Direct Repair of Symptomatic Lumbar Spondylolysis Using Rod-Screw-Cable System

OBJECTIVE

To assess the efficacy of a new direct lysis repair technique using internal fixation with rod, screws, and Songer cable in symptomatic lumbar spondylolysis.

METHODS

Between December 2015 and January 2020, patients who were diagnosed with symptomatic lumbar spondylolysis and surgically treated with a rod-screw-cable system were recruited. Pedicle screwing by the Magerl technique was performed in all included patients, followed by direct lysis repair with bone allograft and demineralized bone matrix by stabilizing the posterior lamina and spinous process using a rod-screw-cable system. Clinical outcome was measured using the visual analog scale and Oswestry disability index preoperatively and 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively.

RESULTS

Sixteen patients were included in this study-11 men and 5 women (mean age: 47 years; range, 26-67 years). The lytic defects were at L4 and L5 in 6 and 10 patients, respectively. The mean follow-up period was 41 months (24-62 months). The visual analog scale values were 7.3, 6.1, 4.3, 3.3, 2.1, and 1.9 preoperatively and 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively, respectively. The Oswestry disability index values were 59.8%, 55.4%, 41.7%, 32.4%, 21.1%, and 16.9% for the same periods, respectively. No patient had an increase in the slip after surgery. There were no significant complications such as implant failure.

CONCLUSIONS

Our technique provides rigid intra-segmental repair of spondylolysis without intersegmental motion interference, even if the patient is older or has disc degeneration.

Clinical characteristics of early-stage lumbar spondylolysis detected by magnetic resonance imaging in male adolescent baseball players

BACKGROUND

Many adolescent athletes experience low back pain; the most common cause is lumbar spondylolysis. Although early identification of lumbar spondylolysis in adolescent athletes is critical, few studies have focused on identifying the early stages of spondylolysis in baseball players. This study aimed to investigate the clinical characteristics of early-stage spondylolysis in male adolescent baseball players.

METHODS

The participants comprised male junior and high school baseball players. Before magnetic resonance imaging, we recorded their demographic data, low back pain characteristics, and physical findings (lumbar flexion, extension, Kemp's test and the provocative tenderness of a spinous process). After the imaging evaluation, the association among low back pain characteristics, physical findings and the final diagnosis (early-stage spondylolysis or not) were investigated using univariate and multivariable analyses.

RESULTS

A total of 171 players were included in this study. Univariate analyses indicated that the characteristics associated with early-stage spondylolysis were longer duration of low back pain (P = 0.0085), low back pain-related interference while running (P = 0.0022), low back pain starting with laterality (P = 0.0001), lumbar extension (P = 0.022), positive Kemp's test (P = 0.020), and the tenderness of a spinous process (P = 0.0003). After adjusting for confounding factors (age and position), we found that early-stage spondylolysis was significantly associated with low back pain duration ≥4 weeks (odds ratio 3.13, 95% confidence interval 1.42-6.92; P = 0.0048), low back pain-related interference while running (odds ratio 2.89, 95% confidence interval 1.30-6.46; P = 0.0094), low back pain starting with laterality (odds ratio 2.78, 95% confidence interval 1.24-6.27; P = 0.0133), and the tenderness of a spinous process (odds ratio 3.00, 95% confidence interval 1.36-6.57; P = 0.0062).

CONCLUSIONS

Male adolescent baseball players with early-stage spondylolysis might have low back pain duration of more than four weeks, low back pain-related interference while running, and a history of low back pain starting with laterality. The tenderness of a spinous process might be helpful in the diagnosis of early-stage spondylolysis in male adolescent baseball players.

Incidence of lumbar spondylolysis in athletes with low back pain: A systematic evaluation and single-arm meta-analysis

BACKGROUND

Low back pain (LBP) is a common chief complaint from athletes. Lumbar spondylolysis (LS) is a common sport injury. Severe LS is likely to cause spinal instability, resulting in lumbar spondylolisthesis or lumbar disc herniation, and even damage to the spinal nerve roots. The incidence of LS is approximately 5% in the adult population, and nearly half of young athletes with LBP are diagnosed with LS. This meta-analysis analyzed the incidence of LS in athletes with LBP.

METHODS

PubMed, Embase, Cochrane (Cochrane Central Register of Controlled Trials), and Web of Science databases were systematically searched for published case report and retrospective analyses related to the topic from the date of database creation to January 1,2023. Relevant literature was screened and information extracted, and risk of bias was assessed for included studies using the methodological index for non-randomized-studies scale. Single-arm Meta-analysis was performed using R4.04 software. Heterogeneity was quantified by Cochran Q test and Higgins I2. Funnel plots were used to visualize publication bias, and Egger test and Begg test were used to statistical tests.

RESULTS

A total of 9 studies (835 patients) were included in this study. Meta-analysis revealed that the prevalence of LS in athletes with LBP was estimated at 41.7%, [95% CI = (0.28-0.55)], but this prevalence varied considerably with the gender and age of the athletes.

CONCLUSION

The estimated prevalence of LS in athletes with LBP is 41.7%, and future correlations between the prevalence of LS in adolescent athletes worldwide need to be assessed from different perspectives, including biomechanical, hormonal, anatomical, behavioral, and gender differences.

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.

Association of spinal anomalies with spondylolysis and spina bifida occulta

PURPOSE

To investigate the association of spinal anomalies with lumbar spondylolysis and spina bifida occulta (SBO).

METHODS

A total of 1190 patients with thoracic, abdominal, and pelvic computed tomography scans available were categorized according to the number of presacral (thoracic and lumbar) mobile vertebrae and the presence or absence of lumbosacral transitional vertebrae (LSTV). The prevalence of spondylolysis and SBO and the association of spinal anomalies with these disorders were evaluated.

RESULTS

Normal morphology (17 mobile vertebra with no LSTV) was found in 607 men (86.5%) and 419 women (85.9%) and about 14% of patients had anomalies. Spondylolysis was found in 74 patients (6.2%), comprising 54 men (7.7%) and 20 women (4.1%). SBO involving the lumbar spine was found in 9 men (1.3%) and 2 women (0.4%). Spondylolysis was significantly more common in men with 18 vertebrae without LSTV (21.1%) than in those with 17 vertebrae without LSTV (7.2%) (p = 0.002). The prevalence of spinal anomalies was 55.6% in men and 50.0% in women with SBO that included a lumbar level was significantly higher than in both men (13.5%, p < 0.001) and women (4.8%, p = 0.003) without SBO.

CONCLUSION

These findings indicate that there is a relationship between spinal anomalies and both spondylolysis and SBO, which may lead to elucidation of the mechanism of onset of spondylolysis and improve its treatment and prognosis. Awareness that patients with SBO involving the lumbar spine have an increased likelihood of a spinal anomaly may help to prevent level errors during spinal surgery.

Spondylolysis of the Thoracic Spine with Instability: A Rare Cause for Myelopathy

CASE

A 51-year-old lady with multiple comorbidities presented with T11 spondylolysis in association with thoracic stenosis and myelopathy. Our patient underwent T11-T12 laminectomy, T10-L1 posterior instrumented stabilization, and T11-T12 transforaminal interbody fusion. She had a good neurological recovery, and the radiographs at 1-year follow-up showed good fusion and implant position.

CONCLUSION

Spondylolysis is an anatomical defect or stress fracture of the pars interarticularis and usually reported in the lumbar region. This case of T11 spondylolysis in association with thoracic stenosis, spinal instability, and myelopathy is highlighted for its rarity and to reiterate the need for high index of suspicion among surgeons for the timely diagnosis.

Axial Low Back Pain in Elite Athletes

Back pain in sport is a common complaint and seen by athletes, trainers, and treating physicians. Although there are a multitude of pain generators, mechanical sources are most common. Certain sports can lead to increased mechanical and axial loading, such as competitive weightlifting and football. Common mechanical causes of pain include disk herniation and spondylolysis. Patients typically respond to early identification and conservative treatment. In others, surgical intervention is required to provide stability and prevent long-term sequelae.

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

CASE

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

CONCLUSION

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

Nonconsecutive Pars Interarticularis Defects

Lumbar spondylolysis is a well-recognized condition occurring in adolescents because of repetitive overuse in sports. Nonconsecutive spondylolysis involving the lumbar spine is rare. In contrast to single-level pars defects that respond well to conservative treatment, there is no consensus about the management of multiple-level pars fractures; a few reports indicated that conservative management is successful, and the majority acknowledged that surgery is often required. The current study presents a rare case of pars fracture involving nonconsecutive segments and discusses the management options. In this case report, we review the patient's history, clinical examination, radiologic findings, and management, as well as the relevant literature. An 18-year-old man presented to the clinic with worsening lower back pain related to nonconsecutive pars fractures at L2 and L5. After 6 months of conservative management, diagnostic computed tomography-guided pars block was used to localize the symptomatic level at L2, which was treated surgically; the L5 asymptomatic pars fracture did not require surgery. At the last follow-up 2 years after surgery, the patient was playing baseball and basketball, and denied any back pain. This article reports a case of rare nonconsecutive pars fractures. Conservative management for at least 6 months is recommended. Successful management depends on the choice of appropriate treatment for each level. Single-photon emission computed tomography scan, and computed tomography-guided pars block are valuable preoperative tools to identify the symptomatic level in such a case.

Surgical Management of 3-Level Lumbar Spondylolyses

Three-level lumbar spondylolyses are extremely rare. So far, only 11 cases were reported in the literature. Treatment of multilevel spondylolyses has not been consistent. Conservative treatment is commonly considered first in most patients, but those who remain symptomatic may benefit from operative treatment. We report here 3 cases of 3-level lumbar spondylolyses that were treated successfully with direct isthmic repair in 2 cases and a combined surgery of isthmic repair and interbody fusion in 1 case. Our clinical results indicated that direct defect repair using the screw-hook technique is a simple and safe procedure for the motion segment with normal disc. If the involved disc shows degenerative change, fusion surgery should be consideredSurgical treatment of multilevel spondylolyses varies between fusion, direct isthmic repair, and combined management associating 2 procedures at different levels. The success of management of the 3 patients with 3-level spondylolyses depends on the choice of appropriate treatment for every patient.

Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis

PURPOSE

The hypothesis that spondylolysis (SL) and/or isthmic spondylolisthesis (IS) cause low back pain (LBP) is widely accepted representing surgical indication in symptomatic cases. If SL/IS cause LBP, individuals with these conditions should be more prone to LBP than those without SL/IS. Therefore, the goal of the study was to assess whether the published primary data demonstrate an association between SL/IS and LBP in the general adult population.

METHODS

Systematic review of published observational studies to identify any association between SL/IS and LBP in adults. The methodological quality of the cohort and case-control studies was evaluated using the Newcastle-Ottawa scale.

RESULTS

Fifteen studies met inclusion criteria (one cohort, seven case-control, seven cross-sectional). Neither the cohort study nor the two highest-quality case-control studies detected an association between SL/IS and LBP; the same is true for the remaining studies.

CONCLUSIONS

There is no strong or consistent association between SL/IS and LBP in epidemiological studies of the general adult population that would support a hypothesis of causation. It is possible that SL/IS coexist with LBP, and observed effects of surgery and other treatment modalities are primarily due to benign natural history and nonspecific treatment effects. We conclude that traditional surgical practice for the adult general population, in which SL/IS is assumed to be the cause of non-radicular LBP whenever the two coexist, should be reconsidered in light of epidemiological data accumulated in recent decades.

[Effectiveness of U-shape titanium screw-rod fixation system with bone autografting for lumbar spondylolysis of young adults]

OBJECTIVE

To investigate the effectiveness of U-shape titanium screw-rod fixation system with bone autografting for lumbar spondylolysis of young adults.

METHODS

Between January 2008 and December 2011, 32 patients with lumbar spondylolysis underwent U-shape titanium screw-rod fixation system with bone autografting. All patients were male with an average age of 22 years (range, 19-32 years). The disease duration ranged from 3 to 24 months (mean, 14 months). L3 was involved in spondylolysis in 2 cases, L4 in 10 cases, and L5 in 20 cases. The preoperative visual analogue scale (VAS) and Oswestry disability index (ODI) scores were 8.0 +/- 1.1 and 75.3 +/- 11.2, respectively.

RESULTS

The operation time was 80-120 minutes (mean, 85 minutes), and the blood loss was 150-250 mL (mean, 210 mL). Primary healing of incision was obtained in all patients without complications of infection and nerve symptom. Thirty-two patients were followed up 12-24 months (mean, 14 months). Low back pain was significantly alleviated after operation. The VAS and ODI scores at 3 months after operation were 1.0 +/- 0.5 and 17.6 +/- 3.4, respectively, showing significant differences when compared with preoperative ones (t = 30.523, P = 0.000; t = 45.312, P = 0.000). X-ray films and CT showed bone fusion in the area of isthmus defects, with the bone fusion time of 6-12 months (mean, 9 months). During follow-up, no secondary lumbar spondyloly, adjacent segment degeneration, or loosening or breaking of internal fixator was found.

CONCLUSION

The U-shape titanium screw-rod fixation system with bone autografting is a reliable treatment for lumbar spondylolysis of young adults because of a high fusion rate, minimal invasive, and maximum retention of lumbar range of motion.

Unsuspected spondylolysis in patients with lumbar disc herniation on MRI: The usefulness of posterior epidural fat

BACKGROUND AND PURPOSE

Lumbar disc herniation (LDH) at the level of non-displaced spondylolysis (isthmic spondylolisthesis) is an uncommon association rarely evaluated in the literature. In this study, authors examine whether the continuous posterior epidural fat between the dura mater and spinous process (continuous double-hump sign) at the level of LDH is a valuable tool to identify patients with non-displaced spondylolysis on MRI.

METHODS

Eighteen patients (group 1) presented at our department (2000-2010) with a LDH associated with an undiagnosed non-displaced spondylolysis on MRI. Spondylolysis was confirmed by direct visualization of the defect on CT-scan, dynamic radiography, MRI or at surgery. To validate this method, we made the same evaluation in 20 surgically treated patients (group 2) with a one-level LDH without spondylolysis.

RESULTS

In all patients of group 1 spondylolysis was unsuspected on the MRI report. However, a positive "continuous double-hump sign" was seen in 16 patients. The spondylolysis was recognized on MRI in six cases, on CT-scan in nine cases and on dynamic radiography in one case. Two cases were diagnosed surgically. In group 2, only one patient had a positive "continuous double-hump sign". This new sign had a specificity of 95%, sensitivity of 88.88%, and accuracy of 92.10% for diagnosis of non-displaced spondylolysis.

CONCLUSIONS

Non-displaced spondylolysis may be associated with adjacent LDH. Although uncommon, it is important for neurosurgeons to be aware of this association because of its implication on the therapeutical management. MRI is not always sufficient to recognize a non-displaced spondylolysis with certainty; however "continuous double-hump sign" may be used as a simple valuable diagnosis tool.

Awake Airtraq intubation in an immobile neck--a case report

A 78 year old patient, whose neck was fixed with polyaxial lateral mass screws and rod was planned for an incisional hernia repair under general anaesthesia. Securing the airway in such an immobile neck is a challenge to the anesthesiologist. Although awake fibreoptic intubation is considered as the gold standard for such challenging patients, we successfully used the Airtraq optical laryngoscope for performing an awake intubation in this case. This example paves the way for the management of similar cases in the future.

Spine problems in young athletes

As the number of young people involved in sports activities increases, acute and chronic back pain has become more common. With a careful medical history and physical examination, along with the judicious use of imaging modalities, the causes of back pain can be correctly diagnosed and treated so that young athletes can quickly return to sports participation. Although most back pain in these young patients is muscular in origin, findings that should trigger increased concern include night pain, marked hamstring tightness, pain with lumbar spine hyperextension, or any neurologic finding. When recently developed vague back pain is present, a delay in radiographic imaging is warranted. With new back pain after trauma, AP and lateral radiographs of the symptomatic spinal area are indicated. CT, bone scans, and MRI should be reserved for special circumstances. Spondylolysis is the most common bony cause of back pain in young athletes. Spondylolysis can be treated with activity limitation, a specific exercise program, a thoracolumbar orthosis, and/or surgery. Treatment should be based on the amount of pain as well as the desire of the young athlete to continue in the sports activity that caused the pain. Other significant causes of back pain that require more extensive treatment in these young athletes include spondylolisthesis, lumbar disk disorders, and sacral stress fractures. It is anticipated that nearly all young athletes can return to sports activity after successful treatment. Even if surgical treatment is needed, return to all sports is expected, with the occasional exception of collision sports.

Painful lumbar spondylolysis among pediatric sports players: a pilot MRI study

INTRODUCTION

For children and adolescents who are very active athletes, fresh lumbar spondylolysis is the main pathologic cause of lower back pain (LBP). However, regarding the terminal-stage spondylolysis (pars defect), there have been few studies to clarify the pathomechanism of LBP. The purpose of this study is to clarify the cause of LBP associated with pars defects in athletes. This is the first report showing a possible pathomechanism of LBP in active athletes with painful pars defect.

METHOD

Six pediatric athletes (5 boys and 1 girl) below 18 years old with painful bilateral lumbar spondylolysis were evaluated. In all cases, spondylolysis was identified as terminal stage (pseudoarthrosis) on CT scan. To evaluate the inflammation around the pars defects, short time inversion recovery (STIR) MRI was performed along with the sagittal section. Fluid collection, which is an indicator of inflammatory events, was evaluated in 12 pars defects as well as in 12 cranial and caudal adjoining facet joints.

RESULTS

Inflammation (i.e., fluid collection) was observed in all 12 pars defects in six subjects at the pseudoarthrotic pars defects. In terms of facet joints, 7 of 12 (58%) pars defects showed fluid collection at the cranial and/or caudal adjoining joints on STIR MRI.

CONCLUSION

The present study showed that inflammation was always present at the pars defects and in some cases at the adjoining facet joints. Thus, it is not difficult to understand how, during sports activity, inflammation may first occur at the pseudoarthrotic site and then spread to the adjoining facet joints. This mechanism could cause LBP associated with terminal-stage (pseudoarthrotics) spondylolysis in athletes.

Progression of spondylolysis to isthmic spondylolisthesis in an adult without accompanying disc degeneration: a case report

Progression of spondylolysis to spondylolisthesis in adults is very rare. It is always accompanied by disc degeneration at the slip level, or at a lower level. The intervertebral disc is indeed the main structure that opposes the anteriorly directed shear forces. Of course, the disc degeneration might also be a consequence, rather than a cause of the slip. The authors describe an unusual case of progression of spondylolysis to spondylolisthesis in an adult, without any disc degeneration. They are not aware of a similar case in the literature. In 1999, an aircraft engineer with known asymptomatic spondylolysis was involved in a low impact motorcycle accident, after which a Grade I spondylolisthesis L4 was diagnosed. There was no predisposing disc space narrowing at any vertebral level. There may have been a certain degree of microscopic disc degeneration L4L5, a possibility which was confirmed by the development of a disc hernia L4L5, seven years after trauma. This case illustrates the potential for progression of spondylolysis to spondylolisthesis in an adult, without radiographical signs of disc degeneration at any level. The minimal trauma might have played a role. The authors recommend that patients with known spondylolysis who sustain acute exacerbation of their back pain should have standing radiographs.

New prognostic factors for adjacent-segment degeneration after one-stage 360° fixation for spondylolytic spondylolisthesis: special reference to the usefulness of pelvic incidence angle

Object.

The purpose of this study was to evaluate the correlation between adjacent-segment degeneration (ASD) and pelvic parameters in the patients with spondylolytic spondylolisthesis. Sagittal balance is the most important risk and prognostic factor in the development of ASD. The pelvic incidence angle (PIA) is an important anatomical parameter in determining the sagittal curvature of the spine and in the individual variability of the sacral slope and the lordotic curve. Thus, the authors evaluated the relationship between the pelvic parameters and the ASD.

Methods.

Among 132 patients with spondylolytic spondylolisthesis who underwent surgery at their institution, the authors selected patients in whom a one-stage, single-level, 360° fixation procedure was performed for Grade I spondylolisthesis and who underwent follow-up for more than 1 year. Parameters in 34 patients satisfied these conditions. Of the 34 patients, seven had ASD (Group 1) and 27 patients did not have ASD (Group 2). The investigators measured degree of spondylolisthesis, lordotic angle, sacral slope angle (SSA), pelvic tilt angle (PTA), PIA, and additional parameters pre-and postoperatively. The radiographic data were reviewed retrospectively.

Results.

The population consisted of nine men and 25 women whose mean age was 48.9 ± 9 years (± standard deviation) (range 28–65 years). Seven patients developed ASD after undergoing fusion. Of all the parameters, pre-and postoperative degree of spondylolisthesis, segmental lordosis, lordotic angle, SSA, preoperative PTA, and pre-operative PIA did not differ significantly between the two groups; only postoperative PTA and PIA were significantly different.

Conclusions.

The development of ASD is closely related to postoperative PIA and PTA, not preoperative PIA and PTA. The measurement of postoperative PIA can be used as a new indirect method to predict the ASD.

[Endoscopic transforaminal lumbar decompression, bone graft fusion and pedicle screw fixation under X-tube system: report of 42 cases]

OBJECTIVE

To evaluate the surgical procedure of unilateral transforaminal discectomy, bone grafting, cage (Telamon) insertion and Dylanok pedicle screw fixation using X-tube operation system for the treatment of lumbar disc herniation combined with segmental instability and Spondylolysis with pars defect.

METHODS

From 2004 to 2006, 42 patients including 17 male and 25 female were treated in our department. The age range from 22 to 77 (mean: 51.6). Etiologies including lumbar disc herniation combined with segmental instability and Spondylolysis with pars defect.

RESULT

Of these 42 patients, the mean operation time was 240 min (110 - 320 min), the average blood loss was 140 ml (80 - 420 ml), the average incision length was 3 cm (2.8 - 3.2 cm) and the average hospitalization time was 12.5 days (5 - 25 days). Nakai criteria, Excellent in 23 cases (62.2%), good in 11 cases (29.2%) and fair in 3 cases (8.6%). 5 patients had postoperative complication (complication rate: 16.3%).

CONCLUSIONS

The surgical procedure has shown predominant benefits: small incision, less stripping of paraspinal muscles, minimal blood loss and rapid postoperative recovery which makes it a valuable alternative to conventional surgical procedures.

Acute L5 pedicle fracture and contralateral spondylolysis in a 12-year-old boy: a case report

Acute unilateral L5 pedicle fracture associated with a pre-existing contralateral spondylolysis is a rare lesion. We report a case in a non-competitive 12-year-old boy. We present the clinical, radiological and specific management of this rare condition. The clinical and radiological draft of this patient was reviewed. The follow-up was 30 months after fracture healing. Some cases reported in the literature were analyzed and our clinical findings and therapeutic strategy was compared and discussed. Non-operative treatment was done including full-time bracing in a modified Boston brace incorporating one thigh for 3 months. Plain radiographs and computed tomographic (CT)-scan performed at 3 and 6 months showed progressive healing of the pedicle fracture and no modification of the contralateral isthmic spondylolytic lesion. At final follow-up, the patient was asymptomatic and resumed all his activities. In skeletally immature patients, we think that conservative treatment should be considered as a treatment option for this unusual injury.

A case of lumbar sciatica in a patient with spondylolysis and spondylolysthesis and underlying misdiagnosed brucellar discitis

We report the case of a patient affected by vertebral pain refractory to conventional analgesic therapy with a diagnosis of spondylolysthesis and also the affects of a misdiagnosed brucellar spondylodiscitis. The absence of a positive response to conventional analgesics, a suggestive medical history (epidemiologic data still show a high incidence of Brucella infections for the Province of Catania), radiological findings and microbiological tests led to the correct diagnosis of algic syndrome in a patient affected by brucellar spondylodiscitis with the concomitant presence of retroperitoneal muscular abscess, and a previously diagnosed spondylolysthesis. All symptoms improved after correct antibrucellar antibiotic therapy and surgical drainage of the retroperitoneal abscess. Vertebral pain is a relatively frequent symptom observed in Pain Medicine Services; in a zone in which Brucella infections may be considered endemic, neurobrucellosis must be considered highly probable in the differential diagnosis of several clinical pictures, including vertebral pain that could result from vertebral localization of Brucella infection. The role of the Pain Medicine Specialist is not only to treat the symptoms, but also to research and confirm the etiopathogenetic mechanisms before starting a correct treatment.

Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis

BACKGROUND

Active spondylolysis is an acquired lesion in the pars interarticularis and is a common cause of low back pain in the young athlete.

OBJECTIVES

To evaluate whether the one-legged hyperextension test can assist in the clinical detection of active spondylolysis and to determine whether magnetic resonance imaging (MRI) is equivalent to the clinical gold standard of bone scintigraphy and computed tomography in the radiological diagnosis of this condition.

METHODS

A prospective cohort design was used. Young active subjects with low back pain were recruited. Outcome measures included clinical assessment (one-legged hyperextension test) and radiological investigations including bone scintigraphy (with single photon emission computed tomography (SPECT)) and MRI. Computed tomography was performed if bone scintigraphy was positive.

RESULTS

Seventy one subjects were recruited. Fifty pars interarticulares in 39 subjects (55%) had evidence of active spondylolysis as defined by bone scintigraphy (with SPECT). Of these, 19 pars interarticulares in 14 subjects showed a fracture on computed tomography. The one-legged hyperextension test was neither sensitive nor specific for the detection of active spondylolysis. MRI revealed bone stress in 40 of the 50 pars interarticulares in which it was detected by bone scintigraphy (with SPECT), indicating reduced sensitivity in detecting bone stress compared with bone scintigraphy (p = 0.001). Conversely, MRI revealed 18 of the 19 pars interarticularis fractures detected by computed tomography, indicating concordance between imaging modalities (p = 0.345). There was a significant difference between MRI and the combination of bone scintigraphy (with SPECT)/computed tomography in the radiological visualisation of active spondylolysis (p = 0.002).

CONCLUSIONS

These results suggest that there is a high rate of active spondylolysis in active athletes with low back pain. The one-legged hyperextension test is not useful in detecting active spondylolysis and should not be relied on to exclude the diagnosis. MRI is inferior to bone scintigraphy (with SPECT)/computed tomography. Bone scintigraphy (with SPECT) should remain the first-line investigation of active athletes with low back pain followed by limited computed tomography if bone scintigraphy is positive.

Traumatic Anterior Lumbosacral Dislocation Caused by Hyperextension Mechanism in Preexisting L5 Spondylolysis

Of many reports referring to injury mechanism in anterior lumbosacral dislocation, there were none concerning hyperextension mechanism. We report a case of a 46-year-old man with preexisting L5 spondylolysis sustaining traumatic complete anterior lumbosacral dislocation. The operative findings, together with the radiologic findings, strongly suggested that the dislocation occurred by hyperextension mechanism. Open reduction was done by applying force of distraction with flexion using a rod and screw system, followed by the internal fixation from the L3 to S1 vertebrae and the postero-superior iliac spine. The lumbosacral dislocation was reduced to 77%. At the follow-up at 5 years after surgery, bony union was obtained and the patient could move with a wheelchair although the neurologic deficit in lower extremities observed preoperatively did not recover. Preexisting L5 spondylolysis was considered to increase the potential for anterior lumbosacral dislocation by additional force of compression with hyperextension. Posterior instrumentation using a rod and screw system was considered a useful method for reduction, decompression, stabilization, and fusion.

Nerve root decompression without fusion in spondylolytic spondylolisthesis: long-term results of Gill's procedure

Nerve root decompression with instrumented fusion is currently most commonly performed in the treatment of patients with spondylolytic spondylolisthesis. The relationship between successful fusion and clinical outcome remains controversial, thereby questioning the necessity of fusion. Nerve root decompression without fusion, i.e. Gill's procedure, might be a less invasive surgical alternative with comparable clinical outcome. The objective of this study is to compare the long-term results of Gills's procedure with data from literature on decompression with fusion, and, moreover, to determine if a future randomised trial is legitimate. We retrospectively reviewed the long-term results of Gill's procedure in patients with grade I or II spondylolytic spondylolisthesis. All patients suffered from leg pain with or without low back pain. No patient had low back pain alone. In 17 patients a bilateral and in 25 patients a unilateral Gill's procedures were performed. The patients were evaluated at three follow-up moments. On moment 1, 38 patients were clinically examined on their last out-patient control (mean follow-up 11 months). On moment 2, 34 patients were interviewed by telephone (mean follow-up 4.4 years). The final long-term follow-up moment 3 (mean follow-up 10.5 years) included a mailed patient-satisfaction questionnaire of 31 patients (response rate 74%). No surgical complication occurred. Ten of the 42 patients were reoperated because of persistent or recurrent radicular pain (mean time interval 2.9 years). Kaplan-Meier analysis showed a disease-free survival rate of 79% at 5 years and 72% at 10 years after the index operation. On the three follow-up moments, the improvement of leg pain was 92, 97 and 88%, respectively. The final long-term follow-up showed 71% good result in terms of patient satisfaction. The Gill's procedure is a less invasive surgical technique in the treatment of patients with leg pain due to low-grade spondylolytic spondylolisthesis. This technique can be considered as an alternative to instrumented fusion in selected cases. Preoperative instability, discectomy at the affected level and neuroforaminal nerve root compression seem to be negative influencing factors, increasing the risk for secondary instrumented surgery. The results of this study justify a randomised trial.

Bone scan as a screening tool in children and adolescents with back pain

Retrospective review of 142 patients from 2 teaching hospitals, investigated for persistent backache. The inclusion criteria were to be up to 18 years, to have no known associated diseases, and to have had a bone scan as a part of their work up. Other tests were also used to reach the final diagnosis. The utility of the bone scan to detect underlying pathology was assessed. On the whole, 75 patients were found to have pathology while only 52 children had a positive bone scan. We also looked for associated findings that could indicate the presence of pathology. The age of the patients, the duration of symptoms, and the presence of night pain seemed to be irrelevant on predicting underlying pathology. The sensitivity of the bone scan was low, 0.613 (95% CI: 0.549-0.654), although it proved to be highly specific, 0.91 (95% CI: 0.83-0.95). A careful analysis of the data and the different diagnosis suggests that Technetium bone scan still holds a place in the study of these patients; however, there is a big concern by the fact that some primary malignancies went undetected on the scan.

Stress fractures in the spine and sacrum

Stress fractures of the pars, pedicle, and sacrum are important considerations in the differential diagnosis of lower back pain in the child or adolescent athlete. A thorough history and physical examination as well as a high index of suspicion are essential when assessing a patient with lower back pain. Diagnostic imaging, including radiographs, bone scans, CT scans, and other imaging modalities are important for further narrowing the diagnosis. The early identification and proper management of stress fractures of the pars, pedicle, and sacrum are integral in the prevention of stress fractures in the adolescent athlete population. This article reviews current concepts in the assessment and management of stress fractures of the lumbosacral spine, particularly of the pars (spondylolysis), pedicles, and sacrum.

Finite element analysis of the spondylolysis in lumbar spine

Spondylolysis is a fracture of the bone lamina in the pars interarticularis and has a high risk of developing spondylolisthesis, as well as traction on the spinal cord and nerve root, leading to spinal disorders or low back pain when the lumbar spine is subjected to high external forces. Previous studies mostly investigated the mechanical changes of the endplate in spondylolysis. However, little attention has been focused on the entire structural changes that occur in spondylolysis. Therefore, the purpose of this study was to evaluate the biomechanical changes in posterior ligaments, disc, endplate, and pars interarticularis between the intact lumbar spine and spondylolysis. A total of three finite element models, namely the intact L2-L4 lumbar spine, lumbar spine with unilateral pars defect and with bilateral pars defect were established using a software ANSYS 6.0. A loading of 10 N.m in flexion, extension, left torsion, right torsion, left lateral bending, and right lateral bending respectively were imposed on the superior surface of the L2 body. The bottom of the L4 vertebral body was completely constrained. The finite element models estimated that the lumbar spine with a unilateral pars defect was able to maintain spinal stability as the intact lumbar spine, but the contralateral pars experienced greater stress. For the lumbar spine with a bilateral pars defect, the rotation angle, the vertebral body displacement, the disc stress, and the endplate stress, was increased more when compared to the intact lumbar spine under extension or torsion.

Spondylolysis and spondylolisthesis in the athlete

Though athletes may be able to return to their sport after treatment of spondylolysis and spondylolisthesis, prevention of back injury in at-risk patient athletes should be the treating physician's primary goal.

A traumatic central cord syndrome occurring after adequate decompression for cervical spondylosis: biomechanics of injury: case report

STUDY DESIGN

Case report with review of the literature.

OBJECTIVES

To present the first case of a central cord syndrome occurring after adequate decompression, and review the mechanics of the cervical spinal cord injury and postoperative biomechanical and anatomic changes occurring after cervical decompressive laminectomy.

SUMMARY OF BACKGROUND DATA

Cervical spondylosis is a common pathoanatomic occurrence in the elderly population and is thought to be one of the primary causes for a central cord syndrome. Decompressive laminectomy with or without fusion has been a primary treatment for spondylotic disease and is thought to be protective against further injury. To our knowledge, there are no cases of a central cord syndrome occurring after adequate decompression reported in the literature.

METHODS

Case study with extensive review of the literature.

RESULTS

The patient underwent C3-C7 cervical laminectomy without complications. After surgery, the patient's spasticity and gait difficulties improved. She was discharged to inpatient rehabilitation for further treatment of upper extremity weakness. The patient fell in the rehabilitation center, with a central cord syndrome despite adequate decompression of her spinal canal. The patient was treated conservatively for the central cord and had minimal improvement.

CONCLUSIONS

Decompressive laminectomy provides an immediate decompressive effect on the spinal cord as seen by the dorsal migration of the cord, however, the biomechanics of the cervical spine after decompressive laminectomy remain uncertain. This case supports the ongoing research and need for more intensive research on postoperative cervical spine biomechanics, including decompressive laminectomies, decompressive laminectomy and fusion, and laminoplasty.

Lumbosacral dislocation injuries: management and outcomes

Lumbosacral dislocations are rare high-energy injuries most often reported as isolated cases. Improved outcomes from major trauma means that these cases will likely become more common. We report six cases treated at our institution in the last decade. Nonoperative care in two cases resulted in severe deformity and pain and required late reconstruction. Surgical decompression, reduction, and stabilization with posterior pedicle screw instrumentation resulted in a stable lumbosacral junction, although in one case, implant failure required revision with anterior column reconstruction to achieve that stability. Nerve root injuries recovered. Two cases had pre-existing spondylolysis/spondylolisthesis. Clinical results were very satisfactory if there was no pre-existing chronic low back pain, although overall function was determined by outcome from other injuries sustained at the initial trauma.

Differential diagnosis of spondylolysis in a patient with chronic low back pain

STUDY DESIGN

Resident's case problem.

BACKGROUND

A 26-year-old male sought physical therapy services via direct access secondary to a flare-up of a chronic low back pain condition. The patient complained of recent onset of lumbosacral joint pain, including (1) constant right-sided deep-bruise sensation, (2) intermittent right-sided sharp stabbing pain, and (3) constant bilateral aching. The patient's past medical history included a hyperextension low back injury while playing football at age 17. Physical examination revealed (1) deep pain with palpation over the right lumbosacral joint region, (2) sharp right lumbosacral joint pain with 1 repetition of active trunk backward bending, and (3) a marked increase in pain and joint hypomobility with right unilateral joint assessment at the L4 and L5 spinal levels.

DIAGNOSIS

The examining therapist referred the patient for radiographic evaluation due to strong suspicions of a pars interarticularis bony defect. Lumbar plain films, oblique views, revealed an L5 bilateral pars defect, leading to a diagnosis of a longstanding bilateral L5 spondylolysis.

DISCUSSION

Patients with low back pain often seek physical therapy services. Identification of pathology requiring examination by other health care providers, leading to patient referral to other health care practitioners, is a potential important outcome of the therapist's examination. This resident's case problem illustrates the importance of a systematic examination scheme, including a thorough medical screening component that led to a patient referral for radiographic evaluation. The resultant diagnosis, although not representing serious pathology, did impact the therapist's patient plan of care.

[Comparison of instrumented posterior fusion with instrumented circumferential lumbar fusion in the treatment of lumbar stenosis with low degree lumbar spondylolisthesis]

OBJECTIVE

To compare and evaluate instrumented posterior fusion with instrumented circumferential lumbar fusion in the treatment of lumbar stenosis with low degree lumbar spondylolisthesis.

METHODS

From April 1998 to April 2003, 45 patients who suffered from lumbar stenosis with low degree lumbar spondylolisthesis were divided into 2 groups (A and B) at random. The patients in group A (n = 24, average age 54 years old) were performed decompressive laminectomy, intertransverse process arthrodesis with bone grafting and transpedicle instrumentation of solid connection (SOCON) system. The patients in group B (n = 21, average age 53 years old) were performed the same procedure as group A except adding posterior lumbar interbody fusion (PROSPACE). The main levels of lumbar spondylolisthesis in 2 groups was L(4 - 5) or L(5)-S(1). All cases were classified as degree 1 to degree 2. All patients in the two groups received preoperative myelography or CTM, and were diagnosed lateral recess stenosis and(or) central lumbar canal stenosis.

RESULTS

All the patients were followed up from 12 to 72 months. In group A, the results showed that the preoperative clinical symptoms disappeared completely in 12 of 24 patients, pain relief was seen in 91.7% (22/24), anatomical reduction rate was 91.7%. No infection or neurologic complication occurred in this series. In group B, the results showed that the preoperative clinical symptoms disappeared completely in 13 of 21 patients, pain relief was seen in 90.5% (19/21), anatomical reduction rate was 95.2%. Four cases of infection or neurologic complication occurred in this series. Two groups had no significant difference in follow-up clinical outcome and anatomical reduction rate. But group A had better intraoperative circumstances and postoperative outcome than group B, group B had better postoperative parameters in X-ray of angle of slipping and disc index than group A.

CONCLUSIONS

The best surgical treatment method of lumbar stenosis with low degree lumbar spondylolisthesis is complete intraoperative decompressive laminectomy, reduction with excellent transpedicle system instrumentation and solid fusion after bone grafting. The use of cage should be conformed to strict indications.

Biomechanical Rationale of Endoscopic Decompression for Lumbar Spondylolysis as an Effective Minimally Invasive Procedure - A Study Based on the Finite Element Analysis

We evaluated the biomechanical behavior of the endoscopic decompression for lumbar spondylolysis using the finite element technique. An experimentally validated, 3-dimensional, non-linear finite element model of the intact L3 - 5 segment was modified to create the L4 bilateral spondylolysis and left-sided endoscopic decompression. The model of Gill's laminectomy (conventional decompression surgery of the spondylolysis) was also created. The stress distributions in the disc and endplate regions were analyzed in response to 400 N compression and 10.6 Nm moment in clinically relevant modes. The results were compared among three models. During the flexion motion, the pressure in the L4/5 nucleus pulposus was 0.09, 0.09 and 0.16 (MPa) for spondylolysis, endoscopic decompression and Gill's procedure, respectively. The corresponding stresses in the annulus fibrosus were 0.65, 0.65 and 1.25 (MPa), respectively. The stress at the adjoining endplates showed an about 2-fold increase in the Gill's procedure compared to the other two models. The stress values for the endoscopic and spondylolysis models were of similar magnitudes. In the other motions, i. e., extension, lateral bending, or axial rotation, the results were similar among all of the models. These results indicate that the Gill's procedure may lead to an increase in intradiscal pressure (IDP) and other biomechanical parameters after the surgery during flexion, whereas the endoscopic decompression did not change the segment mechanics after the surgery, as compared to the spondylolysis alone case. In conclusion, endoscopic decompression of the spondylolysis, as a minimally invasive surgery, does not alert mechanical stability by itself.

Athletes with unilateral spondylolysis are at risk of stress fracture at the contralateral pedicle and pars interarticularis: a clinical and biomechanical study

BACKGROUND

Unilateral spondylolysis is common in youths; its clinical and biomechanical features, especially effects on the contralateral side, are not fully understood.

HYPOTHESIS

Unilateral spondylolysis predisposes the contralateral side to stress fracture, especially in athletes actively engaged in sporting activities involving torsion of the trunk.

STUDY DESIGN

Case series and descriptive laboratory study.

METHODS

Thirteen athletes younger than age 20 with unilateral spondylolysis were included. The contralateral pedicle and pars of spondylolytic vertebrae were examined using computed tomography and magnetic resonance imaging. Using a finite element model of the intact ligamentous L3-S1 segment, stress distributions were analyzed in response to 400-N axial compression and 10.6-N.m moment in flexion, extension, lateral bending, and axial rotation. Unilateral spondylolysis was created in the model at L5. The stress results from the unilateral defect model were compared to the intact model predictions and correlated to the contralateral defects seen in patients.

RESULTS

Among 13 patients, there were 6 early-, 2 progressive-, and 5 terminal-stage defects. Three (23.1%) showed contralateral stress fracture. Among them, 2 belonged to the progressive-stage and 1 to the terminal-stage spondylolysis group. The remaining 4 patients in the terminal defect group showed stress reactions, such as sclerosis at the contralateral pedicle. In the finite element analysis model with an L5 left spondylolysis, the stresses at the contralateral and pars interarticularis were found to increase in all loading modes, with increases as high as 12.6-fold compared to the intact spine.

CONCLUSIONS

Unilateral spondylolysis could lead to stress fracture or sclerosis at the contralateral side due to an increase in stresses in the region.

CLINICAL RELEVANCE

Surgeons should be aware of possibility of contralateral stress fractures in cases in which patients, especially athletes engaged in active sports, show unilateral spondylolysis and persistent low back pain complaints.

Is lumbar spondylosis a cause of urinary retention in elderly women?

OBJECTIVES

Lumbar spondylosis (LS) is a common spinal degenerative disorder which causes various types of lower urinary tract dysfunction (LUTD). However, it is not certain whether LS may cause urinary retention in elderly women.

METHODS

In a period covering the past 3 years, we retrospectively reviewed: a) urodynamic case records of women with urinary retention (post-void residuals, PVR > 100 ml), b) the records of women with LUTD due to LS (cauda equina syndrome and spinal canal narrowing by MRI), and c) uro-neurological features of women who belonged to both a) and b).

RESULTS

a) One-hundred women with a mean age of 58 years had urinary retention. The most common underlying disease was multiple system atrophy [19], followed by multiple sclerosis [13] and cervical/thoracic tumours [8]. LS was the fourth most common [5], with the highest age (71 years) of all diseases. b) Nineteen women with LUTD had LS (12, canal narrowing of 50-70%; 7 > 70 %), with a mean PVR volume of 60 ml. A fourth [5] of them had urinary retention, with severe spinal canal narrowing (all 5 > 70%). c) Thus, 5 women belonged to both a) and b). In 4 of these women, LUTD followed or occurred together with typical cauda equina syndrome symptoms such as sciatica and saddle anesthesia. However, one elderly woman presented with painless urinary retention, and absent ankle reflexes were the sole neurological abnormality. The urodynamic abnormalities underlying urinary retention included an underactive detrusor in all 5, bladder sensory impairment in 3, an unrelaxing sphincter in 2, a low compliance detrusor in one, neurogenic sphincter motor unit potentials in 2 of 4 studied, and cholinergic supersensitivity of the detrusor in one of 3 studied. Surgical decompression ameliorated urinary retention in 1 of 2 women who had surgery.

CONCLUSIONS

In our series, only 5 percent of the women with urinary retention had LS, but LS poses a potential risk for retention, particularly in elderly women with severe spinal canal narrowing. Preganglionic somato-autonomic dysfunctions underlie this condition. It may appear as the sole initial complaint in cases in which no other obvious neurological abnormalities are found.

Dissociation between back pain and bone stress reaction as measured by CT scan in young cricket fast bowlers

BACKGROUND

Bone stress reaction is prevalent among cricket fast bowlers. Few studies have addressed the sensitivity and specificity of imaging for diagnosis, and follow up assessment has been poorly investigated.

OBJECTIVE

To determine whether there was an association between back pain and bone stress reaction as measured by computed tomography (CT) scan in young cricket fast bowlers.

METHODS

Ten young cricket fast bowlers were included in the study. Nine bowlers presented to a physiotherapy practice with low back pain and were later diagnosed with lumbar stress fractures, while one was an experienced bowler with no pain. All players had a CT scan after presenting to the physiotherapy practice. Pain was assessed according to a subjective scale (0-10) where 10 represented the player's subjective, maximum pain score. Recovery and rehabilitation of all players was monitored until they returned to full participation.

RESULTS

There was no consistency in the relationship between pain and CT scan results. For example, one subject had evidence of un-united stress fractures after 15 months of rest but had experienced moderate pain for only 2 weeks after the onset of symptoms, in contrast to another subject who had intermittent pain for 11 months even though CT scan showed multiple stress fractures ranging from partially healed to fully healed status at 3 months.

CONCLUSION

There is dissociation between back pain and bone stress reaction as measured by CT scan. Therefore, CT scan does not provide objective evidence for ongoing management or decision concerning return to sport in cricket fast bowlers.

An instance of an atypical intraspinal cyst presenting as S1 radiculopathy: a case report and brief review of pathophysiology

Intraspinal cysts are rare, but typically they originate from a degenerate zygapophyseal joint. These cysts have been commonly referred to as juxtafacet cysts and occur concomitantly with lumbar and occasionally lower-limb radicular pain. Documented cases have shown pseudoarthroses developing from nonhealing pars defects. Histologic analyses have found synovial tissue within these fibrocartilaginous accumulations. We present a case of S1 radiculopathy indicated by an intraspinal pseudocyst arising as a complication of a chronic spondylolytic defect. A brief review of the related pathophysiology is also included.

Low-back pain in athletes

While most occurrences of low-back pain in athletes are self-limited sprains or strains, persistent, chronic, or recurrent symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stress lesions. The prevalence of radiographic evidence of disc degeneration is higher in athletes than it is in nonathletes; however, it remains unclear whether this correlates with a higher rate of back pain. Although there is little peer-reviewed clinical information on the subject, it is possible that chronic pain from degenerative disc disease that is recalcitrant after intensive and continuous nonoperative care can be successfully treated with interbody fusion in selected athletes. In general, the prevalence of spondylolysis is not higher in athletes than it is in nonathletes, although participation in sports involving repetitive hyperextension maneuvers, such as gymnastics, wrestling, and diving, appears to be associated with disproportionately higher rates of spondylolysis. Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, independent of radiographic evidence of defect healing. In recalcitrant cases, direct surgical repair of the pars interarticularis with internal fixation and bone-grafting can yield high rates of pain relief in competitive athletes and allow a high percentage to return to play. Sacral stress fractures occur almost exclusively in individuals participating in high-level running sports, such as track or marathon. Treatment includes a brief period of limited weight-bearing followed by progressive mobilization, physical therapy, and return to sports in one to two months, when the pain has resolved.

Posterior lumbar interbody fusion using local facet joint autograft and pedicle screw fixation

STUDY DESIGN

This is a retrospective study of 42 patients having lumbar degenerative disease or spondylolytic spondylolisthesis treated by posterior lumbar interbody fusion (PLIF) using local autogenous facet joint graft and pedicle screw fixation with an average follow-up time of 8.5 years.

OBJECTIVES

To evaluate the radiographic and clinical results of patients treated with PLIF using adjacent facet joint autograft and pedicle screw internal fixation.

SUMMARY OF BACKGROUND DATA

Some goals of spinal surgery have been achieved by interbody arthrodesis using a posterior approach popularized by Cloward. However, significant problems including bone graft collapse, resorption, nonunion, persistent neurologic compression, and iliac crest donor complication using the classic PLIF remain. There are few reports describing the results of a PLIF by total facet joint excision.

METHODS

Forty-two patients (average, 53.2 years) treated at our institution with PLIF by total facetectomy were followed for an average period of 8.5 years. The changes in the Japanese Orthopedic Association score, the recovery rate, complications, and radiographic findings were evaluated.

RESULTS

Good radiographic fusion (92.9%) and clinical results (postoperative recovery rate of 76% in the Japanese Orthopedic Association score) were achieved by PLIF using local facet joint autograft and pedicle screw fixation in treating patients with debilitating lumbar degenerative disease. The complications related to the operative procedure occurred in three patients of delayed union.

CONCLUSIONS

For lumbar degenerative diseases with osteophytic changes of facet joints, PLIF using pedicle screw fixation and local autogenous bones obtained from facet excision may be justified as a treatment opinion. The procedure as described offers advantages for spinal surgery when PLIF is warranted.

Direct repair of the pars interarticularis for spondylolysis and spondylolisthesis

Spondylolysis and spondylolisthesis can be associated with significant low back pain, especially in physically active adolescents. Non-operative management is usually successful in improving symptoms, but surgical intervention is occasionally required for those that fail reduction of activity and bracing. In a subpopulation of these patients, direct repair of the pars interarticularis defect can be an effective modality of treatment. The advantage of direct pars repair over intertransverse fusion with or without segmental instrumentation is the preservation of the anatomic integrity and motion of the affected segment. We describe our experience in 5 patients (aged 15-18 years) managed by direct pars interarticularis repair after failing multimodality non-operative treatment. The length of stay averaged 3.2 days (range 3-4 days). All 5 patients were able to return to full activity with either no (60%) or minor (40%) symptoms. No immediate or delayed complications were noted. Patients were followed a minimum of 30 months (range 30-78 months). All 5 patients demonstrated evidence of bony fusion by radiographic criteria. This demonstrates that direct pars repair is a safe and effective modality to treat select groups of patients with spondylolysis and low-grade spondylolisthesis.

Back injuries in young fast bowlers--a radiological investigation of the healing of spondylolysis and pedicle sclerosis

OBJECTIVE

To demonstrate the efficacy of various radiological diagnostic modalities in assessing lower back pain in young fast bowlers.

METHODS

Ten cricketers who presented to either a physiotherapist or a doctor with suspected spondylolysis underwent an X-ray, a single photon emission computed tomography (SPECT) bone scan and a computed tomography (CT) scan to assess the severity of the injury. Three and 12 months after the initial CT scan, second and third CT scans were performed in order to assess whether healing had taken place. After the initial radiological investigation the subjects diagnosed with spondylolysis or pedicle sclerosis underwent prescribed intervention and rehabilitation which included physiotherapy modalities, postural correction, and specific individually graded flexibility, stabilisation, strengthening and cardiovascular programmes.

RESULTS

Radiographs were normal in 8 subjects, while 2 had evidence of sclerosis. The isotope scan showed increased uptake in all of the subjects. The CT scans showed no fracture (N = 3), partial fractures (N = 3), complete fractures (N = 2) and old fractures bilaterally (N = 2). When the follow-up CT scan was carried out at 3 months, 1 of the subjects had developed a partial fracture of the left pars interarticularis on the inferior border, which showed complete union when CT scanned at 12 months. At 3 months the partial and complete fractures showed progressive healing in 2 subjects, with complete healing in all the other cases. Complete healing was achieved in all subjects at 12 months, with the exception of 1 subject who showed near-complete union, with a small area of fibrous union on the inferior border and 2 old bilateral fractures that remained un-united.

RESULTS

From the results it is evident that when a young fast bowler presents with backache after bowling, it would be appropriate to do an X-ray, a bone scan and a CT scan to make the diagnosis. Discontinuing the fast bowling and following an active rehabilitation programme should result in spontaneous resolution and healing of the fractures. If it is not detected early a fibrous or non-union fracture could result.

A new endoscopic technique to decompress lumbar nerve roots affected by spondylolysis. Technical note

The authors describe a new endoscopic technique to decompress lumbar nerve roots affected by spondylolysis. Short-term clinical outcome was evaluated. Surgery-related indications were: 1) radiculopathy without low-back pain; 2) no spinal instability demonstrated on dynamic radiographs; and 3) age older than 40 years. Seven patients, four men and three women, fulfilled these criteria and underwent endoscopic decompressive surgery. Their mean age was 60.9 years (range 42-70 years). No subluxation was present in four patients, whereas Meyerding Grade I slippage was demonstrated in three. For endoscopic decompression, a skin incision of 16 to 18 mm in length was made, and fenestration was performed to identify the affected nerve root. The proximal stump of the ragged edge of the spondylotic lesion, and the fibrocartilaginous mass compressing the nerve root were removed. The follow-up period ranged from 6 to 22 months (mean 11.7 months). Clinical outcome was evaluated using Gill criteria; in three patients the outcome was excellent, and in four it was good. This new endoscopic technique was useful in the decompression of nerve roots affected by spondylolysis, the technique was minimally invasive, and the clinical results were acceptable.

Direct stabilization of lumbar spondylolysis with a hook screw: mean 11-year follow-up period for 113 patients

STUDY DESIGN

A retrospective study involving 113 patients with a spondylolysis who underwent direct repair with a hook screw was conducted.

OBJECTIVES

Spondylolysis with instability can produce low back pain. In adults, fusion of the affected level is the gold standard of treatment. In the adolescent, direct repair of the lysis can save a functional segment.

SUMMARY OF BACKGROUND DATA

It has been proved that direct repair of spondylolysis can accomplish restitutio ad integrum for a functional segment. So far, only short-term results are available in the literature.

METHODS

This study involved 113 patients who underwent direct repair of spondylolysis with a hook screw according to Morscher. After an average follow-up period of 11 years, the patients were reviewed. The main issue was the question of fusion. For this purpose, plain radiographs were taken. For doubtful cases or for the patient experiencing pain, conventional tomography scans or computed tomography scans were taken.

RESULTS

The pseudarthrosis rate was 13.3%. The fusion rate for patients younger than 14 years was higher than that for older patients, especially those older than 20 years.

CONCLUSIONS

Direct repair of spondylolysis can be recommended for patients with a growing skeleton, a slight slip, an instability, or failure of conservative treatment. Thereby, a functional segment can be saved with a relatively small operation.