterior and lateral, standing, roentgenograms of the spine of patients with osteogenesis imperfecta for the occurrence of vertebral pars interarticularis defects.

RESULTS

The patients (5.3%) in our series showed vertebral pars defects, this is not significantly different from the prevalence of vertebral pars defects in the general population.

CONCLUSION

5.3% of the patients with osteogenesis imperfecta showed vertebral pars defects, this does not differ significantly from the occurrence in the general population.

Streamlining the evaluation of low back pain in children

The workup of low back pain in children often results in overimaging so as not to miss organic back pain. The primary goal of this study was to identify which combination of imaging modalities provides the most sensitive and specific screening protocol for children with low back pain. Medical records from 100 consecutive patients between 2 and 18 years of age presenting with low back pain, without night pain or constitutional symptoms, were evaluated. A hyperextension test combined with a radiograph showed a negative predictive value of 0.81 and sensitivity of 0.90. The addition of a bone scan was highly effective in achieving good negative predictive value and sensitivity. Bone scans had perfect negative predictive value and sensitivity when symptom duration was less than 6 weeks. We identified a set of factors that is highly predictive for distinguishing organic back pain from mechanical back pain. Painless hyperextension combined with negative anteroposterior, lateral, and oblique lumbar radiographs and magnetic resonance images predicts mechanical back pain. For patients with nonneurologic back pain of less than 6 weeks duration, bone scan is the most useful screening test because it is accurate, accessible, inexpensive, and unlikely to require sedation.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Low back pain in the adolescent athlete

Low back pain is a common problem among young athletes. These individuals are at risk for significant structural injuries or nonmechanical problems that can be associated with their symptoms. Any athlete who has severe, persisting, or activity-limiting symptoms must be evaluated thoroughly. Clinicians must have a working knowledge of the developmental issues, injury patterns, and particular conditions that may affect a given athlete and be able to work with patients in addition to families, coaches, trainers, and others involved in the care and training of the injured athlete.

[Osteoid osteoma of the inferior articular process of L5 associated with a bilateral spondylosis: a case report]

We report the case of an 8-year-old boy who presented an osteoid osteoma of L5 associated with bilateral spondylolysis involving the same vertebra. Diagnostic bone scintigraphy is highly contributive in children presenting back pain. For us, it is the first intention exploration in patients with isthmic lysis seen on the plain x-ray. Symptomatic spondylolysis is the most frequent cause of back pain in children and is much more frequent than vertebral osteoid osteoma. The presence of isthmic lysis associated with focal uptake on the bone scintigraphy is highly suggestive of symptomatic spondylolysis. In this context, magnetic resonance imaging should be performed for both diagnostic purposes and prognostic assessment. The degree of bone and soft tissue edema in the present case was unusual for symptomatic spondylolysis. Complementary computed tomography finally established the diagnosis of osteoid osteoma of the posterior vertebral arch. To our knowledge, the association of osteoid osteoma with bilateral spondylolysis on the same vertebra has not been described elsewhere. In children, the diagnosis of symptomatic spondylolysis can only be established after ruling out other causes of back pain. The diagnosis of osteoid osteoma must be kept in mind.

Disc space-targeted angled axial MR images of the lumbar spine: a potential source of diagnostic error

OBJECTIVE

To compare the sensitivities of contiguous axial (CA) images and disc space-targeted angled axial (DSTAA) images of the lumbar spine for: (1) the detection of spondylolysis defects, and (2) the identification of disc material which has migrated away from the parent disc.

MATERIALS AND METHODS

Prospective imaging of the lumbar spine was performed over a 22-month period in 103 patients. Imaging protocols included spin-echo T1- and fast spin-echo (FSE) T2-weighted images in the sagittal and axial planes. For each patient, axial images were obtained both contiguously throughout the lumbar spine and as angled images, targeted at the region of the disc space only. Two separate data sets were compiled: one that included contiguous axial images (CA data set) and another that included targeted angled images through the disc spaces only (DSTAA data set). Identical sagittal images were included with both sets. A single radiologist independently interpreted the two data sets for a given patient following an intervening time lapse. The radiologist was blinded to the initial interpretation. Results from the two independent interpretations were then compared.

RESULTS

Spondylolysis defects were identified at 15 different levels in 14 patients (14%) using the contiguous axial imaging protocol compared with 8 (7%) identified using the disc space targeted angled axial imaging protocol (P = 0.12). Migrated disc material was identified in 12 patients (12%) using the CA protocol compared with 3 patients (3%) identified with the DSTAA protocol (P = 0.016).

CONCLUSIONS

MR imaging of the lumbar spine using contiguous axial data obtained through both the level of the disc and vertebral body demonstrates migrated disc material and spondylolysis defects better than did disc space-targeted angled data.

Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes

Although spondylolysis is relatively common in adolescent athletes, there are substantial disagreements in the literature concerning the best methods for diagnosing and treating the condition. Controversy particularly arises regarding the optimal use of available imaging modalities in the diagnosis of athletes with suspected pars defects and the extent of activity restriction or brace use required for appropriate treatment. Because there have been no controlled trials on the treatment of spondylolysis and only a very limited number of studies addressing potential imaging strategies, it is difficult to develop true evidence-based guidelines for this condition. Given the current state of the literature, it is our impression that nuclear imaging with single photon emission computed tomography followed by computed tomography, with a limited role for plain radiography, remains the standard for appropriately diagnosing a symptomatic pars lesion. Treatment hinges on activity restriction for an amount of time adequate to allow for symptom resolution and, when possible, potential bony healing followed by a progressive sport-specific rehabilitation program. The biomechanic effects of brace use in this population are not well understood, but there may be some detrimental effects to the use of a brace and there currently is no evidence that the routine use of a rigid brace results in any significant improvement in radiographic or functional outcome.

Current concepts in the diagnosis and treatment of spondylolysis in young athletes

Spondylolysis is common among young athletes and should be suspected in any young athlete presenting with low back pain that persists for more than a few weeks. Diagnostic evaluation typically includes plain radiographs followed by more sensitive modalities, including single-photon emission CT, CT, or MRI. There is no consensus on the most appropriate protocol for diagnostic evaluation. Treatment usually consists of rest and/or bracing to allow healing to occur, followed by rehabilitation that includes core strengthening. More large-scale controlled studies need to be done in order to clarify the most effective diagnostic and therapeutic protocols.

Spinal injury in sport

Spinal injuries are very common among professional or amateur athletes. Spinal sport lesions can be classified in overuse and acute injuries. Overuse injuries can be found after years of repetitive spinal load during sport activity; however specific overuse injuries can also be found in adolescents. Acute traumas are common in contact sports. Most of the acute injuries are minor and self-healing, but severe and catastrophic events are possible. The aim of this article is to review the wide spectrum of spinal injuries related to sport activity, with special regard to imaging finding.

Degenerative Disease of the Spine

Degenerative disease of the spine is a definition that includes a wide spectrum of degenerative abnormalities. Degeneration involves bony structures and the intervertebral disk, although many aspects of spine degeneration are strictly linked because the main common pathogenic factor is identified in chronic overload. During life the spine undergoes continuous changes as a response to physiologic axial load. These age-related changes are similar to pathologic degenerative changes and are a common asymptomatic finding in adults and elderly persons. A mild degree of degenerative changes is paraphysiologic and should be considered pathologic only if abnormalities determine symptoms. Imaging allows complete evaluation of static and dynamic factors related to degenerative disease of the spine and is useful in diagnosing the different aspects of spine degeneration.

Computed tomography evaluation of spondylolysis and spondylolisthesis in asymptomatic patients

STUDY DESIGN

A retrospective radiographic study involving analysis of abdominal and pelvic computed tomography (CT) scans obtained on patients presenting with clinical conditions other than back pain.

OBJECTIVE

To determine the incidence of spondylolysis and spondylolisthesis in patients requiring inpatient or emergency department CT evaluation for unrelated abdominal and pelvic conditions.

SUMMARY OF BACKGROUND DATA

Spondylolysis and spondylolisthesis are part of a disease process that is thought to be resultant from biomechanical stresses related to bipedal locomotion. The incidence is estimated to be 3% to 10% in the general population. Many of these cases occur without associated symptoms. To our knowledge, there is a relative paucity of data on the use of CT to evaluate the prevalence of these 2 entities in patients seeking medical attention for unrelated conditions.

METHODS

Five hundred ten consecutive abdominal and pelvic multi-detector CT scans obtained on a single scanner (Philips MX8000; Eindhoven, The Netherlands) were reviewed. These patients presented with such complaints as abdominal pain and fever, or were imaged as part of their inpatient evaluation for conditions unrelated to lumbar spine pathology. A board certified radiologist and a radiology resident retrospectively evaluated CT scans for lumbar spondylolysis, spondylolisthesis, and associated degenerative changes. A neuroradiologist confirmed all positive cases.

RESULTS

Of the 510 cases examined, there were 29 cases of spondylolysis at L5, corresponding to a prevalence of 5.7%. Twenty-three of the cases demonstrated bilateral spondylolysis and 6 unilateral. Sixteen of the 23 cases of bilateral spondylolysis also had spondylolisthesis, 13 of which were grade I, and 3 of which were grade II. In patients 45 years old and younger who did not have spondylolysis or spondylolisthesis, we observed a 32.2% incidence of sclerosis involving the L5 lumbar pedicles.

CONCLUSIONS

This study demonstrates a 5.7% prevalence of spondylolysis and a 3.1% prevalence of spondylolisthesis in patients undergoing CT scans of the abdomen and pelvis for unrelated reasons, corresponding to the rate of spondylolysis and spondylolisthesis detected in prospective plain radiographic studies. We observed a 1.2% incidence of unilateral spondylolysis, and approximately 67% of these demonstrated contralateral sclerosis. It is suggested in the literature that sclerosis of the contralateral pedicle seen in cases of unilateral spondylolysis may be a compensatory response to mechanical stresses on an unstable lumbar vertebral body.

Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management

Spondylolysis and spondylolisthesis are often diagnosed in children presenting with low back pain. Spondylolysis refers to a defect of the vertebral pars interarticularis. Spondylolisthesis is the forward translation of one vertebral segment over the one beneath it. Isthmic spondylolysis, isthmic spondylolisthesis, and stress reactions involving the pars interarticularis are the most common forms seen in children. Typical presentation is characterized by a history of activity-related low back pain and the presence of painful spinal mobility and hamstring tightness without radiculopathy. Plain radiography, computed tomography, and single-photon emission computed tomography are useful for establishing the diagnosis. Symptomatic stress reactions of the pars interarticularis or adjacent vertebral structures are best treated with immobilization of the spine and activity restriction. Spondylolysis often responds to brief periods of activity restriction, immobilization, and physiotherapy. Low-grade spondylolisthesis (< or =50% translation) is treated similarly. The less common dysplastic spondylolisthesis with intact posterior elements requires greater caution. Symptomatic high-grade spondylolisthesis (>50% translation) responds much less reliably to nonsurgical treatment. The growing child may need to be followed clinically and radiographically through skeletal maturity. When pain persists despite nonsurgical interventions, when progressive vertebral displacement increases, or in the presence of progressive neurologic deficits, surgical intervention is appropriate.