Factors Associated with the Symptoms of Young Adults with L5 Spondylolysis

Intrinsic variables associated with low back pain and lumbar spine injury in fast bowlers in cricket: a systematic review

BACKGROUND

Lumbar spine injuries in fast bowlers account for the greatest missed playing time in cricket. A range of extrinsic and intrinsic variables are hypothesised to be associated with low back pain and lumbar spine injury in fast bowlers, and an improved understanding of intrinsic variables is necessary as these may alter load tolerance and injury risk associated with fast bowling. This review critically evaluated studies reporting intrinsic variables associated with low back pain and lumbar spine injury in fast bowlers and identified areas for future investigation.

METHODS

OVID Medline, EMBASE, SPORTDiscus, CINAHL, Web of Science and SCOPUS databases were last searched on 3 June 2022 to identify studies investigating intrinsic variables associated with low back pain and lumbar spine injury in cricket fast bowlers. Terms relevant to cricket fast bowling, and intrinsic variables associated with lumbar spine injury and low back pain in fast bowlers were searched. 1,503 abstracts were screened, and 118 full-text articles were appraised to determine whether they met inclusion criteria. Two authors independently screened search results and assessed risk of bias using a modified version of the Quality in Prognostic Studies tool.

RESULTS

Twenty-five studies met the inclusion criteria. Overall, no included studies demonstrated a low risk of bias, two studies were identified as moderate risk, and twenty-three studies were identified as high risk. Conflicting results were reported amongst studies investigating associations of fast bowling kinematics and kinetics, trunk and lumbar anatomical features, anthropometric traits, age, and neuromuscular characteristics with low back pain and lumbar spine injury.

CONCLUSION

Inconsistencies in results may be related to differences in study design, injury definitions, participant characteristics, measurement parameters, and statistical analyses. Low back pain and lumbar spine injury occurrence in fast bowlers remain high, and this may be due to an absence of low bias studies that have informed recommendations for their prevention. Future research should employ clearly defined injury outcomes, analyse continuous datasets, utilise models that better represent lumbar kinematics and kinetics during fast bowling, and better quantify previous injury, lumbar anatomical features and lumbar maturation.

TRIAL REGISTRATION

Open Science Framework https://doi.org/10.17605/OSF.IO/ERKZ2 .

Optimal cutoff point of vertebral body cross-sectional area as a morphological parameter for predicting lumbar spondylolysis

The relationship between vertebral body cross-sectional area (VBCSA) and spinal conditions associated with increased lumbar lordosis, such as lumbar spondylolysis (LSL), is not known. We investigated the morphological parameter, VBCSA, to predict LSL. The VBCSA on MRI has not been studied for its association with LSL. We hypothesized that VBCSA is an important morphological parameter for LSL prediction. We collected VBCSA data from 90 patients (43 males and 47 females) with LSL and 91 control subjects (44 males and 47 females) who underwent lumbar spine magnetic resonance imaging (LS-MRI). Axial T2-weighted LS-MRI images were obtained from all participants. Using our picture archiving and communications system, we analyzed the VBCSA at the level of the L5 vertebral body by utilizing MRI. The average VBCSA was 2263.51 ± 306.02 mm2 in the male control group and 1820.92 ± 224.89 mm2 in the male LSL group. LSL patients had significantly lower VBCSAs (P < .001) than did the male controls. The average VBCSA was 1985.21 ± 258.05 mm2 in the female control group and 1553.73 ± 250.02 mm2 in the female LSL group, and the LSL patients also had significantly lower VBCSAs (P < .001) than did the female controls. The optimal VBCSA cutoff value in the male group was 2014.69 mm2 with 76.7% sensitivity, 75.0% specificity, and an area under the receiver operating curve (AUC) of 0.89 (95% CI: 0.82-0.95). In the female group, the optimal cutoff score was 1814.11 mm2 with 76.6% sensitivity, 76.6% specificity, and an AUC of 0.88 (95% CI: 0.82-0.95). VBCSA is a sensitive objective morphological parameter for assessing LSL, and a lower VBCSA is associated with a higher possibility of LSL. We believe that these results will be useful in diagnostic radiology for evaluating patients with LSL.

Risk factor analysis of disc and facet joint degeneration after intersegmental pedicle screw fixation for lumbar spondylolysis

Background

Patients who do not respond to conservative treatment of the isthmus are often treated with surgery. We used direct repair plus intersegment pedicle screw fixation for the treatment of lumbar spondylolysis. The aim of this observational study was to assess the effects of this technique and evaluate various risk factors potentially predicting the probability of disc and facet joint degeneration after instrumentation.

Methods

The study included 54 male L5 spondylolysis patients who underwent pars repair and intersegment fixation using pedicle screws. Bony union was evaluated using reconstruction images of computed tomography. Radiographic changes, including disc height, vertebral slip, facet joint and disc degeneration in the grade of adjacent and fixed segments, were determined from before to final follow-up. Logistic regression analysis was performed to identify factors associated with the incidence of disc and facet joint degeneration.

Results

Bony union was achieved in all cases. Logistic regression analysis revealed that instrumentation durations of greater than 15.5 months and 21.0 months were significant risk factors for the incidence of L4/5 and L5S1 facet degeneration, respectively.

Conclusions

Intersegmental pedicle screw fixation provides good surgical outcomes and good isthmic bony union rates in patients with lumbar spondylolysis. The duration of fixation was confirmed as a risk factor for facet joint degeneration. Once bony union is achieved, instrument removal should be recommended.

Retrospective Comparative Study of Pedicle Screw Fixation via Quadrant Retractor and Buck's Technique in the Treatment of Adolescent Spondylolysis

Objective

To compare the effectiveness and practicality of pedicle screw fixation via the Quadrant retractor and Buck's technique in the treatment of adolescent spondylolysis.

Methods

A total of 31 patients who underwent pedicle screw fixation or Buck's technique at our hospital from 2012 to 2017 were selected for this retrospective study. The patients were divided into a pedicle screw group (16 patients) and a Buck's technique group (15 patients) according to surgical procedure. Age, sex, disease duration, involved segments, preoperative Oswestry disability index (ODI) scores, visual analogue scale (VAS) scores for low back pain (LBP), intraoperative blood loss, incision length, operative time and length of hospital stay were documented. ODI scores, VAS scores for LBP and fusion rates at 1 month, 6 months, 1 year and 3 years postoperatively were used to evaluate surgical outcomes.

Results

The average follow‐up period was 32.75 ± 11.99 months in the pedicle screw group and 31.02 ± 9.64 months in the Buck's technique group. No significant differences in demographic data and perioperative data were found between the two groups (P > 0.05). The ODI scores and VAS scores for LBP in both groups were significantly improved at 3 years postoperatively compared with the values before surgery (ODI%: 45.74 ± 2.47 vs 10.99 ± 3.00; 45.29 ± 6.94 vs 15.73 ± 6.89. VAS: 5.94 ± 0.68 vs 1.50 ± 0.52; 6.13 ± 0.74 vs 2.13 ± 0.92, P < 0.05). The ODI scores of the patients in the pedicle screw group at 1 month to 3 years postoperatively were lower than those of the patients in the Buck's technique group (P < 0.05). Moreover, the VAS scores for LBP of the patients in the pedicle screw group at 6 months and 3 years postoperatively were lower than those of the patients in the Buck's technique group (P < 0.05). No significant difference in the VAS scores for LBP was found between the two groups at 1 month postoperatively (3.88 ± 0.50 vs 4.20 ± 0.56, P = 0.10). Three years postoperatively, good fusion of the pars interarticularis was achieved in all patients in the pedicle screw group, but four patients in the Buck's technique group did not achieve good fusion (P = 0.02).

Conclusion

Both pedicle screw fixation and Buck's technique can achieve good outcomes in the treatment of adolescent spondylolysis. Pedicle screw fixation via the Quadrant retractor for the treatment of spondylolysis is associated with more satisfactory effects in terms of LBP relief and fusion results.

Sacropelvic Parameters and L5 Spondylolysis: Computed Tomography Analysis

Study Design

Retrospective analysis of computed tomography scans.

Purpose

This study aims to determine the association of sagittal sacropelvic parameters with L5 spondylolysis.

Overview of Literature

The association of increased pelvic incidence (PI) and decreased sacral table angle (STA) with spondylolysis has been reported, but no study has simultaneously analyzed multiple sacropelvic variables to compare their association.

Methods

In this study, computed tomography scans obtained to assess major trauma in patients aged >16 years were analyzed. Scans meeting one of the following criteria were excluded: abnormal anatomy, previous spine or hip/pelvis surgery, or spinal pathology, including deformity, infection, tumor, or trauma. sacral anatomic orientation (SAO), PI, pelvic thickness (PTH), femoro-sacral posterior angle (FSPA), STA, and sacral kyphosis (SK) were measured.

Results

Overall, 202 scans were analyzed: 25 with L5 spondylolysis and 177 normal. Among the groups, a significant difference was observed in SAO (43.3° vs. 51.6°), PI (61.7° vs. 49.8°), STA (95.4° vs. 101.8°), and SK (31.0° vs. 23.7°). Based on the logistic regression analysis, only PI (odds ratio [OR], 1.074; 95% CI, 1.026–1.124) and STA (OR, 0.822; 95% CI, 0.734–0.920) remained significant predictors for the presence of spondylolysis. In the spondylolysis group, PI correlated significantly with PTH (r=−0.589), FSPA (r=0.880), and SK (r=0.576), whereas in the normal group, PI correlated significantly with FSPA (r=0.781) and SK (r=0.728).

Conclusions

By simultaneously assessing multiple sacropelvic parameters, we associated increasing PI with L5 spondylolysis. Decreasing STA, which likely represents a chronic remodeling secondary to spondylolysis, was also associated with increased risk. Back pain in an adolescent or young adult with high PI or low STA should raise suspicion of a possible occult spondylolysis.

Trapezoidal Vertebral Body and Spine-Pelvis Sagittal Alignment in Patients with Lumber Spondylolisthesis

Background

Trapezoidal changes of the vertebral body are more common in patients with lumbar spondylolisthesis than in others. However, we lack an understanding of factors predisposing to the development of a marked trapezoidal deformity. Also, no associations between a trapezoidal vertebrae (TV) and spine-pelvis sagittal parameters have been previously reported.

Material/Methods

A total of 73 subjects with lumbar spondylolisthesis were enrolled and we collected their clinical data. Vertebral body parameters and spine-pelvis sagittal alignment parameters were measured via lumbar spine X-ray. Using the lumbar index (LI), patients were divided into a TV group (LI ≤0.8, n=24) and a control group (LI >0.8, n=49). The clinical data and spine-pelvic sagittal parameters of the 2 groups were compared using the t test or chi-squared test. Pearson’s correlation analysis and multiple linear regression were used to determine relationships among the parameters.

Results

The TV and control groups differed significantly in terms of the slipped segment, extent of slippage, intervertebral disc height (IDH), and sagittal parameters (all P<0.05). Pearson’s correlation analysis and multiple linear regression analysis showed that the slipped segment (r=−0.606), extent of slippage (r=−0.660), and IDH (r=0.698) were risk factors for the development of a TV body. Also, vertebral trapezoidal deformation was closely associated with sagittal parameters.

Conclusions

The vertebral body affected by lumbar spondylolisthesis exhibits a trapezoidal change closely associated with the slipped segment, the extent of slippage, and IDH. The TV group exhibited greater pelvic incidence values and lumbar lordosis, which may have caused wedging of the slipped vertebra.

Neural Arch Bone Marrow Edema and Spondylolysis in Adolescent Cheerleaders: A Case Series

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.

An exploratory study of different definitions and thresholds for lumbar disc degeneration assessed by MRI and their associations with low back pain using data from a cohort study of a general population

BACKGROUND

Lumbar disc degeneration seen on magnetic resonance imaging (MRI) is defined as loss of signal intensity and/or disc height, alone or in combination with other MRI findings. The MRI findings and thresholds used to define disc degeneration vary in the literature, and their associations with low back pain (LBP) remain uncertain.

OBJECTIVE

To explore how various thresholds of lumbar disc degeneration alter the association between disc degeneration and self-reported LBP.

METHODS

An exploratory, cross-sectional cohort study of a general population. Participants in the cohort 'Backs-on-Funen' had MRI scans and completed questionnaires about LBP at ages 41, 45 and 49 years. The MRI variables, signal intensity (Grades 0-3) and disc height (Grades 0-3), were dichotomised at different thresholds. Logistic regression analyses were used to determine associations. Arbitrarily, a difference in odds ratio (OR) of > 0.5 between thresholds was considered clinically relevant. Receiver Operating Characteristic curves were used to investigate differences between diagnostic values at each threshold.

RESULTS

At age 41, the difference in ORs between signal loss and LBP exceeded 0.5 between the thresholds of ≥2 (OR = 2.02) and = 3 (OR = 2.57). Difference in area under the curves (AUC) was statistically significant (p = 0.02). At ages 45 and 49, the difference in ORs exceeded 0.5 between the thresholds of ≥2 and = 3, but the differences between AUC were not statistically significant. At age 41, the difference in ORs between disc height loss and LBP at the thresholds of ≥1 (OR = 1.44) and ≥ 2 (OR = 2.53) exceeded 0.5. Differences in AUC were statistically significant (p = 0.004). At age 49, differences in ORs exceeded 0.5 (OR = 2.49 at the ≥1 threshold, 1.84 at ≥2 and 0.89 at =3). Differences between AUC were not statistically significant.

CONCLUSION

The results suggest that the thresholds used to define the presence of lumbar disc degeneration influence how strongly it is associated with LBP. Thresholds at more severe grades of disc signal and disc height loss were more strongly associated with LBP at age 41, but thresholds at moderate grades of disc degeneration were most strongly associated with LBP at ages 45 and 49.