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Tsutsui T, Iizuka S, Takei S, Maemichi T, Torii S. Risk Factors for Symptomatic Bilateral Lumbar Bone Stress Injury in Adolescent Soccer Players: A Prospective Cohort Study. Am J Sports Med 2023; 51:707-714. [PMID: 36661480 DOI: 10.1177/03635465221146289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Lumbar bone stress injury (BSI) is a high-risk long time-loss injury for adolescent soccer players. However, the risk factors for lumbar BSI are unclear. PURPOSE To identify the risk factors for bilateral lumbar BSI for adolescent soccer players. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Adolescent soccer players underwent orthopaedic examination, whole-body dual energy x-ray scan, lumbar magnetic resonance imaging (MRI), and muscle tightness testing at baseline. Lumbar lordosis (LL), sacral slope, maturity stage of lumbar vertebral body, and bone marrow edema (BME) at the L5 were examined via MRI. In addition, bone mineral density and content; trunk lean body mass via dual energy x-ray scan; and bilateral muscle tightness including the iliopsoas, hamstrings, and quadriceps were measured. Lumbar BSI was diagnosed as positive bilateral BME and extension-based lumbar pain. All participants were examined twice, one at 6 months and one at 1 year, after the baseline examination. Multivariate logistic regression analysis was performed to identify the risk factors for bilateral lumbar BSI. RESULTS A total of 69 (26.3%) players were diagnosed with bilateral lumbar BSI. Asymptomatic BME (odds ratio [OR], 4.260; 95% CI, 2.153-8.431), apophyseal stage of the lumbar vertebral body (OR, 3.438; 95% CI, 1.698-6.959), sacral slope relative to LL ≥5° (OR, 4.067; 95% CI, 2.021-8.181), and hamstring tightness ≥50° (OR, 3.221; 95% CI, 1.385-7.489) were significantly associated with bilateral lumbar BSI. CONCLUSION The incidence of bilateral lumbar BSI was common at 26.2%. Asymptomatic BME, sacral anterior tilt relative to LL, immature lumbar epiphyses, and hamstring tightness were found to be risk factors for bilateral lumbar BSI. The results of this study suggest that regular MRI examination could facilitate the early detection of BME, and improvement in hamstring flexibility and lumbosacral alignment may prevent bilateral lumbar BSI in young athletes.
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Affiliation(s)
- Toshiharu Tsutsui
- Faculty of Sports Science, Waseda University, Tokorozawa, Saitama, Japan
| | - Satoshi Iizuka
- Japan Institute of Sport Sciences, Kita-ku, Tokyo, Japan
| | - Seira Takei
- University of Tokyo Sports Science Initiative, Bunkyo-ku, Tokyo, Japan.,Institute of Human Growth and Development, Waseda University, Tokorozawa, Saitama, Japan
| | - Toshihiro Maemichi
- Faculty of Sports Science, Waseda University, Tokorozawa, Saitama, Japan
| | - Suguru Torii
- Faculty of Sports Science, Waseda University, Tokorozawa, Saitama, Japan
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Ruff AN, Cornelson SM, Wells CB, Kettner NW. Neural Arch Bone Marrow Edema and Spondylolysis in Adolescent Cheerleaders: A Case Series. J Chiropr Med 2020; 18:335-342. [PMID: 32952480 DOI: 10.1016/j.jcm.2019.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/03/2019] [Accepted: 02/17/2019] [Indexed: 10/23/2022] Open
Abstract
Objective Spondylolysis is 1 of the most common sources of low back pain in children and adolescents; however, there is still a great deal of confusion in regard to etiology, clinical presentation, and diagnostic imaging findings. It is imperative for clinicians to recognize that persistent low back pain is strongly indicative of spondylolysis, especially in high-performance athletes. This case series demonstrates a comprehensive diagnostic spectrum of spondylolysis and its treatment in 2 competitive adolescent cheerleaders. Clinical Features In case 1, a 12-year-old female competitive cheerleader presented with a gradual onset of subacute low back pain. Comprehensive clinical examination indicated imaging studies that identified bilateral L5 grade 1 stress reaction, consisting of neural arch bone marrow edema (BME). Treatment included spinal adjustments, rehabilitation, and myofascial therapy. In case 2, 15-year-old female competitive cheerleader presented with insidious chronic low back pain that was provocative with extension. Magnetic resonance imaging revealed a left L5 grade 1 pars interarticularis stress reaction. Computed tomography demonstrated right L5 pars grade 3 and left L5 healing spondylolysis. Treatment included spinal adjustments and rehabilitation exercises. She was also seen by a physical therapist who prescribed a lumbar spine flexion brace. Intervention and Outcome Diagnosis of BME and spondylolysis led to temporary cessation of cheerleading activities in cases 1 and 2. The individual in case 1 self-discharged with a list of rehabilitation exercises and was lost to follow-up. The individual in case 2 was able to return to sport pain free approximately 5 weeks after seeking treatment. Conclusion Spondylolysis is common in adolescent athletes, and the presence of BME precedes spondylolysis. Primary spine providers could consider this diagnosis in any adolescent, especially an athlete, who has persistent low back pain. Timely diagnosis will optimize treatment outcomes.
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Affiliation(s)
- Ashley N Ruff
- Radiology Department, Logan University, Chesterfield, Missouri
| | | | - Courtney B Wells
- Human Performance Center, Logan University, Chesterfield, Missouri
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Plomp KA, Dobney K, Collard M. Spondylolysis and spinal adaptations for bipedalism: The overshoot hypothesis. EVOLUTION MEDICINE AND PUBLIC HEALTH 2020; 2020:35-44. [PMID: 32153781 PMCID: PMC7053264 DOI: 10.1093/emph/eoaa003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/08/2020] [Indexed: 12/19/2022]
Abstract
Background and objectives The study reported here focused on the aetiology of spondylolysis, a vertebral pathology usually caused by a fatigue fracture. The goal was to test the Overshoot Hypothesis, which proposes that people develop spondylolysis because their vertebral shape is at the highly derived end of the range of variation within Homo sapiens. Methodology We recorded 3D data on the final lumbar vertebrae of H. sapiens and three great ape species, and performed three analyses. First, we compared H. sapiens vertebrae with and without spondylolysis. Second, we compared H. sapiens vertebrae with and without spondylolysis to great ape vertebrae. Lastly, we compared H. sapiens vertebrae with and without spondylolysis to great ape vertebrae and to vertebrae of H. sapiens with Schmorl’s nodes, which previous studies have shown tend to be located at the ancestral end of the range of H. sapiens shape variation. Results We found that H. sapiens vertebrae with spondylolysis are significantly different in shape from healthy H. sapiens vertebrae. We also found that H. sapiens vertebrae with spondylolysis are more distant from great ape vertebrae than are healthy H. sapiens vertebrae. Lastly, we found that H. sapiens vertebrae with spondylolysis are at the opposite end of the range of shape variation than vertebrae with Schmorl’s nodes. Conclusions Our findings indicate that H. sapiens vertebrae with spondylolysis tend to exhibit highly derived traits and therefore support the Overshoot Hypothesis. Spondylolysis, it appears, is linked to our lineage’s evolutionary history, especially its shift from quadrupedalism to bipedalism. Lay summary: Spondylolysis is a relatively common vertebral pathology usually caused by a fatigue fracture. There is reason to think that it might be connected with our lineage’s evolutionary shift from walking on all fours to walking on two legs. We tested this idea by comparing human vertebrae with and without spondylolysis to the vertebrae of great apes. Our results support the hypothesis. They suggest that people who experience spondylolysis have vertebrae with what are effectively exaggerated adaptations for bipedalism.
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Affiliation(s)
- Kimberly A Plomp
- Department of Archaeology, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.,Department of Archaeology, Classics and Egyptology, University of Liverpool, 14 Abercromby Square, Liverpool L69 7WZ, UK
| | - Keith Dobney
- Department of Archaeology, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.,Department of Archaeology, Classics and Egyptology, University of Liverpool, 14 Abercromby Square, Liverpool L69 7WZ, UK.,Department of Archaeology, University of Aberdeen, St Mary's, Elphinstone Road, Aberdeen AB24 3UF, UK
| | - Mark Collard
- Department of Archaeology, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada
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Abstract
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.
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Affiliation(s)
- Samuel Tawfik
- University of New South Wales, Sydney, New South Wales, Australia,St George Hospital, Sydney, New South Wales, Australia,Samuel Tawfik, St George Hospital, Sydney, New South Wales, Australia 2217.
| | - Kevin Phan
- University of New South Wales, Sydney, New South Wales, Australia,Neurospine Surgery Research Group, Sydney, New South Wales, Australia
| | - Ralph J. Mobbs
- Neurospine Surgery Research Group, Sydney, New South Wales, Australia,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Prashanth J. Rao
- Neurospine Surgery Research Group, Sydney, New South Wales, Australia,University of Sydney, Sydney, New South Wales, Australia,Westmead Hospital, Sydney, New South Wales, Australia
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Finkenstaedt T, Siriwanarangsun P, Achar S, Carl M, Finkenstaedt S, Abeydeera N, Chung CB, Bae WC. Ultrashort Time-to-Echo Magnetic Resonance Imaging at 3 T for the Detection of Spondylolysis in Cadaveric Spines: Comparison With CT. Invest Radiol 2019; 54:32-38. [PMID: 30157099 DOI: 10.1097/rli.0000000000000506] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to compare the diagnostic performance and confidence of conventional, optimized, and ultrashort time to echo (UTE) magnetic resonance (MR) protocols for detection of simulated lumbar spondylolysis in human cadavers. In addition, we sought to demonstrate the feasibility of the UTE technique in subjects with and without spondylolysis. MATERIALS AND METHODS Four human lumbar spine specimens with 46 individual pars interarticularis were randomly left intact (n = 26) or received experimental osteotomy (n = 20) using a microsurgical saw to simulate spondylolysis. The specimens were imaged using a computed tomography (CT) scan along with 3 "Tiers" of MR protocols at 3 T: Tier 1, conventional lumbar MR protocol; Tier 2, optimized conventional protocol consisting of a sagittal oblique spoiled gradient recall echo and axial oblique T1 and short tau inversion recovery sequences; and Tier 3, a sagittal UTE MR sequence. Two blinded readers evaluated the images using a 4-point scale (1 = spondylolysis certainly absent, 2 = probably absent, 3 = probably present, 4 = certainly present) at each individual pars. For each imaging protocol, diagnostic performance (sensitivity, specificity, and area under the receiver operating characteristic curve, using the surgical osteotomy as the reference) and confidence were assessed and compared using the McNemar test. Furthermore, 2 human subjects were imaged with the conventional and UTE MR protocols to demonstrate feasibility in vivo. RESULTS Diagnostic performance was moderate for Tiers 1 and 2, with a moderate sensitivity (0.70 to 0.75) and high (1.00) specificity. In contrast, CT and Tier 3 UTE MR imaging had both high sensitivity (1.00) and specificity (1.00). The sensitivities of CT or Tier 3 were statistically greater than Tier 1 sensitivity (P = 0.041) and neared statistical significance when compared with Tier 2 sensitivity (P = 0.074). Area under the receiver operating characteristic curve was also significantly greater for CT and Tier 3 (each area = 1.00), compared with the areas for Tier 1 (0.89, P = 0.037) or Tier 2 (0.873, P = 0.024). Diagnostic confidences of CT or Tier 3 were much greater than other Tiers: Both Tiers 1 and 2 had a large percentage of uncertain (>60%, P < 0.001) or wrong interpretations (>10%, P < 0.001), unlike CT or Tier 3 (0% uncertain or wrong interpretations). Preliminary in vivo UTE images clearly depicted intact and fractured pars. CONCLUSIONS Our study demonstrated that the detection of pars fractures using a single sagittal UTE MR sequence is superior in performance and confidence to conventional and optimized MR protocols at 3 T, whereas matching those from CT evaluation. Furthermore, we demonstrated the feasibility of in vivo application of the UTE sequence in subjects with and without spondylolysis.
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Affiliation(s)
- Tim Finkenstaedt
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | | | - Suraj Achar
- Department of Family Medicine, University of California, San Diego, La Jolla
| | | | - Sina Finkenstaedt
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Switzerland
| | - Nirusha Abeydeera
- Department of Radiology, VA San Diego Healthcare System, San Diego, CA
| | - Christine B Chung
- Department of Radiology, VA San Diego Healthcare System, San Diego, CA
| | - Won C Bae
- Department of Radiology, VA San Diego Healthcare System, San Diego, CA
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West AM, d'Hemecourt PA, Bono OJ, Micheli LJ, Sugimoto D. Diagnostic Accuracy of Magnetic Resonance Imaging and Computed Tomography Scan in Young Athletes With Spondylolysis. Clin Pediatr (Phila) 2019; 58:671-676. [PMID: 30813766 DOI: 10.1177/0009922819832643] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Amy M West
- 1 Spaulding Rehabilitation Hospital, Boston, MA, USA.,2 Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Pierre A d'Hemecourt
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA.,3 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston MA, USA.,4 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | | | - Lyle J Micheli
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA.,3 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston MA, USA.,4 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Dai Sugimoto
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA.,3 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston MA, USA.,4 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
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Sudarshan PK, Suthar HR, Varma VK, Krishnan A, Hegde SK. Long-Term Experience With Reduction Technique in High-Grade Spondylolisthesis in the Young. Int J Spine Surg 2018; 12:399-407. [PMID: 30276098 DOI: 10.14444/5047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Surgical management of high-grade spondylolisthesis in the young is not only challenging but also controversial, from in-situ fusion to complete reduction. It is fraught with dangers such as neurological injury, pseudoarthrosis, and progressive deformity with subsequent global sagittal imbalance. We describe our experience of progressive reduction technique and restoration of lumbosacral alignment. Methods This study is a retrospective review of patients who underwent surgery between 1998 and 2012. The surgical technique involved positioning the hips in extension with traction, pedicle screw fixation, correction of lumbosacral kyphosis with a specific distraction maneuver, wide decompression, and gradual reduction of the deformity and maintenance of reduction with interbody fusion. All patients were serially assessed at 1, 3, and 6 months and yearly thereafter with clinical, radiological, and Oswestry Disability Index and Visual Analogue Scale outcome measures. Results Twenty-seven patients with high-grade spondylolisthesis at L5-S1 (3 cases grade 3, 7 grade 4, 17 grade 5) with an average age of 13.9 years were reviewed. Mean follow-up was 120 months (range 24-192). All patients presented a solid fusion at the 6-month visit; mean slip percentage was reduced from 89% to 23%, with all cases reduced to grade 2 or less. The slip angle improved from 45° to 3° postoperatively, with improvement in sacral slope from 13° to 35°. Four spondyloptosis patients had concomitant scoliosis which corrected spontaneously after the surgery and did not need further intervention. All but one patient (96.2%) had good functional outcomes and returned to their full normal activities. One patient developed a deep infection necessitating implant removal, with eventual deformity progression leading to a poor outcome. Three patients (11.1%) suffered partial drop foot that resolved in full by 12 weeks. Conclusion Our technique demonstrated a significant reduction of high grade spondylolisthesis, with restoration of global sagittal balance via correction of the lumbosacral kyphosis. Though surgically demanding, it is safe and reproducible. Level of Evidence IV.
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Dhouib A, Tabard-Fougere A, Hanquinet S, Dayer R. Diagnostic accuracy of MR imaging for direct visualization of lumbar pars defect in children and young adults: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1058-1066. [DOI: 10.1007/s00586-017-5305-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/13/2017] [Accepted: 09/17/2017] [Indexed: 10/18/2022]
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10
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Abstract
BACKGROUND In early studies, magnetic resonance imaging (MRI) had low sensitivity and positive predictive value in the evaluation of the pars interarticularis pathology; however, more recent reports have suggested an expanded role for MRI. The purpose of the present study was to evaluate the effectiveness of MRI in the diagnosis of pars injuries and compare it to computed tomography (CT), which was used as the reference "gold standard" for the detection of fractures. METHODS The radiographic and clinic data of 93 adolescents and young adults with a presumptive diagnosis of spondylolysis based upon history and clinic examination were reviewed. Only 26 patients who had MRI and CT images obtained within 30 days of each other were included. All images were reviewed by a fellowship-trained musculoskeletal radiologist and fellowship-trained pediatric orthopaedist. RESULTS Overall, 39 individual pars lesions (stress reaction or fracture) were identified. MRI was effective in identifying 36 pars lesions. MRI identified 11 lesions in 9 patients with negative CT. Seven of these lesions were stress reactions (grade 1), whereas 4 were frank fractures. Three pars injuries were noted on CT while the MRI was negative. CONCLUSIONS MRI is an effective method (92% sensitivity) for detecting pars injuries. It can detect stress reactions when a fracture is not visible on CT scan, allowing early treatment of these prelysis lesions. The 92% sensitivity of MRI is comparable with that of other diagnostic modalities such as bone scan, with the advantage of no radiation exposure. MRI should be strongly considered as the advanced imaging modality of choice in the evaluation of patients with suspected spondylolysis. LEVEL OF EVIDENCE Level III-diagnostic study.
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Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review. Phys Ther Sport 2015; 16:268-75. [PMID: 25797410 DOI: 10.1016/j.ptsp.2014.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 12/14/2014] [Accepted: 12/31/2014] [Indexed: 12/28/2022]
Abstract
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.
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Ferrari S, Vanti C, O'Reilly C. Clinical presentation and physiotherapy treatment of 4 patients with low back pain and isthmic spondylolisthesis. J Chiropr Med 2012. [PMID: 23204952 DOI: 10.1016/j.jcm.2011.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Spondylolisthesis is a pathological condition characterized by the slipping of a vertebral body, compared with the underlying one, following structural and/or degenerative changes of the spine. The purpose of this case series is to describe clinical presentations and the conservative physiotherapy management of 4 patients with low back pain and lumbar isthmic spondylolisthesis. CLINICAL FEATURES Four patients aged 25, 43, 36, and 50 years presented with low back pain of various duration. Radiographs confirmed the presence of lumbar isthmic spondylolisthesis. Outcome measures included numerical rating scale, disability outcome measure (Oswestry Disability Index), spinal instability tests (Prone Instability Test, Passive Lumbar Extension test), and muscle function tests (Aberrant Movement Patterns, Active Straight Leg Raising, Prone and Supine Bridge Tests). INTERVENTION AND OUTCOMES Treatment consisted of postural reeducation, stretching, and strengthening exercises. Over the course of individualized treatment, ranging from 8 to 10 treatment visits, outcomes improved for all 4 patients. CONCLUSION This report describes varying clinical presentations and treatment of 4 patients with isthmic spondylolisthesis, suggesting that different pain generators could be managed by different conservative approaches.
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Affiliation(s)
- Silvano Ferrari
- Lecturer of Manual Therapy, Masters of Manual Therapy and Musculoskeletal Rehabilitation, University of Padova, Padova, Italy ; Physical Therapist, Private Practitioner, Milan, Italy
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Yamaguchi KT, Skaggs DL, Acevedo DC, Myung KS, Choi P, Andras L. Spondylolysis is frequently missed by MRI in adolescents with back pain. J Child Orthop 2012; 6:237-40. [PMID: 23814624 PMCID: PMC3400003 DOI: 10.1007/s11832-012-0409-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 05/11/2012] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Kent T. Yamaguchi
- />Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 W. Sunset Blvd., Mailstop #69, Los Angeles, CA 90027 USA
| | - David L. Skaggs
- />Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 W. Sunset Blvd., Mailstop #69, Los Angeles, CA 90027 USA
| | - Daniel C. Acevedo
- />Department of Orthopaedics, LAC/USC Medical Center, 1200 N. State St., GNH 3900, Los Angeles, CA 90033 USA
| | - Karen S. Myung
- />Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 W. Sunset Blvd., Mailstop #69, Los Angeles, CA 90027 USA
| | - Paul Choi
- />Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 W. Sunset Blvd., Mailstop #69, Los Angeles, CA 90027 USA
| | - Lindsay Andras
- />Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 W. Sunset Blvd., Mailstop #69, Los Angeles, CA 90027 USA
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Nayeemuddin M, Richards PJ, Ahmed EB. The imaging and management of nonconsecutive pars interarticularis defects: a case report and review of literature. Spine J 2011; 11:1157-63. [PMID: 22208859 DOI: 10.1016/j.spinee.2011.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 10/01/2011] [Accepted: 11/15/2011] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Mohammed Nayeemuddin
- X-ray Department, University Hospital of North Staffordshire NHS Trust, Royal Infirmary, Princes Road, Hartshill, Stoke-On-Trent, Staffordshire, United Kingdom
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Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management. J Chiropr Med 2011; 4:206-17. [PMID: 19674664 DOI: 10.1016/s0899-3467(07)60153-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Indexed: 11/22/2022] Open
Abstract
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.
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17
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Abstract
While back pain presents less frequently in children than in adults, it still poses a significant clinical challenge with respect to making a firm diagnosis and developing an effective treatment plan. When children have back pain and medical attention is sought, an underlying pathology is usually suspected. Pediatric patients are evaluated, first, with a complete clinical history and examination and, second, by an imaging work-up that is based on initial findings, including the child's age and size, signs and symptoms, and suspected etiology. This article describes 1) the epidemiology of back pain in children, 2) the imaging work-up used, and 3) the correlation of imaging findings with disease entities that may cause back pain in the pediatric patient. The list of diseases giving rise to back pain is not meant to be exhaustive but rather reflective of the most commonly identified pathologies and disorders among young children and adolescents, from athletic injuries to lethal cancers.
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Affiliation(s)
- D P Rodriguez
- Harvard Medical School and Division of Neuroradiology, Department of Radiology, Children's Hospital, Boston, Massachusetts 02115, USA
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18
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Streamlining the evaluation of low back pain in children. Clin Orthop Relat Res 2008; 466:1971-7. [PMID: 18553213 PMCID: PMC2584263 DOI: 10.1007/s11999-008-0296-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Accepted: 04/25/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED 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.
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Dunn AJ, Campbell RSD, Mayor PE, Rees D. Radiological findings and healing patterns of incomplete stress fractures of the pars interarticularis. Skeletal Radiol 2008; 37:443-50. [PMID: 18283450 DOI: 10.1007/s00256-008-0449-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Revised: 12/06/2007] [Accepted: 12/22/2007] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective was to retrospectively record the CT and MRI features and healing patterns of acute, incomplete stress fractures of the pars interarticularis. METHOD The CT scans of 156 adolescents referred with suspected pars interarticularis stress fractures were reviewed. Patients with incomplete (grade 2) pars fractures were included in the study. Fractures were assessed on CT according to vertebral level, location of cortical involvement and direction of fracture propagation. MRI was also performed in 72 of the 156 cases. MRI images of incomplete fractures were assessed for the presence of marrow oedema and cortical integrity. Fracture healing patterns were characterised on follow-up CT imaging. RESULTS Twenty-five incomplete fractures were identified in 23 patients on CT. All fractures involved the inferior or infero-medial cortex of the pars and propagated superiorly or superolaterally. Ninety-two percent of incomplete fractures demonstrated either complete or partial healing on follow-up imaging. Two (8%) cases progressed to complete fractures. Thirteen incomplete fractures in 11 patients confirmed on CT also had MRI, and 92% demonstrated oedema in the pars. Ten out of thirteen fractures (77%) showed a break in the infero-medial cortex with intact supero-lateral cortex, which correlated with the CT findings. MRI incorrectly graded one case as a complete (grade 3) fracture, and 2 cases as (grade 1) stress reaction. Six fractures had follow-up MRI, 67% showed partial or complete cortical healing, and the same number showed persistent marrow oedema. CONCLUSIONS Incomplete fracture of the pars interarticularis represents a stage of the evolution of a complete stress fracture. The direction of fracture propagation is consistent, and complete healing can be achieved in most cases with appropriate clinical management. CT best demonstrates fracture size and extent, and is the most appropriate modality for follow-up. MRI is limited in its ability to fully depict the cortical integrity of incomplete fractures of the pars, but the presence of marrow oedema on fat-saturated T2-weighted sequences is a useful means of detecting acute spondylolysis.
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Affiliation(s)
- Andrew J Dunn
- Department of Medical Imaging, Royal Liverpool and Broadgreen University Teaching Hospitals, Prescot Street, Liverpool, L7 8XP, UK
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20
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Khoury NJ, Hourani MH, Arabi MMS, Abi-Fakher F, Haddad MC. Imaging of Back Pain in Children and Adolescents. Curr Probl Diagn Radiol 2006; 35:224-44. [PMID: 17084238 DOI: 10.1067/j.cpradiol.2006.07.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To present the imaging findings of the wide spectrum of musculoskeletal diseases causing back pain in children and adolescents. DISCUSSION Back pain in children is a rare condition but may denote a serious health problem; hence, full clinical history, physical examination, and appropriate laboratory studies should be obtained. In this scientific exhibit, we present the imaging findings of the variable musculoskeletal diseases that are associated with back pain in children and adolescents. These disease processes include scoliosis of various causes; spondylolysis; spondylolisthesis; traumatic injuries; disc degeneration and herniation; Scheuermann's disease; spondylodiscitis; tumors (primary, secondary, hematogenous); and miscellaneous conditions (eg, metabolic disorders, sickle cell disease, osteoporosis). CONCLUSION A wide spectrum of diseases causing back pain in children is presented. Radiologists should be aware of the imaging findings of this rather uncommon entity to help in reaching the appropriate diagnosis.
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Affiliation(s)
- Nabil J Khoury
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon.
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21
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Abstract
Retrospective review of 142 patients from 2 teaching hospitals, investigated for persistent backache. The inclusion criteria were to be up to 18 years, to have no known associated diseases, and to have had a bone scan as a part of their work up. Other tests were also used to reach the final diagnosis. The utility of the bone scan to detect underlying pathology was assessed. On the whole, 75 patients were found to have pathology while only 52 children had a positive bone scan. We also looked for associated findings that could indicate the presence of pathology. The age of the patients, the duration of symptoms, and the presence of night pain seemed to be irrelevant on predicting underlying pathology. The sensitivity of the bone scan was low, 0.613 (95% CI: 0.549-0.654), although it proved to be highly specific, 0.91 (95% CI: 0.83-0.95). A careful analysis of the data and the different diagnosis suggests that Technetium bone scan still holds a place in the study of these patients; however, there is a big concern by the fact that some primary malignancies went undetected on the scan.
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Affiliation(s)
- Ignacio Sanpera
- Pediatric Orthopaedic Unit, Hospital Universitari de Son Dureta, Palma de Mallorca, Spain.
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Cohen E, Stuecker RD. Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects. J Pediatr Orthop B 2005; 14:63-7. [PMID: 15703512 DOI: 10.1097/01202412-200503000-00001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The lumbar spine was assessed by magnetic resonance imaging (MRI) in 14 children (mean age 12.4 years) with unspecific activity-related low back pain for more than 3 weeks presenting with normal plain radiographs. Impending spondylolysis was diagnosed when typical signal abnormalities were confined to the pars interarticularis without signs of thinning or fragmentation. After brace treatment for 3 months, follow-up MRI was performed 3 and 6 months after treatment. MRI signals returned to normal after 3 months in six patients and after 6 months in one patient. MRI showed promising results in detecting and monitoring the early onset of spondylolysis. Bracing and avoiding strenuous activities prevented the formation of pars defects in all our patients.
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Affiliation(s)
- Eugen Cohen
- Pediatric Orthopaedic Department, Children's Hospital Hamburg-Altona, Hamburg, Germany
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Campbell RSD, Grainger AJ, Hide IG, Papastefanou S, Greenough CG. Juvenile spondylolysis: a comparative analysis of CT, SPECT and MRI. Skeletal Radiol 2005; 34:63-73. [PMID: 15668821 DOI: 10.1007/s00256-004-0878-3] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2004] [Revised: 09/02/2004] [Accepted: 09/27/2004] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate whether MRI correlates with CT and SPECT imaging for the diagnosis of juvenile spondylolysis, and to determine whether MRI can be used as an exclusive image modality. DESIGN AND PATIENTS Juveniles and young adults with a history of extension low back pain were evaluated by MRI, CT and SPECT imaging. All images were reviewed blindly. Correlative analyses included CT vs MRI for morphological grading and SPECT vs MRI for functional grading. Finally, an overall grading system compared MRI vs CT and SPECT combined. Statistical analysis was performed using the kappa statistic. RESULTS Seventy-two patients (mean age 16 years) were recruited. Forty pars defects were identified in 22 patients (31%), of which 25 were chronic non-union, five acute complete defects and ten acute incomplete fractures. Kappa scores demonstrated a high level of agreement for all comparative analyses. MRI vs SPECT (kappa: 0.794), MRI vs CT (kappa: 0.829) and MRI vs CT/SPECT (kappa: 0.786). The main causes of discrepancy were between MRI and SPECT for the diagnosis of stress reaction in the absence of overt fracture, and distinguishing incomplete fractures from intact pars or complete defects. CONCLUSIONS MRI can be used as an effective and reliable first-line image modality for diagnosis of juvenile spondylolysis. However, localised CT is recommended as a supplementary examination in selected cases as a baseline for assessment of healing and for evaluation of indeterminate cases.
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Affiliation(s)
- R S D Campbell
- Department of Radiology, Royal Liverpool University Hospital, Prescot St., Liverpool L7 8XP, UK.
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Hollenberg GM, Beattie PF, Meyers SP, Weinberg EP, Adams MJ. Stress reactions of the lumbar pars interarticularis: the development of a new MRI classification system. Spine (Phila Pa 1976) 2002; 27:181-6. [PMID: 11805665 DOI: 10.1097/00007632-200201150-00012] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN In a retrospective study, multiple examiners reviewed lumbar magnetic resonance imaging scans to develop a new grading system for lumbar pars interarticularis stress reaction and spondylolysis. The resulting system can be used as a mechanism for classifying patients, and as a measurement tool for future studies assessing the outcome efficacy of lumbar magnetic resonance imaging in patients with abnormalities of the pars interarticularis. OBJECTIVE To determine the reliability of patient assignment to five different grades of bone stress reaction involving the lumbar pars interarticularis. SUMMARY OF BACKGROUND DATA Injury to the lumbar pars interarticularis (spondylolysis) is reported to be a common cause of low back pain in young patients. High-field-strength magnetic resonance imaging using fat saturation techniques and dedicated coil technology is sensitive in detecting bone stress injuries of the lumbar pars interarticularis, and thus is an excellent method for diagnosis. It also may be useful in prognostic decision making for these patients. A reliable classification system is a fundamental requirement for performing the research assessing the relationship between lumbar MRI findings and prognosis. METHODS For this study, 55 young athletic patients undergoing evaluation for low back pain with suspected stress injury to the lumbar pars interarticularis underwent standardized lumbar magnetic resonance imaging using a 1.5-T scanner. Magnetic resonance images were reviewed by three readers using a new magnetic resonance classification system developed for lumbar spondylolysis. The findings were assessed for both interobserver and intraobserver reliability for five possible combinations in a 5-grade classification system. RESULTS On magnetic resonance imaging, 42% of the patients demonstrated signal abnormalities of the lumbar pars interarticularis. The intraobserver and interobserver reliability coefficients for assigning the grade of pars interarticularis abnormality ranged, respectively, from 0.766 (95% confidence interval [CI], 0.62-0.91) to 0.906 (95% CI, 0.80-1), and from 0.706 (95% CI, 0.55-0.86) to 1. CONCLUSIONS Magnetic resonance findings of stress reactions and spondylolysis of the lumbar pars interarticularis can be reliably classified into five grades by experienced readers. Further study is needed to determine the role of these findings in the management of young athletic patients with low back pain.
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Affiliation(s)
- Gary M Hollenberg
- Department of Radiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
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McGregor AH, Cattermole HR, Hughes SP. Global spinal motion in subjects with lumbar spondylolysis and spondylolisthesis: does the grade or type of slip affect global spinal motion? Spine (Phila Pa 1976) 2001; 26:282-6. [PMID: 11224864 DOI: 10.1097/00007632-200102010-00013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This was a prospective pilot study to investigate the global motion characteristics of the spondylolysis and spondylolisthesis populations. OBJECTIVES The aim of this study is to determine the influence of a spondylolisthesis or a spondylolysis on global spinal motion and to establish whether this is dependent on the cause of the slip or the degree/grade of the slip. SUMMARY OF BACKGROUND DATA The condition of spondylolisthesis has been extensively discussed in the literature with respect to its etiology and management. However, the mechanics and movement of the spine in relation to pathology and the effect of this condition on function have received scant attention. METHODS The motion of the lumbar spine was investigated in 31 patients (19 men, 12 women, mean age 47.7 +/- 17.8 years) who were diagnosed as having either a lumbar spondylolysis or a spondylolisthesis. These patients were compared with a preexisting database of 203 normal subjects (100 men, 103 women, mean age 39.8 +/- 13.4 years). Patients were graded according to the type of spondylolisthesis or spondylolysis they had, and the extent of slip was rated using Meyerding's classification (1932) and measured directly using methods of Boxall et al (1979) and Wiltse et al (1983). RESULTS Direct measurements of the extent of slip using Boxall et al (1979) and Wiltse et al (1983) methods were found to have no significant correlation with the resultant range of motion (ROM) or the speed of movement. This study suggests that motion parameters are influenced by the grade of slip in patients with spondylolisthesis, and the type of spondylolisthesis i.e., whether isthmic or degenerative. In the A-P flexion-extension plane, the results indicate that subjects with a defect only, i.e., a spondylolysis, and thus no slip present with a spinal hypermobility (P < 0.01). Subjects with an isthmic slip tend to be either slightly hypermobile or within the anticipated range of motion, whereas those subjects with a degenerative slip tend to be hypomobile (P < 0.05). Movements into lateral flexion were restricted in both the isthmic and degenerative spondylolisthesis patients, whereas rotation was only influenced by the level at which the defect occurred. In terms of degree of displacement, in higher grades of displacement, there was a trend towards hypermobility. CONCLUSIONS The findings of this study suggest that the grade and type of spondylolisthesis do influence global motion parameters. This information may be useful in the clinical assessment of this patient group.
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Affiliation(s)
- A H McGregor
- Imperial College School of Medicine, Charing Cross Hospital, London, UK
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26
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Abstract
The pediatric rheumatologist cares for children who may have a wide variety of causes of musculoskeletal pain. These include such diverse conditions as arthritis, low-back pain, hypermobility, metabolic bone pain, and amplified pain syndromes such as complex regional pain syndrome and fibromyalgia. This review examines the recent literature on these and other conditions causing musculoskeletal pain in children and adolescents. Overall, headway is being made, but differentiating soma from psyche remains a problem. This is perhaps due to the marked and unique effect pain brings to each of us. Children are different from adults in causes, presentations, and outcome. Vigilance in history, physical examination, and judicious use of laboratory investigations are usually sufficient in establishing a diagnosis, as well as an appreciation for the variety of presentations each condition can manifest.
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Affiliation(s)
- D D Sherry
- Department of Pediatric Rheumatology, Children's Hospital and Regional Medical Center, Rheumatology CH-73, 4800 Sand Point Way, NE, Seattle, WA 98105, USA.
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