Spondylolisthesis, Sacro-Pelvic Morphology, and Orientation in Young Gymnasts

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.

The Incidence of Pars Interarticularis Defects in Athletes

STUDY DESIGN

Literature review.

OBJECTIVE

To conduct a literature review of studies reporting the incidence of pars interarticularis defects in athletes of specific sports, in order to allow more targeted prevention and treatment strategies to be implemented for the groups at highest risk.

METHODS

Electronic searches were performed using PubMed, Ovid Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Cochrane Database of Controlled Trials from their dates of inception to September 2017, with the following keywords: "spondylolysis," "sports," "low back pain," and "pars defects."

RESULTS

A total of 509 total articles were retrieved, of which 114 were used in the final review. The incidence of pars interarticularis defects was found to be highest in diving (35.38%), cricket (31.97%), baseball/softball (26.91%), rugby (22.22%), weightlifting (19.49%), sailing (17.18%), table tennis (15.63%), and wrestling (14.74%). Only 5 studies reported the management instituted for their participants, and these were all case reports. Of 74 players with spondylolysis in these studies, 70 (94.59%) underwent conservative treatment and 4 (5.41%) underwent surgical treatment. 61 (82.43%) returned to their previous level of play, 6 (8.11%) retired, and the disposition of the final 7 was not reported.

CONCLUSION

The current medical literature provides good evidence that the incidence of pars interarticularis defects is higher in the athletic population, with the highest incidence in diving. There remains no gold standard protocol for the management of pars interarticularis defects. Further research is required to compare conservative therapy to surgical therapy and to compare the various surgical techniques to each other.

Association between lumbar sacralization and increased degree of vertebral slippage and disc degeneration in patients with L4 spondylolysis

OBJECTIVE

The aim of this study was to evaluate the effect of lumbar sacralization on the level of vertebral slip and disc degeneration in patients with L4 spondylolysis.

METHODS

The authors analyzed data from 102 cases in which patients underwent surgical treatment for L4 spondylolysis and spondylolisthesis at their institution between March 2007 and September 2016. Lumbar sacralization was characterized by the presence of pseudarthrosis and/or bony fusion between the L5 transverse process and sacrum, and the type of lumbosacral transitional vertebra (LSTV) was evaluated with the Castellvi classification. The amount of vertebral slippage was measured using the Taillard technique and Meyerding grade. Degeneration of the L4-5 segment was quantified using the Pfirrmann and Modic classifications. Patients were divided into 2 groups based on the presence or absence of sacralization, and the amount of vertebral slip and degeneration of the L4-5 segment was compared between groups.

RESULTS

Lumbar sacralization was present in 37 (36%) of 102 patients with L4 spondylolysis. The LSTV was type IIa in 10 cases, type IIb in 7, type IIIa in 2, and type IIIb in 18. The levels of vertebral slip and disc degeneration in the group of patients with sacralization were significantly greater than in the group without sacralization. No significant difference was found between the 2 groups with respect to Modic changes.

CONCLUSIONS

The increased stability between a sacralized L5 and the sacrum may predispose the L4-5 segment to greater instability and disc degeneration in patients with L4 spondylolysis.

Clinical, Functional, and Radiologic Outcome of Single- and Double-Level Transforaminal Lumbar Interbody Fusion in Patients with Low-Grade Spondylolisthesis

Objective:

The main objective is to determine the functional, clinical, and radiological outcome of patients with low-grade spondylolisthesis undergoing single- or double-level transforaminal lumbar interbody fusion (TLIF).

Materials and Methods:

This quasi-interventional study was conducted during a 2-year period from 2016 to 2018 in Shiraz, Southern Iran. We included all the adult (≥18 years) patients with low-grade spondylolisthesis (Meyerding Grade I and II) who underwent single- or double-level TLIF in our center. The spinopelvic parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and segmental LL (SLL) were measured. The pain intensity and disability were measured utilizing the visual analog scale (VAS) for back and leg pain and Oswestry Disability Index (ODI), respectively, after 1 year.

Results:

Overall, we included a total number of 50 patients with mean age of 54.1 ± 10.48 years. After the surgery, the PI (P = 0.432), PT (P = 0.782), and SS (P = 0.466) were not found to be statistically changed from the baseline. However, we found that single- or double-level TLIF was associated with increased LL (P < 0.001) and SLL (P < 0.001). Regarding the clinical outcome measures, both back (P = 0.001) and leg (P < 0.001) VAS improved after the surgery significantly. In addition, we found that improved leg VAS was positively correlated with improved ODI (r = 0. 634; P < 0.001).

Conclusion:

Single- or double-level TLIF is associated with increased global and SLL along with improved leg and back pain and disability in patients with low-grade spondylolisthesis. Interestingly, improved leg pain is correlated to improved disability in these patients.

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

STUDY DESIGN

Structured literature review.

OBJECTIVES

The Scoliosis Research Society (SRS) requested an assessment of the current state of peer-reviewed evidence regarding pediatric lumbar spondylolisthesis with the goal of identifying what is known and what gaps remain in further understanding the diagnostic methods for pediatric spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Spondylolisthesis in the lumbar spine is common among children and adolescents and no formal synthesis of the published literature regarding diagnostic methods has been previously performed.

METHODS

A comprehensive literature search was performed. Abstracts were reviewed and data from included studies were analyzed by the committee. From 6600 initial citations with abstract, 663 articles underwent full-text review. The best available evidence for the clinical questions regarding diagnostic methods was provided by 26 included studies. Six of the studies were graded as Level III (retrospective comparative), and represent the current best available evidence whereas 20 of the studies were graded as Level IV (retrospective case series) evidence. No Level V (expert opinion) studies were included in the final list. None of the studies were graded as Level I or Level II.

RESULTS

Plain radiography is the workhorse imaging modality for diagnosing spondylolisthesis. No association between radiologic grade of spondylolisthesis and clinical presentation were noted; however, grade III and IV slips more often required surgery, and increasing slip angles were associated with worse baseline outcome scores. There is Level III evidence that the Meyerding grade appears to be more accurate for measuring slip percentage whereas the Lonstein Slip angle and Dubousset Lumbosacral Kyphosis angles are the best for measuring lumbosacral kyphosis in spondylolisthesis. In addition, higher sacral table index, pelvic incidence, sacral slope, and lower sacral table angle were associated with spondylolisthesis. True incidence could not be determined by the current literature available. However, studies in adolescent athletes demonstrated an incidence of 6% to 7% across studies.

CONCLUSIONS

The current "best available" evidence to guide the diagnosis and characterization of pediatric spondylolisthesis is presented. Future studies are needed to provide more high-quality evidence to answer these clinically relevant questions.

LEVEL OF EVIDENCE

Level III, review of Level III studies.

The Relationship Between Sacral Slope and Symptomatic Isthmic Spondylolysis in a Cohort of High School Athletes: A Retrospective Analysis

BACKGROUND

Spondylolysis with and without anterolisthesis is the most common cause of structural back pain in children and adolescents, but few predictive factors have been confirmed. An association between abnormal sacropelvic orientation and both spondylolysis and spondylolisthesis has been supported in the literature. Sacral slope and other sacropelvic measurements are easily accessible variables that could aid clinicians in assessing active adolescents with low back pain, particularly when the diagnosis of spondylolysis is suspected.

OBJECTIVE

To examine the relationship between sacral slope and symptomatic spondylolysis in a cohort of active adolescents.

DESIGN

Case-control retrospective study.

SETTING

Academic outpatient physiatry practice.

PATIENTS

Seventy-four patients of primarily adolescent age (between 12 and 22 years old) with a chief complaint of low back pain and presence of lateral radiographs of the lumbar spine were enrolled. Cases (n = 37) were defined as subjects with evidence of spondylolysis on both radiograph and magnetic resonance imaging of the lumbar spine. Controls (n = 37) were defined as subjects without spondylolysis.

METHODS

Using a single sagittal radiograph, taken with the patient standing, a fellowship-trained interventional spine physiatrist measured the sacral slope of each subject (angle between the superior plate of S1 and a horizontal reference on sagittal imaging of the lumbosacral spine). Ages and genders were collected from medical records.

MAIN OUTCOME MEASUREMENTS

The primary outcome was mean sacral slope. Mean sacral slope of cases was compared with mean sacral slope of controls with the Student t-test.

RESULTS

Ages ranged from 12 to 22 for both groups, with no significant differences in age between the groups (cases: 16.8 ± 2.3 years; controls: 17.7 ± 2.7 years). The patients with spondylolysis (cases) consisted of 29 male and 8 female patients, whereas those without spondylolysis (controls) consisted of 15 male and 21 female patients (gender details for 1 patient were not available). The mean sacral slope among cases was 42.4°, whereas the mean sacral slope among controls was 37.4°. The difference achieved significance (P = .014).

CONCLUSIONS

The interdependence of positional parameters, such as sacral slope, with anatomic parameters, such as pelvic incidence, can affect lumbar lordosis and therefore upright positioning and loading of the spine. Sacral slope may be an important variable for clinicians to consider when caring for young athletes with low back pain, particularly when the index of suspicion for spondylolysis is high.

LEVEL OF EVIDENCE

IV.