Conservative treatment of lumbar spondylolysis in childhood and adolescence

Factors associated with non-fusion after direct pars repair of lumbar spondylolysis with pedicle screw and lamina hook: a clinical and CT-assessed study

BACKGROUND

Pedicle screw and lamina hook (PSLH) technique is an effective and popular method for direct pars repair of lumbar spondylolysis. There is a lack of studies to explore factors that may influence the healing of spondylolysis after direct pars repair surgery. The present study aimed to investigate the factors associated with non-fusion after direct pars repair of lumbar spondylolysis with PSLH technique.

METHODS

A total of 55 subjects (average age 21.1 ± 6.3 years, a total of 120 pars defects) diagnosed with symptomatic spondylolysis and underwent pars repair surgery with PSLH were followed up and their clinical data were analyzed. Subjects were divided into a non-fusion group and fusion group according to whether the pars defect had bony fusion at last follow-up assessed by CT. Radiographic data, data related to spondylolysis and clinical outcomes were collected and compared between groups.

RESULTS

The mean follow-up time of the 55 patients was 24.8 ± 12.0 (12-64) months. Among the 120 pars defects, 101 defects were successfully fused and 19 were not fused according to CT. The fusion rate was 84.2%. Multivariable logistic regression analysis showed the factors correlated with non-fusion after pars repair surgery: whether the spondylolysis segment was associated with spina bifida occulta (SBO) (P = 0.001), stage of the defect (P = 0.047), width of the defect (P = 0.002), and disc degeneration (P = 0.014).

CONCLUSION

Direct pars repair by PSHL is a reliable treatment for lumbar spondylolysis with a fusion rate of 84.2%. Association with SBO of the spondylolysis segment, a terminal stage of the defect, a wider defect gap, and grade III disc degeneration may be factors associated with non-fusion after direct pars repair of lumbar spondylolysis with PLSH. Non-fusion patients after pars repair appear to have worse clinical results compared to fusion patients.

Robotic-assisted minimally invasive repair surgery for progressive spondylolysis in a young athlete: a technical note

Presently, the invasiveness of direct repair surgery for lumbar spondylolysis is relatively high. Thus, high school and junior high school students who play sports often cannot return to sports before graduation because of the invasiveness. The use of a robotic system enabled an accurate and minimally invasive procedure. Robotic-assisted minimally invasive direct pars repair surgery is useful for young patients with progressive spondylolysis.

Characteristics of lumbar spondylolysis: L5 versus non-L5

BACKGROUND

Fifth lumbar vertebra (L5) spondylolysis has a lower bone union rate than non-L5 spondylolysis, but the reason for this is unknown. This study aimed to evaluate the differences in patient and lesion characteristics between L5 and non-L5 spondylolysis.

METHODS

A total of 410 patients with lumbar spondylolysis aged 18 years or younger who were treated conservatively were enrolled. Patients and lesions were divided into L5 and non-L5 (L2-L4) spondylolysis. Factors, including sex, age, presence of spina bifida occulta, stage of the main side lesion, whether the lesion was unilateral or bilateral, presence and stage of the contralateral side lesion and treatment duration, were evaluated at the first visit and compared between the two groups.

RESULTS

A total of 250 patients with 349 lesions were included. The bone union rate of L5 lesions was lower than that of non-L5 lesions (75% vs. 86%, p = 0.015). Patients with L5 spondylolysis were more likely to be male (86% vs. 66%) and younger (14.0 vs. 14.6 years) than patients with non-L5 spondylolysis. Lesions of L5 spondylolysis were more likely to be in a progressive stage (28% vs. 15%), less likely to be in a pre-lysis stage (28% vs. 43%) and more likely to be in a contralateral terminal stage (14% vs. 5.3%, p = 0.013) compared with lesions of non-L5 spondylolysis.

CONCLUSIONS

L5 spondylolysis was characterised by a lower bone union rate, more males, younger age, more progressive stage and more contralateral pseudarthrosis than non-L5 spondylolysis.

Factors associated with return to play following conservative treatment for lumbar spondylolysis among young athletes: A retrospective case series using structural equation modeling

INTRODUCTION

Lumbar spondylolysis is the most common underlying cause of lower back pain (LBP) in young athletes. Conservative treatment methods are often used to reduce pain and promote healing. Several parameters may affect the duration of conservative treatment, such as the time to return to play (RTP), patient behavior, and physical parameters; however, no study has comprehensively assessed the factors that affect the time to RTP.

OBJECTIVES

This study aimed to determine the factors associated with the time required for RTP among young athletes with early-stage spondylolysis receiving conservative treatment using structural equation modeling (SEM).

METHODS

In this retrospective case series, 137 young athletes (128 males and 9 females, aged 9-18 years) with early-stage lumbar spondylolysis were enrolled. All patients were examined using plain radiography and magnetic resonance imaging and treated conservatively (sports cessation, wearing a corset, therapeutic exercises, and low-intensity pulsed ultrasound radiation). SEM was used to investigate the factors affecting the time to RTP in these patients.

RESULTS

The final model included the following factors: spondylolysis laterality, symptom duration, lower-extremity flexibility, treatment interval, patient adherence, and residual LBP. SEM revealed that patient adherence to physician orders (p < 0.01), treatment interval (p < 0.001), and spondylolysis laterality (p < 0.001) contributed directly to shortened RTP.

CONCLUSION

Patient adherence is essential for reducing the time to RTP among young athletes receiving conservative treatment for early-stage spondylolysis.

Effects of Spina Bifida Occulta on Bone Union in Fifth Lumbar Spondylolysis

Introduction

The effect of spina bifida occulta (SBO) on bone union in lumbar spondylolysis is controversial. The study aim was to assess the effect of SBO on bone union after conservative treatment of L5 spondylolysis, the most common level.

Methods

The study included 191 lesions in 145 patients (mean age, 14.0 years) with conservatively treated L5 spondylolysis. We examined the relationships between bone union after conservative treatment and the number of SBOs, levels, and single or multilevel status. Fisher's exact probability test, chi-square test, and Welch's T test were performed.

Results

The SBO incidence was 53%, with at least one SBO at any vertebral level. SBO at S1 (p=0.034) or S2 (p=0.0003), two SBOs (p=0.0018), and three SBOs (p=0.011) were associated with a lower bone union rate. The bone union rate was significantly lower for lesions with SBOs at both S1 and S2 than without (42% vs. 79%; p<0.0001).

Conclusions

The SBO incidence in L5 spondylolysis was 53%. SBO at S1 or S2 and a higher number of SBOs were associated with lower bone union rates. In particular, the bone union rate of lesions with SBOs at both S1 and S2 was <50%.

Epidemiological differences between the sexes in adolescent patients with lumbar spondylolysis: a single-institution experience in Japan

BACKGROUND

Lumbar spondylolysis, a common identifiable cause of low back pain in young athletes, reportedly has a higher incidence rate in males. However, the reason for its higher incidence in males is not clear. This study aimed to investigate the epidemiological differences between the sexes in adolescent patients with lumbar spondylolysis.

METHODS

A retrospective study was conducted in 197 males and 64 females diagnosed with lumbar spondylolysis. These patients visited our institution from April 2014 to March 2020 with their main complaint being low back pain, and they were followed-up until the end of their treatment. We investigated associations between lumbar spondylosis, their background factors, and characteristics of the lesions and analyzed their treatment results.

RESULTS

Males had a higher prevalence of spina bifida occulta (SBO) (p = 0.0026), more lesions with bone marrow edema (p = 0.0097), and more lesions in the L5 vertebrae (p = 0.021) than females. The popular sports disciplines were baseball, soccer, and track and field in males, and volleyball, basketball, softball in females. The dropout rate, age at diagnosis, bone union rate, and treatment period did not differ between the sexes.

CONCLUSION

Lumbar spondylolysis was more common in males than in females. SBO, bone marrow edema, and L5 lesions were more frequent in males, and sports discipline varied between the sexes.

Main and contralateral side stages of lesion affected bone union in the conservative treatment of adolescent lumbar spondylolysis: a multivariable analysis of 217 patients and 298 lesions in a retrospective cohort study

BACKGROUND

Factors affecting bone union in the conservative treatment of adolescent lumbar spondylolysis remain controversial. We aimed to examine these factors along with advances in diagnostic imaging using multivariable analysis of a sufficient number of patients and lesions.

METHODS

In this retrospective study, high-school-aged patients or younger (n = 514) who were diagnosed with lumbar spondylolysis from 2014 to 2021 were investigated. We included patients with acute fractures who showed signal changes around the pedicle on magnetic resonance imaging and who completed conservative treatment. The following factors were investigated at the initial visit: age, sex, level of lesion, main side stage, presence and stage of contralateral side lesion, and presence of spina bifida occulta. The association of each factor with bone union was evaluated through a multivariable analysis.

RESULTS

Altogether, 298 lesions in 217 patients (174 boys and 43 girls; mean age: 14.3 years) were included in this study. Multivariable logistic regression analysis of all factors showed that the main side progressive stage was more likely associated with nonunion as compared to the pre-lysis (OR: 5.86; 95% confidence interval [CI]: 2.00-18.8; p = 0.0011) and early stages (OR: 3.77; 95% CI: 1.72-8.46; p = 0.0009). Regarding the contralateral side stage, the terminal stage was more likely to be associated with nonunion.

CONCLUSION

In the conservative treatment of lumbar spondylolysis, the factors affecting bone union were the main and contralateral side stages. Sex, age, level of lesion, or spina bifida occulta had no significant effects on bone union. The main, progressive, and contralateral side terminal stages were negative predictors of bone union. Trial registration This study was retrospectively registered.

Risk Factors for Symptomatic Bilateral Lumbar Bone Stress Injury in Adolescent Soccer Players: A Prospective Cohort Study

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.

Diagnostic Utility of Double-Echo Steady-State (DESS) MRI for Fracture and Bone Marrow Edema Detection in Adolescent Lumbar Spondylolysis

To evaluate the ability of double-echo steady-state (DESS) MRI to detect pars interarticularis fracture and bone marrow edema (BME) in spondylolysis, 500 lumber pars interarticularis from 50 consecutive patients (38 males and 12 females, mean age 14.2 ± 3.28 years) with spondylolysis who underwent both MRI and CT within 1 week were evaluated. All participants were young athletes who complained of lower back pain. Fractures were classified into four grades and CT was used as a reference; BME was evaluated in a binary manner and STIR was used as a reference. The diagnostic performance of fractures on DESS and T1WI, and BME on DESS was assessed by two radiologists independently. For fracture detection, DESS showed high diagnostic performance at a sensitivity of 94%, specificity of 99.5%, and accuracy of 98.8%, whereas T1WI showed lower sensitivity (70.1%). Fracture grading performed by DESS showed excellent agreement with CT grading (Kappa = 0.9). For BME, the sensitivity, specificity, and accuracy of DESS were 96.5%, 100%, and 99.6%, respectively. The inter-rater agreement of DESS for fracture and BME was 0.8 and 0.85, respectively. However, the inter-rater agreement for fracture on T1WI was 0.52. DESS had high diagnostic performance for fracture and BME in pars interarticularis. In conclusion, DESS had potential to detect all critical imaging findings in spondylolysis and may replace the role of CT.

Elastic Lumbar Support Versus Rigid Thoracolumbar Orthosis for Acute Pediatric Spondylolysis: A Prospective Controlled Study

STUDY DESIGN

A prospective study on clinical, radiographic, and health-related quality of life (HRQoL) outcomes in children with acute spondylolysis treated with a rigid thoracolumbar orthosis or with an elastic lumbar support.

OBJECTIVE

To compare outcomes of pediatric spondylosysis treated with a hard brace or an elastic lumbar support.

SUMMARY OF BACKGROUND DATA

The benefits of the use of a rigid orthosis in treatment of spondylolysis are not clear.

MATERIALS AND METHODS

Fifty-seven consecutive children with acute spondylolysis (mean age: 14.1 yr, range: 9-17 yr) were prospectively enrolled. Patients were treated with a rigid thoracolumbar orthosis (Boston brace) or with a low-profile, elastic lumbar support. First 14 patients were randomized the remaining 43 chose brace type themselves. Treatment period was four months. Treatment outcomes included bony union of the spondylolysis assessed with a computed tomography at four months and HRQoL using the Scoliosis Research Society-24 outcome questionnaire filled out before and after the treatment.

RESULTS

Of the 57 patients, 54 completed the treatment protocol. Twenty-nine patients were treated using the Boston brace and 25 patients the elastic lumbar support. Bony union was obtained in 69.0% (20/29) of the Boston brace and in 60.0% (15/25) of the elastic lumbar support group patients. Difference in union rates was not significant (relative risk=1.14, 95% confidence interval: 0.44-2.98, P =0.785). There was no difference in the Scoliosis Research Society-24 total or domain scores at the end of follow-up between the treatment groups ( P >0.159 for all comparisons). In the whole cohort, the bony union did not predict better HRQoL in the end of the treatment ( P =0.869), although the pain domain improved significantly in the whole cohort ( P <0.001).

CONCLUSIONS

A rigid thoracolumbar orthosis did not provide any benefits over an elastic lumbar support in terms of bony union or HRQoL outcomes in children with acute spondylolysis.

LEVEL OF EVIDEN

2.

Current Clinical Concepts: Management of Common Lumbar Spine Posterior Column Disorders in Young, Active Individuals

Although posterior column disorders, such as spondylolysis and spondylolisthesis, are not commonly encountered in the general population, athletic trainers frequently see these conditions in athletic and active individuals due to the repetitive spinal extension and rotational loads placed on the pars interarticularis while participating in sport. Athletic trainers can successfully evaluate patients with posterior column disorders by performing a complete and comprehensive clinical examination to identify the location of pain, test spinal stability, and recognize compensatory movement patterns. Conservative management typically leads to a successful outcome in this population, with rest, bracing, and the use of therapeutic exercise having the best supporting evidence. In this Current Clinical Concepts review, we outlined the etiology and risk factors frequently associated with disorders of the posterior column. Additionally, we synthesized the literature for common evaluation techniques and interventions associated with the posterior column and provided a proposed rehabilitation progression to use in a younger, athletic population.

Characteristics of Adult-Onset Acute Lumbar Spondylolysis Treated Conservatively

Introduction

Lumbar spondylolysis typically arises during adolescence, whereas its onset in adulthood is rare. Several studies have reported incidentally identified terminal-stage spondylolysis in adults, but only one case series has investigated acute lumbar spondylolysis lesions with bone marrow edema in adults.

Methods

We retrospectively investigated lumbar spondylolysis in patients aged 18 years or older. Age at diagnosis, sex, competitive sporting level, and competitive sporting discipline were investigated in each patient. The level of the affected vertebra, pathological stage, bone union, and treatment period were analyzed for each lesion.

Results

The study included nine patients (eight males and one female), aged 18-22 years old, with 14 acute lumbar spondylolysis lesions. Four patients were soccer players (two professionals, and two amateurs), four were amateur track and field athletes, and one was an amateur basketball player. The affected vertebral levels were L3 in two lesions, L4 in seven lesions, and L5 in five lesions. The pathological stage was pre-lysis stage in two lesions, early stage in eight lesions, and progressive stage in four lesions. Ten lesions achieved bone union with conservative therapy. The average treatment period was 84.7 days.

Conclusions

The adult-onset lumbar spondylolysis patients were young, up to their early 20s, and generally professional sportspeople performing at an elite level. Most of them were performing a sport that has been reported to have a high risk of causing lumbar spondylolysis. L4 was the most affected vertebral level in contrast to L5, which has been reported in adolescent lumbar spondylolysis. Bone union was achieved for most lesions with conservative therapy.

Union evaluation of lumbar spondylolysis using MRI and CT in adolescents treated conservatively

BACKGROUND

This study evaluated the union rate of acute lumbar spondylolysis in patients treated conservatively, according to the protocol.

METHODS

The subjects included high school students and younger patients who were diagnosed with lumbar spondylolysis presenting bone marrow edema. We investigated the union rate, the period until union, unilateral or bilateral, vertebral level, laterality (right or left), and pathological stage at the first visit. Some unilateral cases included bilateral spondylolysis with contralateral pseudarthrotic lesion; therefore, the union rate of the "true" unilateral case in which the contralateral side was normal was calculated. We excluded multi-level lesions.

RESULTS

With conservative treatment for lumbar spondylolysis of 189 lesions in 142 cases, 144 healed and 45 were considered as nonunion. The average treatment period until union was 106 days. The union of "true" unilateral cases in which the contralateral side was normal was noted in 68/71 lesions, but that of bilateral cases was noted in 71/94 lesions. The union in L3, L4, and L5 vertebrae was noted in 15/17, 40/49, and 89/123 lesions, respectively. The union was observed in 63/87 on the right and 86/102 on the left. The union was noted in the pre-lysis, early, and progressive stages in 36/39, 81/97, and 27/53 lesions, respectively. Furthermore, the union was noted in stages 0, 1a, 1b, 1c, and 2 in 13/15, 47/52, 30/36, 34/42, and 20/44 lesions, respectively.

CONCLUSION

Accurate union evaluation using CT and MRI showed a union rate of 76% with conservative treatment for spondylolysis. The union rate of the "true" unilateral cases in which the contralateral side was normal was 96%, which was significantly higher than that of the bilateral cases. Moreover, the union rate of lesions in the axial progressive stage and sagittal stage 2 was significantly lower than that of lesions in other stages.

STUDY DESIGN

clinical retrospective study.

Rotation-related sports players demonstrate rotation-type lumbar spondylolysis fracture angle and decreased hip internal rotation range of motion

Relationship between sports and spondylolysis fracture angle (SFA), and hip internal rotation range of motion (IR ROM) between the sports groups among athletes with spondylolysis were investigated. Sports requiring repeated rotation of the trunk and hips during most aspects of the activity was defined as rotation-related sports (RRS). The SFA was defined as rotation-type or horizontal-type by using the axial view of the CT scan. Percentage of rotation type and SFA of the non-dominant side for RRS group was significantly greater than those of non-RRS group. Hip IR ROM of RRS group was significantly smaller than that of non-RRS group.

Level of evidence

Level IV.

Physical characteristics of patients with symptomatic lumbar spondylolysis who have recurrent low back pain after returning to sports

INTRODUCTION

To determine the physical characteristics of patients with symptomatic lumbar spondylolysis (LS) who have recurrent low back pain after returning to sports.

METHOD

Fifty-three adolescent patients with symptomatic LS participated in this study. Patients with symptomatic LS were assessed for flexibility, trunk muscle strength, and Functional Movement Screen (FMS) score, and then divided into two groups according to the degree of pain experienced one month after returning to sport.

RESULTS

Twenty-four patients returned to their pre-injury sports level without pain (excellent group), while the remaining 29 patients had pain and decreased activity level during sports (pain group). The excellent group had a significantly higher shoulder mobility score on the FMS than the pain group, and the effect size was larger. However, there were no significant differences in body flexibility, muscle tightness, trunk muscle strength, or other FMS items.

DISCUSSION

The most important finding of this study is that patients with LS who have recurrent low back pain after returning to sports are characterized by poor functional upper body movement.

CONCLUSIONS

Because upper body functional movement pattern may be an important factor in the management of patients with symptomatic LS, preventive rehabilitation to enhance upper body mobility and motor control should be considered for these patients.

Minimally Invasive Screw Fixation of Non-Pseudoarthorotic Lumbar Spondylolysis for Early Return to Sports

Lumbar spondylolysis is a fatigue fracture that occurs most frequently in middle and high school athletes. Conservative treatment is the first choice when the fracture is fresh. Surgical treatment of lumbar spondylolysis is often reported for pseudarthrosis cases, but surgery for cases of fresh fractures is rare. We report a case of a 16-year-old male, high jump athlete, with recurrent non-pseudoarthorotic lumbar spondylolysis. He presented to our hospital with a chief complaint of back pain, and was diagnosed as right L5, pre-lysis-stage lumbar spondylolysis. After 3 months of conservative treatment, bone union was achieved with no obvious worsening of the fracture. His back pain also disappeared and he was able to return to exercise. At 6 months after the first examination, the lesion recurred and he could no longer continue playing sports, so surgical treatment was indicated. Minimally invasive screw fixation was performed by combining Buck's method and the cortical bone trajectory. After the surgery, he started jogging at 5 weeks, resumed jumping practice at 7 weeks, and returned to competition at 2 months. He set a new personal best in a competition 3 months post-surgery. Bone union was achieved at 4 months. This technique is minimally invasive and does not involve debridement or bone grafting, which provides early pain relief and return to sports.

Lumbar spondylolysis - Current concepts review

Lumbar pars interarticularis (PI) injury or spondylolysis occurs only in humans. This represents a stress fracture of the PI. Excessive loading in repetitive hyperextension is a significant risk factor and occurs most commonly at L5 followed by L4. It is bilateral in 80% of symptomatic cases but can be unilateral defect as well which runs a more benign course. Symptoms of low back pain relating to this lesion are more common in young athletes involved in trunk twisting sports. Like other stress fractures, the pain may come on abruptly or more insidiously over time and only related to certain activities. The pathologic progression starts with a stress reaction in the pars, progressing to an incomplete stress fracture, and then a complete pars fracture. Diagnosis is dependent on clinical examination and radiological imaging studies (plain radiography, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans). Treatment is dependent on symptoms as well as radiographic stage of the lesion. Conservative management is the mainstay of treating early lesions. A comprehensive rehabilitation program incorporates core spinal stabilization exercises. Athletes should not return to sports until pain free. Professional sporting individuals are at increased risk of failure of resolution of symptoms that may require early surgical repair of the PI defect. Modified Buck's technique & pedicle screw-hook constructs for direct repair has a high success rate in patients who have persistent low back pain. Minimally invasive lumbar pars defect repair has given similar successful outcome with added advantage of minimizing muscle injury, preserving the adjacent joint and reduced hospital stay. Functional outcome is evaluated using the Visual Analogue Scale (VAS) for back pain, Oswestry Disability Index (ODI) and 36-Item Short-Form Health Survey (SF-36). Preoperative ODI and SF-36 physical component scores (PCS) are significant predictor of a good functional outcome.

Comparing Surgical Treatments for Spondylolysis: Review on Current Research

STUDY DESIGN

Narrative review.

OBJECTIVE

To compare the various surgical methods of repairing spondylolysis defects in regard to improving pain, restoration of function, radiographic improvement, and complication rate.

SUMMARY OF BACKGROUND DATA

Spondylolysis is a defect in the pars interarticularis of the vertebral arch, typically in the lumbar vertebra. Treatment can be nonoperative and/or surgical. There are various types of surgical repair including spinal compression, fusion, and direct pars repair.

METHODS

A comprehensive review of the English literature was performed utilizing Medline, Embase, and Web of Science. Inclusion criteria included papers or abstracts that evaluated the surgical techniques. Exclusion criteria included non-English-language papers or abstracts with inadequate information about outcomes.

RESULTS

Postoperative pain levels and patient function were consistently improved, regardless of surgical technique chosen. Positive clinical outcomes after surgery were seen more often in patients under age 20 and those who underwent minimally invasive repairs. Positive radiographic improvements were reported broadly, although some reported higher rates of nonunion with spinal compression. Complication rates were low throughout and minimally invasive techniques reported decreased blood loss and shorter hospital stays.

CONCLUSIONS

Present surgical options appear largely comparable in terms of their ability to provide meaningful treatment for spondylolysis where conservative treatments have failed or otherwise remain unattempted.

Immediate functional progression program in adolescent athletes with a spondylolysis

OBJECTIVE

To assess the preliminary evidence for the efficacy and safety of an immediate functional progression program to treat adolescent athletes with an active spondylolysis.

DESIGN

Prospective single-arm trial.

SETTING

Hospital-based sports medicine and physical therapy clinic.

PARTICIPANTS

Twelve adolescent athletes (14.2 ± 2 years, 25% female) with an active spondylolysis.

MAIN OUTCOME MEASURES

Clinical outcomes included time out of sport, Micheli Functional Scale (Function and Pain) and adverse reactions. Clinical outcomes were assessed at baseline, 1 month, 3 months and 6 months. Magnetic resonance imaging was performed at baseline and 3 months to confirm diagnosis and assess healing of lesion.

RESULTS

Eleven participants (92%) fully returned to sport in a median time of 2.5 months (75 days; interquartile range 55 days, 85 days). All participants demonstrated marked improvements in pain and function by the end of the program. One participant (8%) had an adverse reaction during care with a significant recurrence of LBP and had not returned to sport by 6 months. Magnetic resonance imaging demonstrated improvement of the spondylolytic lesion in all but one participant.

CONCLUSION

The immediate functional progression program appears a viable method for treating active spondylolysis and warrants future research.

Factors associated with failure of bony union after conservative treatment of acute cases of unilateral lumbar spondylolysis

Background

If bone union is expected, conservative treatment is generally selected for lumbar spondylolysis. However, sometimes conservative treatments are unsuccessful. We sought to determine the factors associated with failure of bony union in acute unilateral lumbar spondylolysis with bone marrow edema including contralateral pseudarthrosis.

Methods

This study targeted unilateral lumbar spondylolysis treated conservatively in high school or younger students. Conservative therapy was continued until the bone marrow edema disappeared on MRI and bone union was investigated by CT. We conducted a univariate analysis of sex, age, pathological stage, lesion level complicating the contralateral bone defect, lesion level, and intercurrent spina bifida occulta, and variables with p < 0.1 were considered in a logistic regression analysis. An item with p < 0.05 was defined as a factor associated with failure of bony union.

Results

We found 92 cases of unilateral spondylolysis with bone marrow edema and 66 cases were successfully treated conservatively. Failure of bony union in unilateral lumbar spondylolysis with bone marrow edema was associated with progressive pathological stage (p = 0.004), contralateral pseudarthrosis (p < 0.001), and L5 lesion level (p = 0.002). The odds ratio was 20.0 (95% CI 3.0–193.9) for progressive pathological stage, 78.8 (95% CI 13–846) for contralateral pseudarthrosis, and 175 (95% CI 8.5–8192) for L5 lesion level.

Conclusions

Conservative therapy aiming at bony union is contraindicated in cases of acute unilateral spondylolysis when the pathological stage is progressive, the lesion level is L5, or there is contralateral pseudarthrotic spondylolysis.

Bone Healing in Adolescents with Bilateral L5 Spondylolysis with and without Preexisting Contralateral Terminal Spondylolysis

Study Design

Retrospective cohort study

Purpose

To examine bone healing with conservative treatment in cases of adolescent bilateral L5 spondylolysis.

Overview of Literature

We classified bilateral L5 spondylolysis, which is the most affected spinal level, by fracture stage and aimed to compare the bone healing rate according to the fracture stage and evaluate the presence of a preexisting contralateral terminal fracture at the diagnosis of fresh spondylolysis.

Methods

We evaluated 48 patients (38 boys and 10 girls) with bilateral L5 spondylolysis diagnosed during or before high school. L5 spondylolysis was classified into two groups: fresh group (bilateral fresh spondylolysis cases), and terminal group (cases wherein one side had fresh spondylolysis and the contralateral side had terminal spondylolysis). We investigated the age of examination and bone healing rate in both groups. We investigated progressive-stage lesions and bone healing rate with or without progressive-stage lesions.

Results

The bone healing rate in the fresh group was significantly higher than that in the terminal group 72.0% vs. 26.1%, p=0.003). In both the groups, the bone healing rate was significantly higher in patients without progressive-stage lesions than in those with progressive-stage lesions.

Conclusions

Bone healing of progressive-stage fresh spondylolysis was not achieved by conservative treatment when contralateral terminal spondylolysis was present in adolescents with bilateral L5 spondylolysis. Our results suggest that bilateral L5 spondylolysis treatment strategies must be determined based on the combination of the stages present.

Quantitative Assessment of Bone Marrow Edema in Adolescent Athletes with Lumbar Spondylolysis Using Contrast Ratio on Magnetic Resonance Imaging

STUDY DESIGN

Prospective cohort study.

PURPOSE

To quantitatively evaluate bone marrow edema (BME) in the pedicle on magnetic resonance imaging (MRI) for adolescent athlete patients with spondylolysis.

OVERVIEW OF LITERATURE

Spondylolysis, a stress fracture of the pars interarticularis, is a common occurrence in adolescent athletes with low back pain. T2-weighed fat-saturated MRI is reportedly useful for the detection of BME in the pedicle in the early stage of spondylolysis; however, to our knowledge, the quantitative assessment of BME in spondylolysis has not been reported.

METHODS

Adolescent athletes with spondylolysis, including those with symptoms of low back pain, were enrolled. The sporting activity of the patients was restricted, and a hard brace was attached to the spine. The BME range of interest was taken on T2-weighed fat-saturated MRI, and the signal intensity (SI) of the BME (SIedema) was measured. The contrast ratio (CR) between the SI of the BME and SI of the spinal cord (SIcord) was calculated per the following formulae: CRedema=(SIedema-SIcord)/(SIedema+SIcord). The CR of the normal pedicle was measured as a control per the following formulae: CRcontrol=(SIcontrol-SIcord)/(SIcontrol+SIcord).

RESULTS

The study enrolled 32 men and one woman; the mean patient age was 15.2 years (range, 12-18 years). The average CR of the edema and normal pedicle at the first visit was 0.506 (range, 0.097-0.804) and 0.137 (range, -0.741 to 0.572), respectively. The CR of the edema was significantly higher as compared to that of the normal pedicle (p<0.01). MRI that was performed 1 month after the first visit showed that the CR of the edema had decreased to 0.204 (range, -0.152 to 0.517). The CR of the edema 1 month thereafter was significantly lower than that at the first visit (p<0.01).

CONCLUSIONS

Quantitative assessment of BME using CR on MRI is useful in the evaluation of the healing process of spondylolysis.

Surgical management of stress fracture of the contralateral pedicle in a baseball player with unilateral lumbar spondylolysis : A case report

We describe successful surgical treatment in a case of L5 unilateral spondylolysis with contralateral pedicle stress fracture that was not resolved by conservative treatment in a high-performing college baseball player. The 20-year-old man presented with left low back pain that stopped his sports activities. Over the previous year, he had experienced a couple of episodes of pain that subsided with cessation of sports but reappeared after a return to sports. Computed tomography and magnetic resonance imaging revealed a right terminal stage pars fracture and a left pedicle stress fracture at L5. The pain originated from the left pedicle fracture, with no pain from the right unilateral spondylolysis. Given that conservative treatment for 1 year had not been effective, we decided on surgical treatment. Bilateral pedicle screws and the smiley face rod method were applied, and both fractures subsequently healed. In the 2 years since the surgery, the patient has returned to sports and has the potential to become a professional player. J. Med. Invest. 67 : 382-385, August, 2020.

Characteristics of adolescent lumbar spondylolysis with acute unilateral fatigue fracture and contralateral pseudoarthrosis

Purpose: This study aimed to examine the characteristics of lumbar spondylolysis with acute lumbar spondylolysis on one side and pseudoarthrotic spondylolysis on the other, relative to acute lumbar spondylolysis on one side only.

Patients and Methods: Short-tau inversion recovery images obtained through magnetic resonance imaging were used to diagnose 58 patients with acute lumbar spondylolysis with bone marrow edema on one side only. A total of 20 patients who had pars defects on the contralateral side (terminal-stage pseudoarthrotic spondylolysis) were included in the contralateral pseudoarthrosis group (P group). The remaining 38 patients with normal images for the contralateral pars interarticularis were included in the unilateral lesion group, in which the contralateral side was normal (U group). We investigated the union rate, age, sex, lesion laterality, vertebral level, pathological stage, and existing spina bifida occulta in both groups.

Results: The P group was characterized by a higher proportion of right-side cases, L5 lesions, more progressed pathological stage, and spina bifida occulta and a significantly lower union rate than the U group.

Conclusion: The union rate in patients with lumbar spondylolysis with acute lumbar spondylolysis on one side and pseudoarthrotic spondylolysis on the opposite side was only 15%. We should inform patients with acute unilateral spondylolysis lesions and contralateral pseudoarthrosis about this poor union rate and urge them to choose their therapy accordingly.

Radiological healing of lumbar spine stress fractures in elite cricket fast bowlers

OBJECTIVES

Review magnetic resonance imaging (MRI) of elite adult fast bowlers with a history of lumbar spine stress fracture for evidence of bone healing. The findings will determine whether bone healing can occur in this population, and whether MRI may be used as a tool to assess bone healing and inform clinical decision making.

DESIGN

Retrospective cohort.

METHODS

Participants were elite Australian fast bowlers who sustained a lumbar spine stress fracture confirmed on MRI and had at least one subsequent MRI. Two radiologists independently reviewed all images.

RESULTS

Thirty-one fractures from 20 male fast bowlers were reviewed. Median maximum fracture size was 6mm (range 2-25mm). Twenty-five fractures achieved bone healing, with a median 203 (IQR 141-301) days between the initial MRI (to confirm diagnosis) and the MRI when bone healing was observed. Fracture size and signal intensity of bone marrow oedema were positively associated with the number of days to the MRI when bone healing was observed (r²=0.245, p<0.001 and r²=0.292, p<0.001 respectively). Fractures which occurred at the same site as a previously united fracture took longer to heal than the first fracture (median 276 days to the MRI when bone healing was observed compared to 114 days for first fracture; p=0.036).

CONCLUSIONS

Lumbar spine stress fractures in elite adult fast bowlers are capable of achieving complete bone healing, as demonstrated in the majority of bowlers in this study. Larger fractures, greater bone marrow oedema, and history of previous injury at the same site may require longer healing time which may be monitored with MRI.

Stress Injuries of the Spine in Sports

Spine sports stress injuries account for a significant amount of time loss at play in athletes, particularly if left unrecognized and allowed to progress. Spondylolysis makes up most of these stress injuries. This article focuses on spondylolysis, bringing together discussion from the literature on its pathomechanics and the different imaging modalities used in its diagnosis. Radiologists should be aware of the limitations and more importantly the roles of different imaging modalities in guiding and dictating the management of spondylolysis. Other stress-related injuries in the spine are also discussed including but not limited to pedicle fracture and apophyseal ring injury.

What Type of Orthosis is Optimal for Conservative Treatment of Lumbar Spondylolysis?: A Biomechanical Analysis

Introduction

To analyze the extent to which various types of orthoses can restrict motion of the lumbar spine and provide basic evidence regarding the optimal orthosis for conservative treatment of lumbar spondylolysis (LS), particularly. Although several orthoses have been developed and applied for LS with better outcomes for bony healing, basic data regarding which is optimal are still lacking.

Methods

Ten healthy voluntary participants were included in this study. Lumbar spine range of motion (ROM) was analyzed using a three-dimensional motion capture system (NEXUS 2.2, Vicon Motion Systems Ltd., UK) under five conditions wearing no orthosis (NB) and four types of lumbar-sacral orthoses (LSO): custom-made hard LSO (HO), soft LSO supported by four aluminum stays and a custom-molded back cast-panel named "Return to Sports" braces (RS), custom-made soft LSO known as Damen type elasticity corset (DC), and off-the-shelf soft LSO.

Results

HO showed the highest restriction of motion in all directions than the others. Especially, ROM of rotation and side bending were reduced to 58.3% and 63.6% compared with NB, respectively. The other three LSOs showed significantly higher restriction in extension, rotation, and side bending than NB. In flexion and side bending, DC showed significantly higher restriction than NB.

Conclusions

HO showed high restriction in all directions. RS showed higher restriction in extension than NB and less restriction in flexion and side bending than other custom-made LSOs. DC was the only soft LSO showing higher restriction than NB in flexion.

Low-Intensity Pulsed Ultrasound for Early-Stage Lumbar Spondylolysis in Young Athletes

OBJECTIVE

To examine the effect of low-intensity pulsed ultrasound (LIPUS) on early-stage spondylolysis in young athletes.

DESIGN

Case-control study.

SETTING

A single outpatient orthopedic and sports clinic.

PATIENTS

A total of 82 young athletes (80 boys and 2 girls; mean age, 14.8 years; range, 10-18 years) with early-stage lumbar spondylolysis were enrolled in this study. All patients were examined by plain radiography and magnetic resonance imaging.

INTERVENTIONS

Patients received either standard conservative treatment combined with LIPUS (n = 35) or without LIPUS (n = 47), according to the sequence of admission. The standard conservative treatment included thoracolumbosacral brace, sports modification, and therapeutic exercise.

MAIN OUTCOME MEASURES

The time required to return to previous sports activities was analyzed by using Kaplan-Meier methods with the log-rank test.

RESULTS

The baseline parameters of both groups were not significantly different. The median time to return to previous sports activities was 61 days [95% confidence interval (CI): 58-69 days] in the group treated with LIPUS, which was significantly shorter than that of the group treated without LIPUS (167 days, 95% CI: 135-263 days; P < 0.01).

CONCLUSIONS

These results suggest that LIPUS combined with conservative treatment for early-stage lumbar spondylolysis in young athletes could be a useful therapy for quick return to playing sports.

Incidental Idiopathic Bilateral Pedicle Fracture - Case Report and Literature Review

In rare cases, pedicle fracture is associated with spine surgery, spondylolysis, or stress fracture. We report a patient without trauma whose bilateral lumbar pedicle fracture was detected incidentally. A 67-year-old woman reported leg numbness and pain. Lumbar MRI showed spinal canal stenosis at the L4/L5 level. Drug treatment was only partially effective. A lumbar computed tomography (CT) scan performed 3 months later revealed bilateral pedicle fracture at L4. A second lumbar MRI showed fresh bilateral L4 pedicle fracture that was not observed on the first scan. Due to the presence of osteoporosis we prescribed daily teriparatide and the wearing of a lumbo-sacral corset. Her subsequent clinical course was uneventful and the fractures fused under conservative treatment. During this period, she had no low back pain (LBP). Only 12 earlier patients with spontaneous bilateral pedicle fracture without trauma, spinal surgery, or bone abnormality have been reported. In 8 patients, including ours, the fracture level was at L4. In all except our patient, LBP was the most common symptom. Pedicle fracture as detected incidentally in our patient. Of the 13 patients, 4 were physically active adolescents; of the 9 others, 5 were women with osteoporosis. Our case is the first report of incidental spontaneous bilateral pedicle fracture.

Prevalence of curable and pseudoarthrosis stages of adolescent lumbar spondylolysis

Objective: The aim of this study was to determine the prevalence of curable and pseudoarthrosis stages of adolescent lumbar spondylolysis under high school students complaining of and seeking medical consultation for low back pain.

Patients and Methods: We analyzed age, sex, morbidity, presence of spina bifida occulta (SBO), and competitive sport discipline of patients with lumbar spondylolysis. We then stratified their pathological stage using a modified classification system via magnetic resonance imaging and computed tomography.

Results: Of 507 patients, 451 lesions in 268 patients were diagnosed with lumbar spondylolysis (average age, 14.7 years; sex ratio, 215:53 male/female). Morbidity levels were as follows: L1, 1 lesion in 1 patient; L2, 9 lesions in 5 patients; L3, 38 lesions in 25 patients; L4, 106 lesions in 74 patients; L5, 297 lesions in 189 patients, and SBO verified in 111 patients. A total of 264 patients played a specific sport: baseball, 93; soccer, 49; volleyball, 21; track and field, 21; basketball, 20; others, 164. The prevalence of curable- and pseudoarthrosis-stage lumbar spondylolysis was 206 lesions in 142 patients, and 141 lesions in 87 patients, respectively.

Conclusion: With 59.3% of patients having curable-stage lumbar spondylolysis, adolescent athletes with low back pain are urged to seek consultation. Furthermore, clinicians should perform magnetic resonance imaging to avoid misdiagnosis.

MRI bone marrow oedema precedes lumbar bone stress injury diagnosis in junior elite cricket fast bowlers

OBJECTIVES

Lumbar bone stress injury ('bone stress injury') is common in junior fast bowlers. The repetitive loading of cricket fast bowling may cause bone marrow oedema (BMO), detectable on MRI, before the bowler suffers from symptomatic bone stress injury. We investigated the temporal relationship between BMO, bone stress injury, along with bowling workload correlates, in elite junior fast bowlers throughout a cricket season.

METHODS

65 junior fast bowlers were prospectively monitored for one 8-month cricket season. For research purposes, participants had up to six MRI scans at set times in the season; findings were withheld from them and their clinicians. Standard practices for bowling workload monitoring and injury diagnosis were followed.

RESULTS

15 (23%) participants developed bone stress injury during the study. All 15 of these participants had BMO detected on at least one of the preceding MRI scans, including the scan immediately prior to diagnosis. The risk of BMO progressing to bone stress injury during the season was greatest for participants with BMO present 2 weeks prior to the national championship tournament (period of high load) (RR=18.9, OR=44.8). Both bone stress injury and BMO were associated with bowling a higher percentage of days in training and having a shorter bowling break during the season. The number of balls bowled and acute-to-chronic workload were not associated with imaging abnormalities or injury.

CONCLUSION

The presence of BMO on MRI in asymptomatic junior cricket fast bowlers confers a very high risk for bone stress injury. The risk may be managed by MRI screening and monitoring bowling frequency.

Segmental Lordosis of the Spondylolytic Vertebrae in Adolescent Lumbar Spondylolysis: Differences between Bilateral L5 and L4 Spondylolysis

Study Design

Retrospective study.

Purpose

This study aimed to investigate whether segmental lumbar hyperlordosis of the affected vertebra in patients with spondylolysis occurs only at L5 or also occurs at L4.

Overview of Literature

To the best of our knowledge, increase in segmental lordosis of the spondylolytic vertebrae has only been investigated in bilateral L5 spondylolysis; it has not been examined at different levels of bilateral spondylolysis. According to the characteristics of segmental lordosis in bilateral L5 spondylolysis, patients with bilateral L4 spondylolysis may also have increased segmental lordosis of the L4 vertebra.

Methods

Patients with bilateral spondylolysis of the L5 or L4 vertebra in 2013–2015 were retrospectively identified from the hospital database. Standing lateral lumbar radiographs were assessed for the angle of segmental lordosis of the L5 and L4 vertebra, sacral slope, and lumbar lordosis. The differences in segmental lordosis of the L5 and L4 vertebra, sacral slope, and lumbar lordosis were determined using non-paired Student t-test.

Results

Overall, 15 cases of bilateral L4 spondylolysis and 41 cases of bilateral L5 spondylolysis satisfied the inclusion and exclusion criteria. Lordosis of the L4 vertebra was significantly greater in the bilateral L4 spondylolysis group (24.2°±7.0°) than that in the L5 spondylolysis group (20.3°±6.1°, p=0.047). Lordosis of the L5 vertebra was significantly lower in the L4 spondylolysis group (27.7°±8.2°) than that in the L5 spondylolysis group (32.5°±7.3°, p=0.040). The sacral slope and lumbar lordosis did not significantly differ between the groups.

Conclusions

Adolescent patients with bilateral spondylolysis have segmental hyperlordosis of the affected vertebra not only at the L5 level but also at the L4 level.

Successful Endoscopic Surgery for L5 Radiculopathy Caused by Far-Lateral Disc Herniation at L5-S1 and L5 Isthmic Grade 2 Spondylolisthesis in a Professional Baseball Player

Background

We report the case of a professional baseball player who had severe leg pain due to lumbar lateral disc herniation at L4-5 and isthmic spondylolisthesis at L5 (double crash syndrome). For early recovery to competitive level, we performed minimally invasive endoscopic decompression surgery without fusion. There are few reports to discuss the usefulness of minimally invasive treatment for top athletes.

Methods

A 29-year-old professional baseball player who played catcher was referred to us with a complaint of right leg pain. The previous doctor diagnosed far-lateral disc herniation and Grade 2 isthmic spondylolisthesis and recommended arthrodesis at L5-S1 as treatment for both pathologies. Radiological imaging showed that the right L5 nerve root was impinged by the 2 lumbar disorders, namely, far-lateral disc herniation and a ragged edge around a pars defect. We had taken into account the patient's occupation and his wish to avoid a lengthy sick leave, and we had performed endoscopic decompression surgery during the offseason. The far-lateral disc herniation at L5-S1 was removed under local anesthesia by percutaneous endoscopic discectomy, after which the ragged edge at the pars defect was removed under general anesthesia using a microendoscopic discectomy system. Given that the patient did not have any low back pain, arthrodesis was not considered.

Results

The leg pain resolved after surgery. The following year (2015), the patient resumed playing baseball from the beginning of the season and played in 41 games. In the 2016 season, he played in 71 games without any symptoms. No further slippage was observed at radiological follow up 1 year after the surgery.

Conclusions

Minimally invasive endoscopic surgery is an option for radiculopathy in very active patients who need an early return to their previous level of physical activity.

Is the Scotty Dog Sign Adequate for Diagnosis of Fractures in Pediatric Patients with Lumbar Spondylolysis?

Introduction

Recent advances in diagnostic imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI), have allowed early diagnosis of lumbar spondylolysis (LS). However, few outpatient clinics are equipped with such imaging apparatuses and must rely on plain radiographs for the diagnosis of LS. The aim of this retrospective study was to identify how accurately fracture lines can be detected on plain radiographs in patients with LS.

Methods

Patients with a diagnosis of LS were staged as early, progressive, or terminal. We evaluated whether fracture lines could be detected on plain radiographs and compared the detection rates under the following conditions: two directions including anteroposterior and lateral views (2 views), four directions including both oblique views (4 views), four directions including dynamic lateral views (4-D views), and all six directions (6 views).

Results

In early LS, the fracture line detection rate was 11.4% using 2 views, 20.5% using 4 views and 4-D views, and 22.7% using 6 views. In progressive LS, the fracture line detection rate was 54.2% using 2 views, 70.8% using 4-D views, 75.0% using 4 views, and 79.2% using 6 views. The respective detection rates for terminal LS were 85.0%, 100%, 100%, and 100%.

Conclusions

Although terminal LS was diagnosed accurately on plain radiographs in all patients, the detection rates were only 22.7% and 79.2% in patients with early and progressive LS, respectively. These results suggest that plain radiographic films can no longer be considered adequate for early and accurate diagnosis of LS. Advanced imaging procedures, such as MRI in the early diagnosis or CT for persistent cases, are recommended to obtain an accurate diagnosis of early stage LS in pediatric patients requiring conservative treatment to achieve bony healing.

Association between reduced trunk flexibility in children and lumbar stress fractures

Background

We noticed that most of active sports children with low back pain (LBP) have muscle tightness around the pelvis and reduced trunk flexibility. Abnormalities in short-time inversion recovery (STIR) images on magnetic resonance imaging (MRI) can show stress fracture. Therefore, we investigated the associations among LBP, trunk flexibility, and lumbar stress fractures.

Methods

A total of 130 patients under the age of 18 years complained of LBP were investigated in STIR MRI images. Among these 130 patients, 65 cases of lumbar stress fracture were diagnosed and 65 cases were not diagnosed as a lumbar stress fracture. We compared between a group suspected of stress fracture (suspected group) and a group of stress fracture(stress fracture group)about their trunk flexibility. These groups were investigated about their initial trunk flexibility about below items; Finger floor distance (FFD), Heel to buttock distance (HBD), straight leg raising (SLR).

Results

Significant differences were observed between suspected group and stress fracture group about every items; SLR (P < 0.001), FFD (P < 0.01), HBD (P < 0.002). Most cases of stress fracture group had reduced trunk flexibility, and low flexibility in pelvic area muscles was observed in 93.8% (61/65) of cases at the initial examination. Otherwise, that of suspected group was 73.8%(48/65).

Conclusions

Most patients of lumbar stress fracture had reduced trunk flexibility, and their reduced trunk flexibility might not be caused by LBP. In the early diagnosis of lumbar stress fractures using STIR MRI images, there were indicated that reduced trunk flexibility was one of helpful item for lumbar stress fracture.

Utility of STIR-MRI in Detecting the Pain Generator in Asymmetric Bilateral Pars Fracture: A Report of 5 Cases

Lumbar spondylolysis usually occurs as a stress fracture in the pars interarticularis of the vertebra. It is a prevalent sports-related disorder and a common cause of low back pain. We encountered five athletes (4 males, 1 female) with severe low back pain. Mean age was 14.5 years. All five patients were found to have bilateral pars fracture. In all cases, staging based on the findings from computed tomography scan of the right and left pars fracture was different. On short tau inversion recovery magnetic resonance imaging (STIR-MRI) of the comparatively newer more recently injured side, high signal intensity changes were obvious and dominant at the intra- and extraosseous area, which would indicate tissue edema and/or bleeding. Furthermore, the imaging findings corresponded to the side of the low back pain. In conclusion, STIR-MRI can effectively distinguish between painful pars fracture and painless pars fracture.

Timing of Physical Therapy Referral in Adolescent Athletes With Acute Spondylolysis: A Retrospective Chart Review

OBJECTIVES

The purposes of this study were (1) to determine whether the duration of rest before referral to physical therapy (PT) affects the time to make a full return to activity for patients with an acute spondylolysis, (2) to assess the safety of an early referral to PT in patients with an acute spondylolysis.

STUDY DESIGN

Retrospective chart review.

SETTING

Hospital-based sports medicine clinic.

PATIENTS

The medical charts of 196 adolescent athletes (mean age = 14.3 ± 1.8 years) with an acute spondylolytic injury met the inclusion criteria and were reviewed.

INDEPENDENT VARIABLE

Patients were subgrouped based on physician referral to PT.

PATTERNS

An aggressive referral group (<10 weeks) and a conservative referral group (>10 weeks).

MAIN OUTCOME MEASURES

Duration of rest before clearance to a full return to activity and the frequency of adverse reactions during the course of treatment. Safety was assessed by calculating the risk of experiencing an adverse reaction in each group.

RESULTS

Median days to a full return to activity for aggressive referral group (115.5 days, interquartile range 98-150 days) and conservative referral group (140.0 days, interquartile range 114.5-168 days) were significantly different (P = 0.002). Eleven patients had adverse reactions during the course of treatment. The risk of adverse reaction was not statistically significant between groups (P = 0.509).

CONCLUSIONS

Patients with acute spondylolysis in the aggressive referral group were able to make a full return activity almost 25 days sooner. No differences in the risk of adverse reactions were noted between aggressive and conservative referral groups.

Low-intensity pulsed ultrasound is effective for progressive-stage lumbar spondylolysis with MRI high-signal change

PURPOSE

This study aimed to investigate the treatment effects of low-intensity pulsed ultrasound (LIPUS) on progressive-stage spondylolysis. Spondylolysis is a stress fracture of the pars interarticularis. Based on the results of computed tomography, spondylolysis was classified into three categories: early, progressive, and terminal. Bone healing was prolonged or not obtained in progressive-stage spondylolysis. The progression of spondylolysis to nonunion has been associated with an increased incidence of spondylolisthesis. To prevent these clinical conditions, achieving bony healing of the spondylolysis site should be the goal of treatment.

METHODS

15 consecutive pediatric patients with progressive-stage spondylolysis (defects) with MRI high-signal change were analyzed. Nine patients were treated conservative treatment including avoidance of any sport activity and the use of a brace during treatment (conventional). Six patients were treated using LIPUS everyday during treatment in addition to conservative treatment. Approximately every 1.5 months, bone healing was evaluated via CT. Cases that retained defects after 4.5 months were defined as nonunion.

RESULTS

Two patients dropped out during the study period. A total of 13 patients (mean 14.6 ± 2.5 years) from the database met with 19 interarticularis defects. The bone union rate in LIPUS group was significantly higher than that in conventional group (66.7 vs. 10.0%, p = 0.020). The treatment period to bone union was 3.8 months and 2.7 ± 0.3 months in conventional and LIPUS groups.

CONCLUSIONS

This study revealed that LIPUS treatment might be effective for bone union in patients with progressive-stage spondylolysis with MRI high-signal change.

LEVEL OF EVIDENCE

4.

A rare case of non-traumatic, multi-level, bilateral pedicle fractures of the lumbar spine in a 60-year-old patient

INTRODUCTION

We report a 60-year-old patient who sustained non-traumatic, multi-level, bilateral lumbar pedicle fractures in the setting of unilateral lumbar spondylolysis. A possible fracture mechanism is evaluated and a review of the literature is presented. Whereas contralateral pedicle fractures of lumbar vertebrae with unilateral spondylosis are well described in young athletes, there is only one case report of multi-level, bilateral pedicle fractures of the lumbar spine in a young patient who sustained a high-impact motorcycle accident. To our knowledge, this is the first report of multi-level, bilateral pedicular fractures of the lumbar spine without a history of trauma.

METHODS

The clinical case of a 60-year-old patient with lumbar pain radiating in both legs without antecedent trauma is presented. Besides an idiopathic primary adrenal failure, no further co-morbidities existed. Radiologic investigations showed acute bilateral pedicles' fractures of the lumbar vertebrae two to four (L2-4) and a unilateral spondylolysis L4-5. Dorsoventral instrumentation from L1 to L5 was performed in two steps.

RESULTS

The patient had no neurological deficits at discharge. Perioperative cortisol substitution was arranged and continued in the course. At final follow-up after 6 years the patient was pain-free and radiographs confirmed complete fusion of L1-5 with mild degeneration of the adjacent segments.

CONCLUSION

The presented fracture pattern has not been described to date. Because of multi-level involvement, instability requiring operative stabilisation was presumed and confirmed during surgery.

Long-Term Clinical Outcomes and Factors That Predict Poor Prognosis in Athletes After a Diagnosis of Acute Spondylolysis: A Retrospective Review With Telephone Follow-up

Study Design Retrospective review with telephone follow-up. Background Acute spondylolytic injuries have a dramatic impact on the young athlete. Excellent short-term clinical outcomes have been observed, but not enough is known about long-term clinical outcomes. Objectives (1) To report long-term clinical outcomes for patients diagnosed with acute spondylolysis, and (2) to assess the prognostic ability of retrospective variables for long-term outcomes. Methods Patients from 2010 through 2013 were retrospectively reviewed to identify patients and to obtain demographic, baseline, and short-term outcomes. Long-term follow-up data were collected by telephone from patients diagnosed with acute spondylolysis to assess recurrence rate of low back pain, perceived outcome, pain, and functional ability. Patients were categorized as having a good or poor long-term outcome based on these measures. Logistic regression analysis was performed to assess the prognostic ability of the retrospective variables for long-term outcomes 3.4 years (range, 1.5-5.6 years) after treatment. Results One hundred twenty-one (71.6%) patients completed the follow-up questionnaire (48 female; mean age at baseline, 14.4 years). At follow-up, 81 (66.9%) patients were able to maintain their same or a higher level of sport. Recurrence of significant symptoms was reported by 55 (45.5%) patients, with 41 (33.9%) requiring medical treatment. The final logistic regression model revealed that female sex, adverse reaction during care, and multilevel injury were significant predictors of poor long-term outcome (R² = 0.22). Conclusion Although excellent short-term outcomes were noted, 42% of patients reported a poor outcome at long-term follow-up. Female sex, multilevel injury, and experiencing an adverse reaction during care were significant predictors of poor long-term clinical outcome for patients diagnosed with acute spondylolysis. Level of Evidence Prognosis, level 4. Registered January 15, 2015 at www.clinicaltrials.gov (NCT02332200). J Orthop Sports Phys Ther 2016;46(12):1029-1036. Epub 8 Nov 2016. doi:10.2519/jospt.2016.7028.

Lumbar Posterior Apophyseal Ring Fracture Combined with Spondylolysis in Pediatric Athletes: A Report of Three Cases

CASE

Lumbar posterior apophyseal ring fracture is an uncommon finding in children, but lumbar spondylolysis is a common disorder. Both disorders are prevalent in young athletes. We describe 3 adolescent athletes who showed both lumbar spondylolysis and lumbar posterior apophyseal ring fracture. Because lumbar spondylolysis is comparatively easy to diagnose, a concurrent posterior lumbar apophyseal ring fracture is likely to be overlooked.

CONCLUSION

In patients with severe low back and radicular pain in whom spondylolysis is suspected, it is important to perform not only magnetic resonance imaging and radiography but also computed tomography for identifying posterior apophyseal ring fractures.