MR imaging differentiating features between lytic and degenerative lumbosacral spondylolisthesis

Spondylolisthesis is characterized by the displacement of one vertebral body in relation to the adjacent vertebra. It is commonly observed in the lower lumbar region and can be caused by a variety of factors, including spondylolysis (a fracture in the pars interarticularis) or degenerative disease. Magnetic resonance imaging (MRI) is becoming increasingly popular as the primary modality for evaluation of low back pain and is often used in the absence of radiographs or Computed Tomography. However, it can be challenging for radiologists to differentiate between the two types of spondylolisthesis based on MRI alone. The goal of this article is to identify key imaging features on MRI that can aid radiologists in differentiating between spondylolysis and degenerative spondylolisthesis on MRI. Five key concepts are discussed: the "step-off" sign, the "wide canal" sign, T2 cortical bone signal on MRI, epidural fat interposition, and fluid in the facet joints. The utility, limitations and potential pitfalls of these concepts are also discussed to provide a comprehensive understanding of their use in differentiating between the two types of spondylolisthesis on MRI.

Using the pedicle screw-U rod system for the treatment of double-level lumbar spondylolysis and isthmic spondylolisthesis

Objective

The aim of this study was to evaluate the efficacy of the pedicle screw-U rod system in treating double-level lumbar spondylolysis with or without spondylolisthesis.

Methods

A retrospective study was conducted. Twenty-six patients were included in this study and followed up at 3, 6, and 12 months. Patients without spondylolisthesis were treated with double U-shaped rods (group I), and patients with spondylolisthesis were treated with a lengthened U-shaped rod (group II). Japanese Orthopedic Association (JOA) scores, Oswestry disability index (ODI) scores, disc range of motion (ROM), intervertebral space height of fixed levels and adjacent levels, and grading the degeneration of adjacent segmental intervertebral discs were evaluated preoperatively and postoperatively.

Results

JOA and ODI scores improved significantly at 3 months both in groups I and II. The average bone grafting healing time was 6.1 ± 3.1 months for group I and 6 ± 2.8 months for group II. The intervertebral space heights of L4/L5 and L5/S1 were improved significantly at the final follow-up (p < 0.05 for both groups). Surgical segmental and adjacent segmental ROM had no significant change at the final follow-up, in comparison with data preoperatively (p > 0.05). No significant changes of intervertebral space height (L3/L4) and grading of intervertebral disc degeneration were noted before and after surgery (p = 0.141 and 0.484, respectively).

Conclusions

The pedicle screw-U rod system provided advantages of being easy in repairing symptomatic double-level lumbar spondylolysis. This technique improved disabilities of patients, preserved the lumbar spine ROM, and delayed the degeneration of adjacent segments.

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.

Spondylolysis and Spondylolisthesis in Athletes

This article is an update on spondylolysis and spondylolisthesis in athletes, from diagnosis to treatment, based on our service experience and a literature review.

[Lumbar Facet Joint Injection: A Review of Efficacy and Safety]

Facet joint arthrosis is a progressive degenerative disease that is frequently associated with other spinal degenerative disorders such as degenerative disc disease or spinal stenosis. Lumbar facet joint arthrosis can induce pain in the proximal lower extremities. However, symptoms and imaging findings of "facet joint syndrome" are not specific as they mimic the pain from herniated discs or nerve root compression. Currently, evidence for therapeutic intra-articular lumbar facet joint injections is still considered low, with a weak recommendation strength. Nevertheless, some studies have reported therapeutic effectiveness of facet joint injections. Moreover, the use of therapeutic facet joint injections in clinical practice has increased. This review article includes opinions based on the authors' experience with facet joint injections. This review primarily aimed to investigate the efficacy of lumbar facet joint injections and consider their associated safety aspects.

Tophaceous gouty arthritis with spondylolysis: a case report

Spinal gout is a rare occurrence, and the combination of gout with lumbar spondylolysis has not been reported. We present a unique case involving a 29-year-old male who complained of low back pain for 1 month. Computed tomography and magnetic resonance imaging revealed articular subchondral erosions and a mass in the left L5-S1 facet joints. Initially treated for a spinal infection, the patient subsequently underwent lumbar spinal canal decompression and fusion, achieving complete relief. Postoperative pathology confirmed the spinal lesions to be tophaceous gout. Dual-energy CT or biopsy can assist in confirming the diagnosis. This report discusses another rare case of tophaceous gouty arthritis with spondylolysis to be added to the literature.

Total body bone mineral density and various spinal disorders: a Mendelian randomization study

Introduction

Observational studies have yielded inconsistent findings regarding the correlation between bone mineral density (BMD) and various spinal disorders. To explore the relationship between total-body BMD and various spinal disorders further, we conducted a Mendelian randomization analysis to assess this association.

Methods

Two-sample bidirectional Mendelian randomization (MR) analysis was employed to investigate the association between total-body BMD and various spinal disorders. The inverse-variance weighted (IVW) method was used as the primary effect estimate, and additional methods, including weighted median, MR-Egger, simple mode, and weighted mode, were used to assess the reliability of the results. To examine the robustness of the data further, we conducted a sensitivity analysis using alternative bone-density databases, validating the outcome data.

Results

MR revealed a significant positive association between total-body BMD and the prevalence of spondylosis and spinal stenosis. When total-body BMD was considered as the exposure factor, the analysis demonstrated an increased risk of spinal stenosis (IVW odds ratio [OR] 1.23; 95% confidence interval [CI], 1.14-1.32; P < 0.001) and spondylosis (IVW: OR 1.24; 95%CI, 1.16-1.33; P < 0.001). Similarly, when focusing solely on heel BMD as the exposure factor, we found a positive correlation with the development of both spinal stenosis (IVW OR 1.13, 95%CI, 1.05-1.21; P < 0.001) and spondylosis (IVW OR 1.10, 95%CI, 1.03-1.18; P = 0.0048). However, no significant associations were found between total-body BMD and other spinal disorders, including spinal instability, spondylolisthesis/spondylolysis, and scoliosis (P > 0.05).

Conclusion

This study verified an association of total-body BMD with spinal stenosis and with spondylosis. Our results imply that when an increasing trend in BMD is detected during patient examinations and if the patient complains of numbness and pain, the potential occurrence of conditions such as spondylosis or spinal stenosis should be investigated and treated appropriately.

Minimally Invasive Surgery for Managing Grade IV and V Spondylolisthesis

Surgical treatment of high-grade spondylolisthesis is controversial and aims at restoring the spinopelvic sagittal balance through complete or partial reduction of the listhesis. Nerve decompression and interbody fusion are necessary for patients presenting with neurological deficit, severe pain, lower limb asymmetry, or deformities. We present the case and the results of a patient with high-grade spondylolisthesis, in whom minimally invasive management was performed. A narrative review in this topic is also provided. We performed a literature review of high-grade spondylolisthesis to compare our technique to current surgical alternatives. We included articles from PubMed, Embase, Scopus, Ovid, and Science Direct published between 1963 and 2022 that were written in English, German, and Spanish. The terms used were the following: "high grade spondylolisthesis," "spondyloptosis," "surgical management," "interbody fusion," and "arthrodesis." In all, 485 articles were displayed, from which we filtered 112 by title and abstract. At the end, 75 references were selected for the review. Different interbody fusion techniques can be used to correct the lumbosacral kyphosis and restore the spinopelvic parameters. A complete reduction of the listhesis is not always required. The surgical procedure carried out in our patient corresponds to the first known case of minimally invasive circumferential arthrodesis with iliac screws and sacral fixation in a high-grade dysplastic spondylolisthesis. This approach guarantees the correction of the lumbosacral kyphosis and a complete reduction of the listhesis. Further studies are required to determine whether the results of this case can be extrapolated to other patients with high-grade spondylolisthesis.

Diagnostic Performance of the Darth Vader Sign for the Diagnosis of Lumbar Spondylolysis in Routinely Acquired Abdominal CT

Spondylolysis is underdiagnosed and often missed in non-musculoskeletal abdominal CT imaging. Our aim was to assess the inter-reader agreement and diagnostic performance of a novel "Darth Vader sign" for the detection of spondylolysis in routine axial images. We performed a retrospective search in the institutional report archives through keyword strings for lumbar spondylolysis and spondylolisthesis. Abdominal CTs from 53 spondylolysis cases (41% female) and from controls (n = 6) without spine abnormalities were identified. A total of 139 single axial slices covering the lumbar spine (86 normal images, 40 with spondylolysis, 13 with degenerative spondylolisthesis without spondylolysis) were exported. Two radiology residents rated all images for the presence or absence of the "Darth Vader sign". The diagnostic accuracy for both readers, as well as the inter-reader agreement, was calculated. The "Darth Vader sign" showed an inter-reader agreement of 0.77. Using the "Darth Vader sign", spondylolysis was detected with a sensitivity and specificity of 65.0-88.2% and 96.2-99.0%, respectively. The "Darth Vader sign" shows excellent diagnostic performance at a substantial inter-reader agreement for the detection of spondylolysis. Using the "Darth Vader sign" in the CT reading routine may be an easy yet effective tool to improve the detection rate of spondylolysis in non-musculoskeletal cases and hence improve patient care.

A Novel Technique for Pars Defect Direct Repair with a Modified Smiley Face Rod for Spondylolysis and Isthmic Spondylolisthesis

Introduction

Lumbar spondylolysis is a common fatigue fracture of the pars interarticularis of the lamina of the lumbar spine in adolescent athletes presenting with pars clefts. Some pseudarthrotic lumbar spondylolysis causes low back pain or radiculopathy. This study presents a case of pseudarthrotic lumbar spondylolysis that was successfully treated using a modified smiley face rod technique.

Technical Note

We developed a modified smiley face rod technique, which places pedicle screws in the lateral edge of the pedicle to preserve the erector spinae muscles and inserts a U-shaped rod between the spinous processes to preserve the supraspinous ligament. When a U-shaped rod penetrates the interspinous ligament subcutaneously, the resection of the supraspinous ligaments can be avoided. When the screw head is positioned more anterolaterally, a compression force is applied perpendicular to the surface of the pars cleft by rod clamping. This intrasegmental fusion technique preserves the mobile segment and simultaneously repairs the pars cleft. It is less invasive and more appropriate than interbody fusion for young athletes to avoid the possibility of future adjacent segment disorders.

Conclusions

This is a minimally invasive procedure that can easily achieve bone fusion and should be introduced for patients who are suffering from the symptoms of pseudarthrotic lumbar spondylolysis.

Management of lumbar bone stress injury in cricket fast bowlers and other athletes

Background

Recent guidelines (including a special series in The Lancet) have emphasised a minimal role for imaging when assessing low back pain in adults, as the majority of patients will have non-specific findings on imaging that do not correlate well with pain.

Objective

To assess whether the diagnosis of lumbar bone stress injuries in young athletes should be considered an exception to the recommendation to avoid imaging for low back pain in adults.

Method

Narrative review.

Results

Early lumbar bone stress injury diagnosis has been available via traditional MRI sequences (and its precursor Single Photon Emission Computed Tomography (SPECT)) for 25-30 years. MRI assessments using bone window sequences (such as Volumetric Interpolated Breath-hold Examination (VIBE)) have allowed a better understanding of the diagnosis and prognosis of lumbar bone stress injury in young athletes. MRI with bone sequences has allowed non-radiating scans to serially follow the healing of unilateral stress fractures. In the majority of cases, non-chronic unilateral fractures can heal; however, this takes three-six months rather than the six-ten weeks that would be the typical unloading period if using symptoms (only) as a guide. The use of MRI to provide evidence of bony healing (as opposed to fibrous union, which creates the pars defect that predisposes to further bone stress lesions) can lead to better long-term outcomes in athletes. There is evidence to flag this as a structural lesion which is both painful and, more importantly, can heal/resolve if managed correctly. Therefore it represents an important 'specific' diagnostic subset within adult low back pain.

Conclusion

Structural (rather than functional) management of bone stress injuries in high-demand athletes, such as cricket pace bowlers, is in contrast to the recommendation of functional management for general back pain in adults. Structural management is justified when there are demonstrable superior outcomes of having better structure. Although this has not yet been shown in randomised trials of elite athletes, apparent lengthier Test cricket careers of pace bowlers who do not have pars defects suggest better athletic outcomes if bony healing is achieved. For lower demand young adults, or athletes with established bilateral pars defects, functional management may be more pragmatic.

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.

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.

Spondylolysis

Spondylolysis is a bony defect of the pars interarticularis and most often results from repetitive stress. Although spondylolysis is usually asymptomatic, symptomatic spondylolysis is the most common cause of identifiable back pain in children and adolescent athletes. A thorough history and physical exam, as well as appropriate imaging studies are helpful in diagnosis. General first-ine therapy for spondylolysis is conservative and consists of rest from sports, core strengthening, as well as spinal bracing. Patients who have failed conservative therapy may consider surgical repair. This article aims to review the epidemiology, pathophysiology, presentation, and treatment options of spondylolysis.

Transverse Pedicle Angle Is Associated With Pelvic Incidence and Increased in Lumbar Isthmic Spondylolisthesis

STUDY DESIGN

Retrospective radiographic review.

OBJECTIVES

Investigate and quantify transverse pedicle angle (TPA), the medial-to-lateral pedicle angulation, and its potential association with pelvic incidence (PI) in patients with isthmic lumbar spondylolisthesis (ISLS) and compare to those with degenerative lumbar spondylolisthesis (DSLS) and controls.

METHODS

A total of 200 patients (64 ISLS, 70 DSLS, 66 control) were included. TPA was calculated at the L3-5 vertebral levels using axial computed tomography slices. PI was measured on lateral radiographs. Two independent observers completed the measurements. As a sensitivity analysis, TPA was also measured at the most cranial and caudal aspects of the L3-5 vertebral levels of a subset of participants (29 ISLS, 31 DSLS, 35 control) and the cranial to caudal change (ΔTPA) was calculated.

RESULTS

TPA values (mean ± SD) at L4 and L5 for ISLS (L4: 17.3° ± 3.7°, L5: 26.0° ± 5.2°) were significantly higher than those for the DSLS (L4: 14.3° ± 3.8°, L5: 22.2° ± 5.0°) and control (L4: 14.5° ± 3.9°, L5: 20.7° ± 3.8°) groups. TPA in the DSLS group was significantly higher than controls at L5, but not L4. High PI predicted wider TPA at L5 in both DSLS and ISLS. ΔTPA (mean ± SD) increased sequentially proceeding through the L3-5 spinal levels for the ISLS (L3: 6.8° ± 4.4°, L4: 8.7° ± 5.2°, L5: 15.6° ± 9.0°), DSLS (L3: 8.2° ± 6.0°, L4: 8.3° ± 5.9°, L5: 18.3° ± 7.2°), and control (L3: 6.8° ± 4.4°, L4: 8.2° ± 4.7°, L5: 17.7° ± 7.0°) groups.

CONCLUSIONS

TPA was significantly increased in ISLS compared with DSLS and controls. High PI significantly predicted high TPA at the L5 vertebral level in ISLS and DSLS. ΔTPA increased sequentially proceeding through the lumbar spine across groups.

The prevalence of spondylolysis and intervertebral disc degeneration in male pole vaulters

BACKGROUND

The lower back is the most common injury location in pole vaulters, but the prevalence of lumbar spondylolysis and intervertebral disc degeneration is not known.

OBJECTIVE

This study aimed to determine the prevalence of lumbar spondylolysis and intervertebral disc degeneration in pole vaulters.

METHODS

This cross-sectional study was conducted in the Tokai area of Japan and included 21 pole vaulters (mean ± standard deviation [range]: age, 22.2 ± 3.2 [18-28] years; height, 172.2 ± 4.7 [165.0-182.0] cm; body weight, 67.6 ± 7.3 [54.0- 80.0] kg). The majority of pole vaulters were collegiate athletes. We performed anterior, lateral, and oblique radiography at 45∘ and magnetic resonance imaging in the sagittal and coronal planes of the lumbar spine. The evaluation was performed independently of whether the athletes had lower back pain (LBP). Moreover, we investigated the duration of pole-vaulting experience and history and current presence of LBP using a questionnaire.

RESULTS

The prevalence of lumbar spondylolysis and intervertebral disc degeneration was 28.6% (6/21) and 38.1% (8/21), respectively. Herniation was found in six discs in four vaulters (19.0%). All athletes had a history of LBP. The prevalence of lumbar spondylolysis was high (28.6%).

CONCLUSIONS

Sport-specific movements performed by pole vaulters may be a risk factor for lumbar spondylolysis.

Prevailing treatment methods for lumbar spondylolysis: A systematic review

Background:

Aim of this study was to systematically review the prevailing treatment methods for lumbar spondylolysis.

Methods:

Manuscripts published between 1951 and 2020 were searched by using PubMed, Medline, Scopus, Springer, Web of Science databases. The study protocol was registered with PROSPERO (CRD42020218651). The inclusion criteria for all articles of prevailing treatment methods for spondylolysis were:

Standards have been independently applied by using 2 reviewers and another author resolved disagreements.

Results:

Data extraction screened 12 full-length articles. Description, treatment, outcome, and findings were individually extracted and cross-referenced.

Discussion:

Current review has suggested that the noninvasive treatment method specifically low intensity pulsed ultrasound, electro acupuncture and pulsed electromagnetic filed is effective for bone union while operative treatment specifically pedicle screw fixation +/- interbody fusion depending the extent of disk degeneration and craniocaudal foraminal stenosis is effective for minimizing pain and functional disability in patients with spondylolysis. This review concluded that the noninvasive treatment method specifically low intensity pulsed ultrasound is effective for bone union.

Review Registration:

PROSPERO (CRD42020218651).

Comparison of L5 pedicle morphology in patients with and without L5 spondylolysis

Only a small number of studies have reported on L5 pedicle morphology in the presence of spondylolisthesis let alone isolated spondylolysis and findings are therefore variable. The aim of this radiographic study was to analyze L5 pedicle morphology in the presence and absence of L5 spondylolysis. The was a retrospective cross-sectional analysis of computed tomographic (CT) imaging. Assessment of the L5 pedicle morphology (height, width, length, transverse angle and screw length) were measured in patients with and without L5 spondylolysis. Pelvic measures including pelvic incidence, sacral anatomic orientation and sacral table angle were recorded. Patients were matched for age and gender. Twenty-three patients with spondylolysis were matched to 46 patients without. The presence of spondylolysis alone did not have a significant influence on either pelvic or pedicle morphologic parameters. Only with the presence of associated spondylolisthesis was there a difference noted with an increase in pedicle length observed. Correlation analysis suggested further morphologic changes may result with increased remodeling. Isolated spondylolysis at L5 appears to have little influence on pedicle morphology in this CT-based analysis. Morphologic changes appear likely to become significant only with associated spondylolisthesis and associated remodeling.

Impact of corset bracing on 3D spine kinematics during ADL in children with Spondylolysis

Spondylolysis is a stress fracture of the vertebral pars interarticularis that frequently affects adolescents involved in sports. Conservative bracing methods may assist the clinician in treating spondylolysis, though there is a need to further validate these techniques. The goal of this study was to evaluate differences in the 3D movements of the thoracic and lumbar spine before and after bracing. Five patients (mean age 14.4 ± 1.3 years) with spondylogenic back pain were evaluated for kinematic measurements using a Vicon motion capture system. Patients performed activities both with and without a lumbar corset brace including walking, kneeling, standing from a chair, standing from the floor, ascending and descending stairs, and lifting. Patients were evaluated for differences in thoracic and lumbar range of motion (ROM) in the braced and unbraced condition. While wearing the brace, patients demonstrated reduced extension ROM of the thoracic spine while walking (mean reduction = 0.4°), ascending stairs (3.0°), descending stairs (2.1°), lifting (14.8°), standing from a chair (4.1°), standing from the floor (16.7°), and kneeling (8.4°). Patients also exhibited reduced extension ROM of the total lumbar spine while ascending stairs (mean reduction = 1.8°), lifting (12.7°), standing from a chair (9.5°), standing from the floor (11.8°), and kneeling (4.7°). These results provide evidence that bracing reduces stress on the pars interarticularis and relieves symptoms in the athlete with spondylogenic back pain, thereby facilitating a return to sports.

Repair of spondylolysis using a pedicle screw U-shaped rod construct: A preliminary study of 25 young patients with a mean follow-up of 24 months

Study Design:

Prospective case series, therapeutic Level IV.

Objectives:

Functional and radiographic outcome evaluation of patients with spondylolysis treated with pars interarticularis defect repair with iliac bone grafting and application of a construct consisting of a pair of polyaxial pedicle screws connected by a U-shaped rod passing beneath the spinous process.

Methods:

Twenty-five patients (27 operated lumbar levels) with an average of 20 months of follow-up (range 12–24 m) with spondylolysis who met our inclusion criteria were treated with the above-mentioned technique. Functional assessment was by the Visual Analog Score (VAS) for low back pain (LBP) and Oswestry Disability Index (ODI). Fusion was confirmed with plain x-rays and when indicated with computed tomography scan. Return to activities of daily living (ADL) was also assessed.

Results:

There were 16 males (64%) and 9 females (36%), with a mean age of 18 ± 3 years at surgery, with a mean operating time of 79 ± 13 min and a mean blood loss of 186 ± 57 ml. ODI significantly improved from a mean of 63 ± 7 preoperatively to 10 ± 4 at 12 months postoperatively (P < 0.001). The mean preoperative LBP VAS score 8 ± 1 showed also a statistically significant decrease of values to 1 ± 1 at 12 months, (P < 0.001). At 12 m, all patients returned to unrestricted ADL. Pars healing was present in 19 patients (76%) at 6 months and in all patients at 12 months.

Conclusions:

Polyaxial pedicular screws with a U-shaped rod offer an effective and reproducible treatment for spondylolysis with an appropriate fusion rate, predictable return to daily activities, and good pain relief in young adults.

Familial development of lumbar spondylolysis: a familial case report of 7- and 4-year-old brothers and their father

The incidence of lumbar spondylolysis is affected by sex, race, and congenital abnormalities. These differences suggest a genetic component to the etiology of spondylolysis. However, no definitive evidence has been presented regarding the inheritance of lumbar spondylolysis. We report familial cases of lumbar spondylolysis in 7- and 4-year-old brothers and their father, each of whom visited our clinic complaining of low back pain. Spondylolysis in the fifth lumbar vertebra (L5) was identified in both boys and their father from clinical, radiographic, computed tomographic, and magnetic resonance imaging examinations. Conservative treatment was provided for both boys. No bony union of any spondylolytic lesions was obtained, but they returned to sports activity without low back pain. Frequent development of spondylolysis, even at younger ages, in all male family members might indicate an underlying genetic etiology in lumbar spondylolysis, primarily in the form of autosomal dominant inheritance. However, information on patients and their parents should be considered carefully, as bony union with conservative therapy is not expected in such patients.

Predictors of Spondylolysis on Magnetic Resonance Imaging in Adolescent Athletes With Low Back Pain

Background:

Spondylolysis and undiagnosed mechanical low back pain (UMLBP) are the main causes of low back pain (LBP) in adolescent athletes. No studies have evaluated the difference in clinical and radiographic factors between these 2 conditions. Furthermore, it remains unclear which adolescent athletes with LBP should undergo advanced imaging examination for spondylolysis.

Purpose:

To compare the clinical and radiographic factors of adolescent athletes with spondylolysis and UMLBP who did not have neurological symptoms or findings before magnetic resonance imaging (MRI) evaluation and to determine the predictors of spondylolysis findings on MRI.

Study Design:

Cohort study, Level of evidence, 3.

Methods:

The study population included 122 adolescent athletes aged 11 to 18 years who had LBP without neurological symptoms or findings and who underwent MRI. Of these participants, 75 were ultimately diagnosed with spondylolysis, and 47 were diagnosed with UMLBP. Clinical factors and the following radiographic parameters were compared between the 2 groups: spina bifida occulta, lumbar lordosis (LL) angle, and the ratio of the interfacet distance of L1 to that of L5 (L1:L5 ratio, %). A logistic regression analysis was performed to evaluate independent predictors of spondylolysis on MRI scans.

Results:

Significantly more athletes with spondylolysis were male (82.7% vs 48.9%; P < .001), had a greater LL angle (22.8° ± 8.1° vs 19.3° ± 8.5°; P = .02), and had a higher L1:L5 ratio (67.4% ± 6.3% vs 63.4% ± 6.6%; P = .001) versus athletes with UMLBP. A multivariate analysis revealed that male sex (odds ratio [OR], 4.66; P < .001) and an L1:L5 ratio of >65% (OR, 3.48; P = .003) were independent predictors of positive findings of spondylolysis on MRI scans.

Conclusion:

The study findings indicated that sex and the L1:L5 ratio are important indicators for whether to perform MRI as an advanced imaging examination for adolescent athletes with LBP who have no neurological symptoms and findings.

Inter-Disciplinary Conservative Management of Bilateral Non-United Lumbar Pars Defects in a Junior Elite Golfer

The prevalence of spondylolysis amongst adolescent athletes presenting with low back pain has been reported as high as 47-55%. Youth athletes participating in sports involving movements combining compression, extension and rotation appear most susceptible. As such, young golfers are a high-risk group, particularly given the high shear and compressive forces associated with the golf swing action. This is compounded by a culture which encourages very high practice volumes, typically poorly monitored. Although non-operative interventions are deemed the gold-standard management for this condition, surgery is indicated for more severe presentations and cases of 'failed' conservative management. The case presented herein outlines an inter-disciplinary, non-operative management of a 17-year old elite golfer with a moderate to severe presentation. A 4-stage model of reconditioning is outlined, which may be of use to practitioners given the paucity of rehabilitation guidelines for this condition. The report highlights the benefits of a graded program of exercise-based rehabilitation over the typically prescribed "12 weeks rest" prior to a return to the provocative activity. It also supports existing evidence that passive therapeutic approaches should only be used as an adjunct to exercise, if at all in the management of spondylolysis. Finally, and crucially, it also underlines that to deem non-surgical rehabilitation 'unsuccessful' or 'failed', clinicians should ensure that (long-term) exercise was included in the conservative approach.

LEVEL OF EVIDENCE

4-Case Report.

An Alternative Model of Care for the Treatment of Adolescent Athletes with Extension-Based Low Back Pain: A Pilot Study

BACKGROUND AND PURPOSE

Half of adolescent athletes report low back pain (LBP) and there is a significant risk of vertebral injury in this population. The current model of care for adolescent athletes with LBP is to first confirm a medical diagnosis of spondylolysis which frequently requires advanced imaging. However, routine use of advanced imaging increases cost, delays treatment, and can expose the athlete to radiation.

PURPOSE

The purpose of this pilot study was to assess the viability of a physical therapist guided functional progression program to manage low back pain (LBP) in adolescent athletes.

STUDY DESIGN

Non-randomized, controlled clinical trial.

METHODS

Sixteen adolescents (15 ± 1.8 years, 50% female) with extension-based LBP were assigned to the biomedical model or physical therapy first model. The biomedical model sought to determine a spondylolysis diagnosis to guide treatment. In the physical therapy first model, patients began early therapeutic exercise and their ability to functionally progress determined the course of care. Dependent variables were change in Micheli Function Score, use of imagining, days out of sport, and ability to return to sport. Adverse events were monitored in order to assess safety. Descriptive statistics were completed to assess the viability of the alternative model.

RESULTS

Both models had similar improvements in pain and function. The physical therapy first model reduced use of advanced imaging by 88% compared to the biomedical model. Patients in the biomedical model who did not sustain a vertebral injury returned to sport sooner than the physical therapy first model (3.4 days versus 51 days), while those with a vertebral injury took longer in the current model (131 days versus 71 days). All of the patients in the physical therapy first model and 88% of patients in the current model made a full return to sport. Two adverse events occurred in the biomedical model, and none were noted in the physical therapy first model.

CONCLUSION

This pilot study demonstrated that the physical therapist guided functional progression program may be a viable method for treating young athletes with LBP and further research is warranted.

LEVEL OF EVIDENCE

3b.

Influence of Spondylolysis on Clinical Presentations in Patients With Lumbar Degenerative Disease

BACKGROUND

There is insufficient current information regarding the prognosis of patients with lumbar spondylolysis when bone union is not achieved. To examine the number, age, and surgically treated levels of patients with lumbar degenerative disease who underwent lumbar spine surgery, and to compare the results between patients with spondylolysis and without spondylolysis, a cross-sectional study was performed.

METHODS

Patients with degenerative lumbar disease who underwent lumbar spine surgery were retrospectively reviewed (n=354). The prevalence of spondylolysis was determined using CT images. Patients were divided into a spondylolysis group and a non-spondylolysis group, and the patients' age, sex, and surgically treated levels were compared between the two groups.

RESULTS

The prevalence of lumbar spondylolysis in the 354 patients was 6.50% (23/354). The patients' age was significantly lower in the spondylolysis group (54.2 ± 13.5 years) than in the non-spondylolysis group (63.8 ± 14.2). The number of surgically treated levels was significantly lower in the spondylolysis group (1.33 ± 0.56 levels) than in the non-spondylolysis group (1.70 ± 0.87). The percentage of patients who underwent surgery at L5-S1 was significantly higher in the spondylolysis group; whereas the percentage of patients who underwent surgery at L3-L4 or L4-L5 was significantly higher in the non-spondylolysis group.

CONCLUSIONS

Our results suggest that the presence of spondylolysis may not increase the incidence of degenerative lumbar spinal disorders requiring spinal surgery. However, spondylolysis patients frequently have severe degenerative disease at one level caudal to the spondylolysis, and infrequently have multilevel lumbar degenerative disease requiring spinal surgery.

CONSIDERATION OF SPORT DEMANDS FOR AN 18-YEAR-OLD LACROSSE PLAYER WITH RECALCITRANT SYMPTOMATIC SPONDYLOLYSIS: A CASE REPORT

Background and Purpose

Spondylolysis is an anatomical defect or fracture of the pars interarticularis and encompasses almost half of all cases of low back pain in adolescent athletes. Most athletes return to sport with conservative treatment, but it is possible that consideration of sport demands may further improve rate of successful return. When surgery is performed, complication rate is high, so all conservative measures should be explored before considering surgical intervention. The purpose of this case report is to present a program where demands of sport were considered and allowed successful return to sport for a subject with recalcitrant symptomatic spondylolysis that had failed to respond to prior treatment.

Case Description

An 18-year-old lacrosse player with a history of recalcitrant symptomatic spondylolysis that failed three courses of conservative treatment and had been unsuccessful in returning to sport. A multi-phase program with a focus on multi-planar and full kinetic chain activities that addressed the nature of the sport demands is described, along with improvements in pain level, strength, range of motion, and subjective outcome scores.

Outcomes

The subject was able to successfully return to sport after 10 weeks of physical therapy and complete the remaining few months of his lacrosse season without reinjury. Range of motion and strength testing was markedly improved upon discharge. The subject's Modified Oswestry Disability Index improved from 16% to 0% and his pain level did not rise above 2/10 with any sport activity upon return.

Discussion/Conclusions

Although return to sport rates following spondylolysis in young athletes is high, this case report demonstrates that a consideration of sport demands may increase return to sport rates in athletes that do not respond to standard care and prevent surgical intervention.

Level of Evidence

Level 4, single case report.

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.

A long-term follow-up study of spinal abnormalities and pain in adults with cerebral palsy and spastic diplegia more than 25 years after selective dorsal rhizotomy

OBJECTIVE

The main purpose of selective dorsal rhizotomy (SDR) is to reduce spasticity in the lower extremities of children diagnosed with cerebral palsy (CP) and spastic diplegia. The potential for developing spinal abnormalities and pain is a concern, especially in the aging CP population. Therefore, the aim of this study was to evaluate spinal abnormalities, level of pain, and disability (due to back or leg pain) in adults with CP, and associations with participant characteristics, more than 25 years after SDR.

METHODS

This is a 9-year follow-up study with data collection conducted in 2008 and 2017. Radiographs were assessed for the degree of scoliosis, thoracic kyphosis and lumbar lordosis curvatures, and prevalence of spondylolysis and spondylolisthesis, while level of pain and disability was determined with a self-developed questionnaire and the Oswestry Disability Index (ODI) questionnaire, respectively.

RESULTS

Twenty-five participants were included (15 males; median age 35.9 years, IQR 34.3-41.5 years), with a follow-up time after SDR ranging from 25 to 35 years. No clinically relevant changes were found for spinal curvatures, spondylolysis and spondylolisthesis, perceived pain frequency, and ODI scores between 2008 and 2017. While the prevalence of spondylolysis was 44%, spondylolisthesis was found in 20% (of whom 15% were grade I and 5% grade II), lumbar hyperlordosis was found in 32%, thoracic hyperkyphosis in 4%, and scoliosis in 20%. The Cobb angle was < 25°, and no patient required surgery for scoliosis. In addition, the low back was reported as the most common site of pain, with 28% of the adults with CP having daily pain. This resulted in 80% of the cohort indicating none or minimal disability due to pain based on the ODI. The only correlation found was between hyperkyphosis and female gender.

CONCLUSIONS

At follow-up more than 25 years after SDR, no progression in spinal abnormalities, level of pain, and disability was found when compared with findings 15 years after SDR. The prevalence of scoliosis, thoracic hyperkyphosis, and lumbar hyperlordosis was within the range reported for adults with CP, while spondylolysis and spondylolisthesis occurred more often than would be expected. It is difficult, however, to establish the role of SDR in this finding, given the limited data on the natural history of CP. Despite the encouraging outcome of this long-term follow-up study after SDR, it is important to continue monitoring adults with CP during the aging process.

Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis

BACKGROUND

Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players.

PURPOSE

To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance.

RESULTS

During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode.

CONCLUSION

Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.

The Incidence of Pars Interarticularis Defects in Athletes

STUDY DESIGN

Literature review.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robot-assisted direct repair of spondylolysis: A case report

INTRODUCTION

Direct repair of the pars defect in lumbar spondylolysis is an effective surgical procedure, but it is technically challenging. We assessed the feasibility of a new robotic system for intralaminar screw fixation of spondylolysis.

PATIENT CONCERNS

A 26-year-old man complained about frequent low back pain after failed conservative treatments.

DIAGNOSIS

The lumbar computed tomography images demonstrated the presence of bilateral spondylolysis at the L5 level, with no spondylolisthesis.

INTERVENTIONS

We performed one surgery of direct intralaminar screw fixation under the guidance of the TiRobot system. The trajectory of the screw was planned based on intraoperative 3-dimensional radiographic images. Then, the robotic arm spontaneously moved to guide the guide wires and screw insertion.

OUTCOMES

Bilateral L5 intralaminar screws were safely and accurately placed. No intraoperative complications occurred. Postoperative computed tomography showed good radiological results, without cortical perforation.

CONCLUSION

We report the first case of robot-assisted direct intralaminar screw fixation for spondylolysis using the TiRobot system. Robotic guidance for direct repair of spondylolysis could be feasible.

Relationship between individual payload weight and spondylolysis incidence in Turkish land forces

OBJECTIVEThe aim of this study was to investigate the relationship between lumbar spondylolysis and payload weight between different combat units of Turkish land forces (TLF).METHODThe authors reviewed clinical and radiological data of the military personnel with low-back pain (LBP) admitted to their clinic between July 2017 and July 2018. Age, BMI, average payload weight, and military service unit were recorded. CT scans were evaluated for pars interarticularis fractures and spondylolisthesis, whereas MRI studies were evaluated for spondylolisthesis, Modic-type endplate changes, or signal loss on T2-weighted images compatible with disc degeneration.RESULTFollowing exclusion, a total of 642 all-male military personnel were included. Of these personnel, 122 were commandos, 435 were infantry, and 85 were serving in the artillery units. Bilateral pars interarticularis fracture was noted in 42 commandos (34.42%) and 2 infantrymen (0.45%). There was no spondylolysis in the artillery units. There was no multiple-level spondylolysis and the most common level of spondylolysis was L5. Commandos had a significantly higher incidence of spondylolysis and more average payload weight (p < 0.001). Twelve patients (27.2%) with spondylolysis had accompanying MRI pathologies at the same level, whereas 32 patients (72.7%) had no accompanying MRI pathologies.CONCLUSIONSIncreased payload weight in military personnel is associated with spondylolysis, and commandos in the TLF have significantly heavier payloads, which causes an increased rate of spondylolysis compared to other units. Additionally, spondylolysis without adjacent-level changes on MRI could be undiagnosed. LBP in active military personnel who have a history of carrying heavy payloads should be evaluated extensively with both MRI and CT scans.

Phenotypic characterization of Slc26a2 mutant mice reveals a multifactorial etiology of spondylolysis

Confusion persists over pathogenesis of spondylolysis. To confirm pathogenicity of the previously identified causative mutation of spondylolysis and investigate the genetic etiology, we generate a new mouse line harboring D673V mutation in the Slc26a2 gene. D673V mutation induces delayed endochondral ossification characterized by transiently reduced chondrocyte proliferation in mice at the early postnatal stage. Adult D673V homozygotes exhibit dysplastic isthmus and reduced bone volume of the dorsal vertebra resembling the detached vertebral bony structure when spondylolysis occurs, including the postzygopophysis, vertebral arch, and spinous process, which causes biomechanical alterations around the isthmic region of L4-5 vertebrae indicated by finite element analysis. Consistently, partial ablation of Slc26a2 in vertebral skeletal cells using Col1a1-Cre; Slc26a2 ^fl/fl mouse line recapitulates a similar but worsened vertebral phenotype featured by lamellar isthmus. In addition, when reaching late adulthood, D673V homozygotes develop an evident bone-loss phenotype and show impaired osteogenesis. These findings support a multifactorial etiology, involving congenitally predisposed isthmic conditions, altered biomechanics, and age-dependent bone loss, which leads to SLC26A2-related spondylolysis.

A comparison of the techniques of direct pars interarticularis repairs for spondylolysis and low-grade spondylolisthesis: a meta-analysis

OBJECTIVE Spondylosis with or without spondylolisthesis that does not respond to conservative management has an excellent outcome with direct pars interarticularis repair. Direct repair preserves the segmental spinal motion. A number of operative techniques for direct repair are practiced; however, the procedure of choice is not clearly defined. The present study aims to clarify the advantages and disadvantages of the different operative techniques and their outcomes. METHODS A meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following databases were searched: PubMed, Cochrane Library, Web of Science, and CINAHL ( Cumulative Index to Nursing and Allied Health Literature). Studies of patients with spondylolysis with or without low-grade spondylolisthesis who underwent direct repair were included. The patients were divided into 4 groups based on the operative technique used: the Buck repair group, Scott repair group, Morscher repair group, and pedicle screw-based repair group. The pooled data were analyzed using the DerSimonian and Laird random-effects model. Tests for bias and heterogeneity were performed. The I² statistic was calculated, and the results were analyzed. Statistical analysis was performed using StatsDirect version 2. RESULTS Forty-six studies consisting of 900 patients were included in the study. The majority of the patients were in their 2nd decade of life. The Buck group included 19 studies with 305 patients; the Scott group had 8 studies with 162 patients. The Morscher method included 5 studies with 193 patients, and the pedicle group included 14 studies with 240 patients. The overall pooled fusion, complication, and outcome rates were calculated. The pooled rates for fusion for the Buck, Scott, Morscher, and pedicle screw groups were 83.53%, 81.57%, 77.72%, and 90.21%, respectively. The pooled complication rates for the Buck, Scott, Morscher, and pedicle screw groups were 13.41%, 22.35%, 27.42%, and 12.8%, respectively, and the pooled positive outcome rates for the Buck, Scott, Morscher, and pedicle screw groups were 84.33%, 82.49%, 80.30%, and 80.1%, respectively. The pedicle group had the best fusion rate and lowest complication rate. CONCLUSIONS The pedicle screw-based direct pars repair for spondylolysis and low-grade spondylolisthesis is the best choice of procedure, with the highest fusion and lowest complication rates, followed by the Buck repair. The Morscher and Scott repairs were associated with a high rate of complication and lower rates of fusion.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnosis of Spondylolysis and Spondylolisthesis Is Delayed Six Months After Seeing Nonorthopedic Providers

STUDY DESIGN

Retrospective single center.

OBJECTIVE

Our purpose was to quantify the time to diagnosis of spondylolysis/spondylolisthesis in symptomatic patients after first seeking medical care.

SUMMARY OF BACKGROUND DATA

Several studies have found a high prevalence of pars defects in adolescent athletes with back pain, up to 47%. A review by the Scoliosis Research Society Evidence-Based Medicine Committee reports that both nonsurgical and surgical treatment of symptomatic spondylolysis effectively relieves pain and allows most patients to return to activities. Nonoperative treatment outcomes improve with early diagnosis.

METHODS

A retrospective chart review was conducted of patients presenting at our institution between 2005 and 2015 with symptomatic spondylolysis or spondylolisthesis with radiographic confirmation. Medical records were reviewed for demographics, date of symptom onset, date of initial presentation to a health care provider, type of provider, and date of diagnosis.

RESULTS

Forty-six patients met the inclusion criteria. Average patient age was 14 years (range: 6-19 years). Forty-one percent (19/46) of patients had spondylolysis, and 59% (27/46) of patients had spondylolisthesis. Of those with spondylolisthesis, 20 had grade I, 4 had grade II, 2 had grade III, and 1 had grade IV slips. The average time between onset of symptoms and initial presentation was 24 weeks (orthopedic: 21 weeks, nonorthopedic: 29 weeks, unknown: 18 weeks; p = .26). The average delay between initial presentation to a health care provider and diagnosis was 15 weeks. Time from initial presentation to diagnosis was 1 week for orthopedic surgeons, 25 weeks for nonorthopedic providers, and 10 weeks for unknown providers; this difference was significant (p = .02).

CONCLUSION

Diagnosis of spondylolysis/spondylolisthesis was significantly longer after seeing a nonorthopedic versus an orthopedic provider. Education of primary care providers on this topic is warranted. Children suffering from back pain from spondylolysis/spondylolisthesis may benefit from early referral to an orthopedic surgeon.

LEVEL OF EVIDENCE

Level II.

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.

Physical features of pediatric patients with lumbar spondylolysis and effectiveness of rehabilitation

The purpose of this study was to evaluate the physical features of pediatric patients with lumbar spondylolysis (LS), factors that increase the load during compensatory movements at the lumbar spine, and the outcomes of rehabilitation. Twenty patients were included. Fifteen items were used:fingertip-to-floor distance (FFD), straight leg raising (SLR), heel-to-buttock distance (HBD), tightness of the rectus femoris, the lateral and medial rotator muscles, iliopsoas, tensor fascia lata, adductor muscles, soleus muscle, and latissimus dorsi, and trunk rotation, sit-ups and endurance of the abdominal and back muscles. Initial findings were judged as positive or negative using previously reported cut-off values and were re-evaluated 2 or 3 months later. Positive tests were found for HBD and tightness of the rectus femoris in 85% of the patients, for endurance of the abdominal muscles in 75%, SLR and sit-ups in 70%, and FFD and tightness of the external rotator muscles in 60%. The physical features varied according to the type of sport played, and some patients were refractory to rehabilitation. Only 17.6%, 33.3%, and 40.0% of patients with initially positive findings for HBD, tightness of the external rotator muscles, and endurance of the abdominal muscles, respectively, achieved improvements after rehabilitation. J. Med. Invest. 65:177-183, August, 2018.

The Role of Sacral Slope in the Progression of a Bilateral Spondylolytic Defect at L5 to Spondylolisthesis: A Biomechanical Investigation Using Finite Element Analysis

STUDY DESIGN

A biomechanical study using finite element analysis.

OBJECTIVES

The main objective of this study was to investigate the role of sacral slope in the progression of a L5 bilateral spondylolytic defect to spondylolisthesis.

METHODS

A 3-dimensional model of lumbosacral spine was built using computed tomography (CT) data procured from an anonymized healthy male subject. The segmented CT data was manipulated to generate 3 more models representing L5 bilateral spondylolytic defect with normal sacral slope (SS), sacral slope increased by 10° (SS+10), and sacral slope decreased by 10° (SS-10). The 3D models were imported into finite element modelling software Strand7 for preprocessing, running nonlinear static solves, and postprocessing of the results.

RESULTS

Directional biomechanical instabilities were induced in the lumbosacral spine as a result of changes in the L5-S1 disc shape secondary to the changes in sacral slope. Compared with the normal L5 lytic model, wedging of the L5-S1 disc (SS+10) resulted in a significantly greater range of motion in flexion (18% ↑) but extension motion characteristics were similar. Conversely, flattening of the L5-S1 disc (SS-10) resulted in a significantly greater range of motion in extension (16% ↑) but flexion motion characteristics were similar to that of the normal L5 lytic model.

CONCLUSIONS

Variations in sacral slope while preserving the L5-S1 mid-disc height and orientation of the L5 vertebra resulted in variations in the L5-S1 disc shape. The results suggest that for such extremities in the L5-S1 disc shape different pathomechanisms exist for the progression of the L5 lytic defect to spondylolisthesis.

Bony Healing of Discontinuous Laminar Stress Fractures Due to Contralateral Pars Defect or Spina Bifida Occulta

Introduction

Although there has been a dramatic improvement in the outcomes of conservative treatment to achieve bony healing due to advances in diagnostic and therapeutic tools, in some patients, the results continue to be unfavorable. The purpose of this study was to investigate the outcomes of conservative treatment in pediatric patients with stress fractures occurring in the lamina that are discontinuous due to a contralateral pars defect or spina bifida occulta (SBO).

Methods

The medical records at our outpatient clinic for 103 consecutive patients (83 boys, 20 girls) with lumbar spondylolysis (LS) were reviewed to identify those who had presented with a stress fracture and a contralateral pars defect or with SBO at the affected lamina level.

Results

Twelve patients (11 boys, 1 girl) of mean age 12.3 (range 8-16) years were identified. Except for 1 stress structure that occurred at L4, all the stress fractures occurred at L5. Six patients had a pars defect, 5 had SBO, and 1 had both. Two of the 6 patients with a contralateral pars defect had early LS, 3 had progressive LS, and 1 had a pedicle fracture. The fracture healed in 1 (50%) of the 2 patients with early LS and in the patient with the pedicle fracture, but did not heal in any of the patients with progressive LS. Two of the 5 patients with SBO at the affected lamina level had early LS and 3 had progressive LS. The bony healing rate was 100% in the 2 patients with early LS and 66.7% in the 3 patients with progressive LS. The fracture healed in the patient with progressive LS and both a pars defect and SBO at the affected lamina.

Conclusions

Contralateral pars defect remains an unfavorable factor for bony healing discontinuous laminar stress fractures.

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.

Return to Play in Adolescent Athletes With Symptomatic Spondylolysis Without Listhesis: A Meta-Analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVES

To assess return to play (RTP) rates in adolescent athletes with lumbar spondylolysis without spondylolisthesis treated conservatively or operatively.

METHODS

A review of Medline, EMBASE, and Cochrane Reviews was performed. The pooled results were performed by calculating the effect size based on the logit event rate. Studies were weighted by the inverse of the variance. Confidence intervals were reported at 95%. Heterogeneity was assessed using the Q statistic and I² value.

RESULTS

The initial literature search resulted in 724 articles, of which 29 were deemed relevant on abstract review. Overall, 11 studies provided data for 376 patients with a pars interarticularis defect. Return to athletic competition, based on logit event rate, was found to be statistically favored after both nonoperative and operative treatment (92.2% vs 90.3%). There was no heterogeneity noted among the studies reporting nonoperative treatment (Q value of 4.99 and I² value of 0). There was mild heterogeneity within the operative studies (Q value of 3.54 and I² value of 15.18).

CONCLUSIONS

Adolescent athletes RTP 92.2% of the time with nonoperative management, compared with 90.3% when treated operatively, though both treatment groups strongly favor RTP. As this is the first study to pool results of all relevant literature, it provides strong evidence to guide decision making and help manage expectations in this unique patient population.

Lumbar spondylolysis: A report of four cases from two generations of a family

Spondylolysis is a major cause of back pain in children and adolescents. The prevalence of spondylolysis depends on the sex, race, and congenital abnormality. These biases suggest hereditary predisposition as an etiology of spondylolysis. However, no conclusive evidence still exists regarding the inheritance for spondylolysis. Herein, we report rare cases with familial occurrence of lumbar spondylolysis. In two generations of a Japanese family, three brothers including identical twins complained of back pain related to sports activities. Clinical, radiographic, and computed tomographic examinations identified spondylolysis at L4 and L5 in all these boys. The father experienced long-term back pain and had spondylolisthesis at L4-L5 and healed spondylolysis at L5. The daughter and mother did not show any lumbar spondylolysis. The frequent development of spondylolysis at L4, a rarely affected segment, in four of six family members (66.7%) support that lumbar spondylolysis has an underlying genetic etiology, primarily autosomal dominant inheritance.

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.

Rehabilitation of a Young Athlete With Extension-Based Low Back Pain Addressing Motor-Control Impairments and Central Sensitization

OBJECTIVE

  To describe the conservative management of a young athlete with extension-based (EB) low back pain (LBP).

BACKGROUND

  We present the case of a 15-year-old female high school gymnast with a 4-year history of EB LBP. Magnetic resonance imaging revealed a healed spondylolysis and significant atrophy with fatty infiltrate of the lumbar multifidi muscles (LMM). She had several courses of outpatient orthopaedic rehabilitation that focused on core muscle strengthening (improving activation and strength of the LMM and transversus abdominus muscle in a neutral pelvic position) without long-lasting improvement. She was unable to tolerate higher levels of training or compete.

DIFFERENTIAL DIAGNOSIS

  The LMM are rich in muscle spindles and provide continuous feedback to the central nervous system about body position. Atrophy and fatty infiltrate of the LMM can compromise neuromuscular function and contribute to dysfunctional movement patterns that place a greater demand on lumbar spine structures. Ongoing motor-control impairments perpetuate nociceptive input, leading to central sensitization.

TREATMENT

  The athlete had difficulty controlling trunk extension during sport-specific activities; she moved early and to a greater extent in the lumbar spine. The aim of the treatment was to teach the athlete how to control her tendency to overload her lumbar spine when bending backward, thus reducing nociceptive input from lumbar spine structures and desensitizing the nervous system.

UNIQUENESS

  Treating EB LBP by addressing motor-control impairments and cognitive-affective factors as opposed to core strengthening.

CONCLUSIONS

  Activity modification, bracing, and traditional core-strengthening exercises may not be the most appropriate treatment for athletes experiencing EB LBP. Addressing cognitive-affective factors in addition to correcting maladaptive motor behavior and moving in a pain-free range reduces nociceptive input, desensitizes the nervous system, and allows athletes to gain control over their pain.

Spondylolisthesis with spondylolysis in a 17-month-old: a case report

Spondylolysis is frequently seen in adolescents, typically at the L5 vertebral level. While there may be a congenital predisposition for spondylolysis, it has long been suggested that the defect results from a fatigue or stress fracture of the pars interarticularis. Spondylolisthesis may result from a bilateral spondylolytic defect and is frequently asymptomatic. There is a paucity of literature on infant and toddler spondylolysis, as the focus is primarily on school-aged children, typically those over ten years of age. This case report presents an incidentally discovered L5 spondylolysis with spondylolisthesis in a 17-month-old female. The patient presented to the emergency department with multiple facial abrasions and bruises from reportedly being struck by her 4-year-old sister. Her past medical history included a hospitalization four months prior for a distal radius buckle fracture from a thirty foot fall from a window. A routine non-accidental trauma work-up was performed, including a skeletal survey which demonstrated L5 bilateral pars defect with Myerding grade 2 spondylolisthesis. An MRI of the lumbar spine was performed, again demonstrating the L5 bilateral pars defect with position dependent reduction of the spondylolisthesis. The patient was seen back in the orthopedic office three months later which is her latest follow-up. Dynamic plain films of the lumbar spine were unchanged from previous imaging, without evidence of instability or slip progression. Further progression of her slip should warrant consideration for further treatment, whether it be cast immobilization or surgery.

Indirect pars repair for pediatric isthmic spondylolysis: a case series

BACKGROUND

Isthmic spondylolysis (ISY) is a common cause of back pain in the pediatric population. Historically, non-operative treatments have had a very high success rate. The purpose of this study was to review the mid-term results of an indirect pars repair technique on reducing the visual analog score for pain (VAS), spondylolysis defect healing, complication rates and rates of return to pre-surgery activity level in pediatric patients who failed conservative care for ISY.

METHODS

A retrospective review of all pediatric patients (<18 years old) treated surgically by one surgeon over a 5-year period was performed. Patients were treated with indirect pars repair utilizing pedicle screws and laminar hooks and local autograft. Preoperative VAS was compared to the final follow-up score, and return to activity was evaluated. Radiographs were reviewed to evaluate healing.

RESULTS

Nine patients (6 females, 3 males) were treated surgically. Average age at the time of surgery was 15.4 years, (range, 13 to 17 years). Average length of final follow-up was 11.9 months (range, 6 to 24 months). Preoperative VAS averaged 5.6 points (range, 2 to 8 points) compared to final follow-up of 1.2 (range, 0 to 3). Definitive bony healing was noted in 7 of 9 cases (77.8%) with at least 6 months follow-up. Eight of nine patients (88.9%) returned to preoperative competitive sports activity level. No complications were noted during the follow-up period.

CONCLUSIONS

Pediatric patients treated surgically with indirect pars repair appear to achieve satisfactory mid-term outcomes. This technique appears safe, and has both a high healing rate and return to competitive athletics. Further study is needed to determine durability of this procedure.

Surgical treatment of bilateral nondisplaced isthmic lysis by interlaminar fixation device

STUDY DESIGN

Spondylolysis is a defect in the portion of pars interarticularis. The latter affects approximately 6% of the population. It is caused by repetitive trauma in hyperextension. Low back pain is the most common symptom.

METHODS

We implanted interspinous process devices in 12 patients with isthmic lysis without spondylolisthesis for low back pain. The purpose of the surgery was to conduct a minimally invasive procedure.

RESULTS

In eight cases, patients became asymptomatic. In two cases, there has been a considerable improvement. In two cases, no change had been noted.

CONCLUSION

This good result motivates us to consider this approach a part of therapeutic arsenal for some cases of spondylolysis.

High-grade spondylolytic spondylolisthesis

Case reports of high-grade spondylolisthesis have been rarely published in the chiropractic literature. Documented here is a case involving a 28-year-old woman who presented to the World Spine Care clinic in the Dominican Republic with minimal neuromusculoskeletal symptoms despite a grade 4 spondylolytic spondylolisthesis. The key imaging and etiological features of this clinical disorder are presented.

Evaluation and management of lower back pain in young athletes

Lower back pain in young athletes is a common problem. The prevalence of back pain from different causes in adolescent age group is between 20% and 30%. However, the incidence of low back pain in young athletes varies widely in different sports. Overuse injuries are the most common cause of low back pain in young athletes. In case of overuse injuries, the cause and effect relationship between back pain and specific condition is often difficult to establish. In adolescent athletes, the most common underlying identified cause of low back pain is lumbar spondylolysis. During adolescent growth spurt, the severity of the pain generally correlates with adolescent growth spurt. Participation in sports starting at an early age and for a longer duration tends to increase the risk for back pain. Numerous conditions cause low back pain in athletes. These include acute trauma, chronic overuse or repetitive trauma, and referred pain. Our focus in here will be on selected conditions that cause recurrent or chronic low back pain.