Significance of bone scintigraphy in symptomatic spondylolysis

High-Grade Spondylolisthesis in Adults: Current Concepts in Evaluation and Management

Background

Information regarding the treatment of high-grade spondylolisthesis (HGS) in adults has been previously described; however, previous descriptions of the evaluation and surgical management of HGS do not represent more recent and now established approaches. The purpose of the current review is to discuss current concepts in the evaluation and management of patients with HGS.

Methods

Literature review.

Results

HGS is diagnosed in up to 11.3% of adults with spondylolisthesis and typically presents as nonspecific lower back pain. Regarding evaluation, a thorough history and physical examination should be performed, which may help predict the presence of HGS. Diagnostic imaging, and specifically the use of spino-pelvic parameters, are now commonly implicated in guiding treatment course and prognosis. When surgical intervention is indicated, surgical approaches include in situ fusion variations, reduction and partial reduction with fusion, and vertebrectomy. Although the majority of studies suggest improvements with these approaches, the literature is limited by a low level of evidence with regards to the superiority of one technique when compared with others.

Conclusions

HGS is a unique cause of low back pain in adults that carries considerable morbidity, but rarely presents with neurologic symptoms. Although the definitions, classifications, and methods of diagnosis of this spinal deformity have been established and accepted, the ideal surgical management of this deformity remains highly debated. Fusion in situ techniques are often technically easier to perform and provide lower risk of neurologic complications, whereas reduction and fusion techniques offer greater restoration of global spino-pelvic balance. Preoperative spino-pelvic parameters may have utility in assisting in procedural selection; however, future, higher-quality and longer-term studies are warranted to determine the optimal surgical intervention among the widely available techniques currently used, and to better define the indications for these interventions.

Primary pain generator identification by CT-SPECT in patients with degenerative spinal disease

OBJECTIVE

Axial spinal pain generators are difficult to identify using current diagnostic modalities. Merging CT with SPECT (CT-SPECT) scans allows for accurate identification of areas with increased osteoblastic activity, which may reflect pain generators. In this study, the authors aimed to evaluate the degree of pain improvement in patients who underwent surgery, addressing primary pain generators identified by CT-SPECT.

METHODS

The authors retrospectively reviewed all patients with chronic axial spine pain who underwent diagnostic CT-SPECT at their institution and analyzed pain improvement in those who underwent surgical treatment in order to determine whether CT-SPECT correctly identified the primary pain generator.

RESULTS

A total of 315 patients underwent diagnostic CT-SPECT between January 2014 and August 2018. Forty-eight patients underwent either cervical or lumbar fusion; there were 26 women (16 cervical, 10 lumbar) and 22 men (9 cervical, 13 lumbar). The overall axial spinal pain, as assessed through self-reporting of visual analog scale scores at 6 months postoperatively, improved from 9.04 ± 1.4 to 4.34 ± 2.3 (p = 0.026), with cervical fusion patients improving from 8.8 ± 1.8 to 3.92 ± 2.2 (p = 0.019) and lumbar fusion patients improving from 9.35 ± 0.7 to 4.87 ± 2.3 (p = 0.008).

CONCLUSIONS

CT-SPECT may offer a diagnostic advantage over current imaging modalities in identifying the primary pain generator in patients with axial spinal pain.

Current Evidence Regarding Diagnostic Imaging Methods for Pediatric Lumbar Spondylolysis: A Report From the Scoliosis Research Society Evidence-Based Medicine Committee

BACKGROUND

Spondylolysis is common among the pediatric population, yet no formal systematic literature review regarding diagnostic imaging has been performed. The Scoliosis Research Society (SRS) requested an assessment of the current state of peer reviewed evidence regarding pediatric spondylolysis.

METHODS

Literature was searched professionally and citations retrieved. Abstracts were reviewed and analyzed by the SRS Evidence-Based Medicine Committee. Level I studies were considered to provide Good Evidence for the clinical question. Level II or III studies were considered Fair Evidence. Level IV studies were considered Poor Evidence. From 947 abstracts, 383 full texts reviewed. Best available evidence for the questions of diagnostic methods was provided by 27 studies: no Level I sensitivity/specificity studies, five Level II and two Level III evidence, and 19 Level IV evidence.

RESULTS

Pain with hyperextension in athletes is the most widely reported finding in history and physical examination. Plain radiography is considered a first-line diagnostic test for suspected spondylolysis, but validation evidence is lacking. There is consistent Level II and III evidence that pars defects are detected by advanced imaging in 32% to 44% of adolescents with spondylolysis based on history and physical. Level III evidence that single-photon emission computed tomography (SPECT) is superior to planar bone scan and plain radiographs but limited by high rates of false-positive and false-negative results and by high radiation dose. Computed tomography (CT) is considered the gold standard and most accurate modality for detecting the bony defect and assessment of osseous healing but exposes the pediatric patient to ionizing radiation. Magnetic resonance imaging (MRI) is reported to be as accurate as CT and useful in detecting early stress reactions of the pars without a fracture.

CONCLUSION

Plain radiographs are widely used as screening tools for pediatric spondylolysis. CT scan is considered the gold standard but exposes the patient to a significant amount of ionizing radiation. Evidence is fair and promising that MRI is comparable to CT.

Diagnostic accuracy of 3-T magnetic resonance imaging with 3D T1 VIBE versus computer tomography in pars stress fracture of the lumbar spine

OBJECTIVE

To compare the diagnostic accuracy of 3-T magnetic resonance imaging (MRI) with thin-slice 3D T1 VIBE sequence to 128-slice computer tomography (CT) in pars stress fractures of the lumbar spine.

MATERIALS AND METHODS

3-T MRI and CT of 24 patients involving 70 pars interarticularis were retrospectively reviewed by four blinded radiologists. The fracture morphology (complete, incomplete, or normal) was assessed on MRI and CT at different time points. Pars interarticularis bone marrow edema (present or absent) was also evaluated on MRI.

RESULTS

In total, 14 complete fractures, 31 incomplete fractures and 25 normal pars were detected by CT. Bone marrow edema was seen in seven of the complete and 25 of the incomplete fractures. The overall sensitivity, specificity and accuracy of MRI in detecting fractures (complete and incomplete) were 97.7, 92.3, and 95.7 %, respectively. MRI was 100 % accurate in detecting complete fractures. For incomplete fractures, the sensitivity, specificity, and accuracy of MRI were 96.7, 92.0, and 94.6 %, respectively.

CONCLUSIONS

3-T MRI with thin-slice 3D T1 VIBE is 100 % accurate in diagnosing complete pars fractures and has excellent diagnostic ability in the detection and characterization of incomplete pars stress fractures compared to CT. MRI has the added advantages of detecting bone marrow edema and does not employ ionizing radiation.

SPECT/CT bone scintigraphy to evaluate low back pain in young athletes: common and uncommon etiologies

Low back pain of various etiologies is a common clinical presentation in young athletes. In this article, we discuss the utility of SPECT/CT bone scintigraphy for the evaluation of low back pain in young athletes. The spectrum of lower spine lesions caused by sports injuries and identifiable on bone scan is presented along with strategies to avoid unnecessary irradiation of young patients. Also covered are pitfalls in diagnosis due to referred-pain phenomenon and normal skeletal variants specific to this age group.

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.

Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management

OBJECTIVE

To review current literature regarding the etiology, diagnosis, and conservative treatment of spondylolysis and spondylolytic spondylolisthesis.

METHODS

The PubMed database was searched for articles on spondylolysis and/or spondylolisthesis and their incidence, diagnosis, imaging, treatment, and prognosis. The bibliographies of articles determined to be relevant were also reviewed.

RESULTS

A PubMed search of spondylolysis or spondylolis-thesis yielded over 800 citations. Sixty-eight articles were selected based on an opinion of perceived relevance to the subjects of spondylolysis and spondylolisthesis.

CONCLUSIONS

Spondylolysis affects approximately 6% of the population. The lesion likely represents a stress fracture and the typical age of onset is early childhood and adolescence. Most individuals are asymptomatic. Adolescents with low back pain may have an impending or new pars defect. A high index of suspicion for a new pars defect should prompt utilization of physiologic imaging to determine the likelihood of pars union in young patients. Restrictive bracing may lead to healing of the fracture and cessation of pain. Spondylolisthesis is a common complication of spondylolysis. Spondylolisthesis progression is typically small and most likely in young individuals. Significant progression in adults is rare. The finding of spondylolysis and spondylolisthesis in an adult patient is usually incidental and not likely to be a direct source of pain unless there is concurrent instability.

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.

Spondylolysis in young tennis players

The general aetiology, diagnosis, and treatment of spondylolysis, a bone defect in the pars interarticularis of the vertebra, are reviewed. A retrospective study of young tennis players diagnosed between 2000 and 2004 with spondylolysis with or without spondylolisthesis, assessed by radiography and planar bone scintigraphy, is described. If the radiographic results were negative, computed tomography was performed. Sixty six cases were evaluated: 53 L5 lesions, eight L4 lesions, two L3 lesions, and one bilateral lesion at the L2 level. Two more lesions at two levels were found (bilateral L5 and unilateral L4 and L3 on the right side). Classification, treatment, and outcome of the cases are reported. A combination of radiography, planar bone scintigraphy, and SPECT is useful for evaluating spondylolysis in tennis players and recommending treatment. Use of a brace did not appear to achieve significant results.

The diagnosis and treatment of back pain in children and adolescents: an update

The conditions described for the most part are diagnosed by characteristic history, comprehensive physical examination, and selective laboratory and imaging studies. Most can be treated by nonoperative means. With the exception of tumors, surgical intervention is performed only after a thorough trial of conservative management. Should the diagnosis remain elusive or response to treatment less than expected, orthopedic referral is encouraged.

Young athletes with low back pain: skeletal scintigraphy of conditions other than pars interarticularis stress

PURPOSE

Skeletal scintigraphy is an important method for showing evidence of stress injuries affecting the partes interarticulares of young athletes with low back pain. Other etiologies of low back pain may also cause uptake abnormalities in these patients. How often do the results of skeletal scintigraphy support diagnoses other than stress injuries to the partes interarticulares and what are these diagnoses?

MATERIALS AND METHODS

We retrospectively reviewed the records of 209 young patients (149 females, 60 males; age range: 8-21 years, mean: 15.7 years) with low back pain and no previously treated vertebral condition who were consecutively referred from a sports medicine clinic to skeletal scintigraphy.

RESULTS

Sites of high uptake supportive of diagnoses other than pars interarticularis stress were shown in 36 (17%) of the 209 patients. Other diagnoses supported by skeletal scintigraphy included stress at the articulation between a transitional vertebra and the sacrum, injuries to the vertebral body ring apophysis, sacral fracture, spinous process injury, and sacroiliac joint stress.

CONCLUSION

Skeletal scintigraphy shows uptake abnormalities supportive of diagnoses other than pars interarticularis stress in a significant number of young patients with low back pain. The uptake abnormalities shown are usually stress-related in this select population.

Symptomatic spondylolysis: diagnosis and treatment

PURPOSE OF REVIEW

Approximately 35% of adolescents experience back pain. In athletic adolescents, spondylolysis is the most common offending cause. With growing numbers of adolescents participating in sports with higher levels of intensity, spondylolysis is becoming an increasingly common clinical problem.

RECENT FINDINGS

A recent report demonstrated the benign natural history of asymptomatic spondylolysis. However, long-term follow-up studies of patients who experience painful spondylolysis as adolescents remain unavailable. Modern imaging modalities have led to earlier diagnosis with greater accuracy. Conservative management with bracing continues to be a mainstay of treatment. In patients who are not helped by conservative therapy, recent studies have demonstrated the satisfactory long-term results of surgical repair.

SUMMARY

The long-term sequelae of symptomatic spondylolysis and unhealed pars defects require investigation. MRI promises to be a valuable tool for diagnosis and clinical stratification, but further studies are necessary to demonstrate its clinical utility.

Imaging of sports injuries in children and adolescents

Imaging plays an important role in the diagnosis and management of sports injuries of childhood and adolescence. The injuries discussed are typical of those seen in the skeletally immature athlete. Imaging specialists must be able to apply the full range of imaging modalities when evaluating the injured young athlete.

Spondylolysis: a critical review

AIM

To provide an understanding of the current concepts in the natural history, pathophysiology, diagnosis, and treatment of spondylolysis based on the available medical literature.

METHODS

Articles were selected for review by the following methods: (a) MEDLINE searches with review of abstracts to select relevant articles; (b) review of multiple textbooks considered likely to contain information on spondylolysis; (c) review of references in articles identified by (a) and (b). Over 125 articles were ultimately reviewed fully. Publications were selected for inclusion in this article on the basis of perceived scientific and historical merit, particularly as thought to be relevant to achieving the stated purpose of this review. As no controlled clinical trials were identified, this could not be used as an inclusion criterion.

CONCLUSIONS

Isthmic spondylolysis is considered to represent a fatigue fracture of the pars interarticularis of the neural arch. There is a relatively high incidence of radiographically identified spondylolysis in the general population, but the vast majority of these lesions probably occur without associated symptoms. Symptomatic pars lesions appear to be particularly a clinical problem in adolescents, especially adolescent athletes. The optimal diagnostic and treatment algorithms are not well identified in the current literature. Multiple imaging studies may have a role in the diagnosis of a pars lesion, and treatment seems likely to require at least relative rest and physical rehabilitation with consideration of bracing or, rarely, surgical intervention depending on the clinical context.

SPECT in the management of patients with back pain and spondylolysis

PURPOSE

Single photon emission computed tomography (SPECT) bone scans of the lumbar spine were evaluated in the management of patients with low back pain and suspected spondylolysis.

MATERIALS AND METHODS

Thirty-three patients (mean age, 30 years) with high clinical suspicion of pars interarticularis defects were included in the study. The results of lumbar radiographs and SPECT bone scintigraphy were compared and the influence of these results on patient management was evaluated.

RESULTS

Twenty-six of the 33 patients had abnormal results of lumbar radiographs. Of the 21 patients with radiographs indicating spondylolysis, six had abnormal uptake in the pars regions on bone scintigraphy. One patient with normal results of lumbar radiographs had a SPECT bone scan showing uptake in the region of the pars interarticularis.

CONCLUSIONS

SPECT bone scanning of the lumbar spine has a role in the treatment of patients with symptomatic spondylolysis.

Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population

Spondylolysis and low-grade spondylolisthesis are diagnoses that, for most patients, have a benign prognosis and can be managed nonoperatively. For most symptomatic patients for whom this management fails, fusion in situ yields satisfactory and lasting results and remains the gold standard against which other surgical treatment must be compared. Patients with high-grade slips and slip angles may benefit from instrumented fusion in situ or combined anterior/posterior procedures, or may be considered for reduction and fusion. Reduction maneuvers are technically demanding and carry significant risk of neurologic injury. Surgical experience and in-depth understanding of the indications, the complications, and, especially, the limitations of each technique are required.

Back pain in children

Children and adolescents occasionally have back symptoms, but rarely come to a physician's office for more severe back pain. When a child or adolescent appears in the clinic with complaints of back pain, a careful detailed evaluation is appropriate. The incidence of findings in children with significant back pain is high; therefore, a detailed history, physical examination, and evaluation are needed. It is also legitimate to continue monitoring children even if no obvious cause is initially identified because often a diagnosis subsequently will be made.

The radiological investigation of lumbar spondylolysis

Lumbar spondylolysis represents a stress fracture of the pars interarticularis and occurs most commonly at the L5 level. Pars defects can be imaged with plain radiography, bone scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI). Plain radiographic projections of particular value include the coned lateral view of the lumbosacral junction, which displays the majority of defects, and the anteroposterior view with 30 degrees cranial angulation. The value of oblique radiography is unproven. Planar bone scintigraphy (PBS) is more sensitive than radiography and single photon emission computed tomography (SPECT) more sensitive and specific than PBS. Both these techniques, however, are less specific than radiography and CT. CT, when performed with a reverse gantry angle and thin sections, is the investigation of choice for identifying radiographically occult lyses. Conventional lumbar spine MRI techniques are valuable for demonstrating normality of the pars, but may be associated with a high false positive rate for the diagnosis of pars defects.

Role of technetium-99m planar bone scanning in the evaluation of low back pain

The records of 1018 patients with low back pain in a tertiary spine referral practice were reviewed. One hundred thirty-nine out of 1018 (13.6%) underwent technetium-99m planar bone scanning as part of their investigation. Seventy-three out of 139 scans (52%) showed increased uptake in some area, but only 27 out of 139 (19.4%) showed increased uptake specifically in the low back. Scans consistently yielded no findings with reference to the back when the prescan diagnosis was spinal stenosis, lumbar pain syndrome, herniated nucleus pulposus, or postlaminectomy syndrome. Some scans gave positive findings in patients with a diagnosis of degenerative disc disease, pseudarthrosis, spondylolisthesis, fracture, infection, metabolic disorder, or tumor. Positive scans were generally obtained early after presentation (within 3 months) and negative scans obtained later (after 6 months), suggesting that clinical suspicion is still the main indication for early scanning. Planar bone scanning was helpful in both diagnosis and therapeutic decision-making in many conditions.

Symptomatic spondylolysis: correlation of CT and SPECT with clinical outcome

Twenty-seven patients with spondylolysis and back pain were considered for spinal fusion. All patients underwent clinical evaluation, multiplanar computed tomography (CT) and single photon emission computed tomography (SPECT). After clinical evaluation 12 patients were not considered suitable for fusion on clinical grounds. SPECT was normal in these patients. Fifteen underwent a trial of lumbar immobilization and nine of those rendered pain free subsequently underwent spinal fusion. The results of clinical examination, lumbar immobilization, imaging and final outcome were compared in these patients. Those patients rendered pain free by surgery all had positive SPECT scans. Those with persistent pain after surgery had negative scans. This small series suggests a positive relationship between SPECT scanning and patient outcome following fusion. These findings need to be confirmed by larger studies with longer periods of follow-up.