Diagnosis and Medical Management of Spondylolysis & Spondylolisthesis William Primos, MD, FAAP Northeast Georgia Physicians Group Sports Medicine Disclosures
I have no financial interests, relationships, or potential conflicts of interest relative to this presentation Lower Back Pain in Young Athletes
• Incr. sports participation in young people has led to back pain becoming more common • 17.8% reported episode during 2 year period • Most case are muscular • Unlike in adults – often a specific diagnosis Lower Back Pain Evaluation • Obtain a history ▪ When? Onset, duration
▪ Why? Reason for pain, injury
▪ Where? Location of pain
▪ Describe pain. Type, severity, local or general, constant or intermittent Lower Back Pain Evaluation History (cont.) • Neurological Symptoms
• Bowel / bladder incontinence
• Aggravation/alleviation
• Medication
• Associated symptoms
• Nighttime awakening
• Family history RED FLAGS
❑ Watch for these in a patient with low back pain
❑ May indicate a more serious condition as a cause of the back pain RED FLAGS ❖ Significant trauma (fracture)
❖ Disabling pain –stops pleasurable activities (fracture, disc)
❖ Nighttime awakening (tumor, infection)
❖ Neurological Deficit / Radiating symptoms (disc, tumor) RED FLAGS ❖ Unexplained weight loss (tumor)
❖ Fever or constitutional symptoms (infection
❖ Young patient (<4yrs)
❖ Bowel or bladder incontinence (cauda equina syndrome) Physical Exam of the Spine INSPECTION ▪ Gait ▪ Symmetry ▪ Posture ▪ Skin lesions/abnormalities ▪ Pelvis level ▪ Leg length comparison Physical Exam of the Spine Range of Motion – Is there pain? • Flexion • Extension • Rotation • Lateral bend • Hamstring flexibility • Hip motion Physical Exam of the Spine ❑ Palpate – localize tenderness ❑ Straight leg raise ❑ FABER TEST – SI joint ❑ Neurological exam • Reflexes • Sensation • Strength Imaging for Back Pain ❖Get plain films
❖AP/lateral views
❖Possibly oblique views Causes of back pain in adolescents ➢ Spondylolysis/Spondylolisthesis ➢ Acute Lumbosacral Strain ➢ Mechanical Low Back Pain ➢ Degenerative Disc / Discogenic pain ➢ Scheurmann’s Kyphosis ➢ Infection ➢ Fracture ➢ Tumor SPONDYLOLYSIS ❖ Anatomical defect of the pars interarticularis of the vertebral arch.
❖ May be unilateral or bilateral
❖ Most common- L5 (85-95%), then L4 (5-15%) SPONDYLOLYSIS
❑ Most common bony cause of back pain in young athletes
❑ Studies show spondylolysis causes 30-40% of low back pain in adolescent athletes
❑ In adolescent athletes, 8-14% have spondylolysis seen on x-rays
❑ Asymptomatic in majority
❑ Incidence ratio of 2:1 male to female SPONDYLOLYSIS ❑ Develops during ambulatory activity
❑ Studies have shown spondylolysis is absent at birth or in non-ambulatory individuals
❑ Studies show prevalence of 4.4% in 6 years old
❑ Heredity plays a factor since it occurs more commonly in relatives than in general population Spondylolysis Pathophysiology ❑May occur suddenly as an acute injury
❑But usually develops gradually due to overuse or repetitive hyperextension • Repetitive forces cause minute damage to bone
• When the rate of damage overcomes the ability of the bone to repair itself
• Then a stress fracture results. Spondylolysis Pathophysiology
❑ Abnormalities that may increase risk • Inflexibility due to rapid skeletal growth during adolescence
• Poor physical condition / core weakness
• Spina bifida occulta (posterior spinal fusion anomaly)
• Hyper-lordosis of the spine
• Scoliosis SPONDYLOLYSIS Occurs more frequently in certain sports such as gymnastics, weight-lifting, baseball, soccer, football lineman Pathophysiology
❑ Spondylolysis may progress to spondylolisthesis
❑ Displacement or slip of a vertebra on the other Spondylolisthesis Graded by amount of displacement I : 1-25%
II : 26-50%
III : 51-75%
IV : 76-100%
V : > 100% Categories of Spondylolisthesis ❖ Type I o Dysplastic- congenital deformity with abnormal rounding of superior aspect of S1 vertebral body that allows L5 vertebra to slip
❖ Type II o Isthmic- stress or acute fracture in the pars interarticularis that leads to the slip
❖ Type III o Degenerative- slip occurs due to instability of the vertebra because of arthritis Categories of Spondylolisthesis ❖ Type IV o Traumatic- acute fracture from high energy trauma to spine results in the slip
❖ Type V o Pathological- bone disease, tumor, or infection that causes weakness and the slippage
❖ Type VI o Iatrogenic- potential sequelae of spinal surgery which weakened the spine SPONDYLOLYSIS History • Back pain often begins after an increase in training • Pain worsens with activity, especially extension of back • Often unable to continue their sport due to pain • Pain near lower lumbar spine, may be either right or left of spine or in midline SPONDYLOLYSIS Study by Hirano showed association of pain with lumbar hyperextension and spondylolysis ▪ 100 young athletes with lower back pain
▪ 69% had pain with hyperextension
▪ All patients had x-rays, then CT if x-rays negative
▪ 42 had spondylolysis o 34 of 42 (81%) had pain with hyperextension
▪ 58 did not have spondylolysis o 35 of 58 (60%) had pain with hyperextension PHYSICAL EXAM ✓ Tenderness over lower spine ✓ Pain / stiffness with extension and rotation of back ✓ Usually, no pain with flexion ✓ Worsens with the stork test ✓ Negative straight leg raise test ✓ Hamstring inflexibility often present ✓ May feel step-off in spondylolisthesis SPONDYLOLYSIS Radiographs:
▪ May be seen with just AP/LAT views
▪ Obliques not always ordered SPONDYLOLYSIS Radiographs: • May show “Scottie dog collar” sign on oblique view SPONDYLOLYSIS IMAGING- further studies to get if suspect : • CT Scan
• MRI
• SPECT Bone scan SPONDYLOLYSIS IMAGING: • SPECT Scan – very sensitive but not specific
• Radiation exposure SPONDYLOLYSIS IMAGING: ❑ CT Scan • Effective in evaluating for fx and determining acuteness
• Radiation exposure SPONDYLOLYSIS IMAGING: ❑ MRI • Improving effectiveness • No radiation • Order with thin cuts and oblique views to improve sensitivity SPONDYLOLYSIS ▪ Differing recommendations
▪ Most agree plain radiographs are reasonable screening tool
▪ SPECT bone scan, then CT provides anatomical and physiological info needed
▪ MRI potentially shows the info and also does not expose pt. to radiation IMAGING (Congeni) Radiographs : AP/LAT/OBL • Positive- no more studies and treat • Negative o SX greater than 6 weeks- get MRI o SX less than 6 weeks- get SPECT scan IMAGING (Gregory, et al) Radiographs • Positive: treat • Negative: get SPECT Scan o Positive SPECT : get CT scan o Negative SPECT :get MRI SPONDYLOLYSIS TREATMENT ❑ No definite standard of care
❑ Numerous opinions on proper treatment SPONDYLOLYSIS TREATMENT Controversial questions
• Is fracture healing possible?
• How long to rest from sports?
• Is a brace necessary? SPONDYLOLYSIS TREATMENT Is fracture healing possible? Depends on how recently occurred.
• Chronic fracture (> 6 months ago ) unlikely to heal
• Recent fracture (<6 months ago ) more likely to heal SPONDYLOLYSIS TREATMENT Chronic fracture (> 6 months ) • Rest until pain-free • Then start rehab and progressive RTP
Recent fracture (<6 months ) • Complete rest from sports (6-8 weeks) • Rehab (after 6-8 weeks)/ progressive RTP SPONDYLOLYSIS TREATMENT Brace or not? • In the past, brace recommended to immobilize the spine to allow healing
• Recent studies show bracing may not be needed and improvement occurs with just rest and PT SPONDYLOLYSIS TREATMENT Brace – even though constant bracing not needed for healing it can help relieve pain and also control activity SPONDYLOLYSIS TREATMENT Physical Therapy • Core strengthening
• Hamstring stretches
• Spine range of motion SPONDYLOLYSIS TREATMENT
❑ Low-intensity pulsed ultrasound may help bony healing
❑ Has been shown to speed healing time and improve success of treatment SPONDYLOLISTHESIS TREATMENT ❑Grades 1 and II spondylolisthesis -usually treated conservatively, same as in spondylolysis
❑Grades II, IV, V spondylolisthesis –possible will need surgical treatment Factors that may lead to surgery
▪ Progressive slippage ▪ Spondylolisthesis Stages III, IV, V ▪ Instability of the spine ▪ Neurological findings ▪ Cauda equina syndrome ▪ Severe, unremitting pain ▪ Failure to improve with conservative treatment for 6 months
References
• Gagnet P, Kern K, Andrews K, Elgafy H, Ebraheim N. Spondylolysis and spondylolisthesis: a review of the literature. J Orthop 2018;15(2): 404-407.
• Gregory P, Batt M, Kerslake R, Scammell B, Webb J. The value of combining single photon emission computerised tomography and computerised tomography in the investigation of spondylolysis. Eur Spine J 2004: 13:503-509.
• Congeni J. Evaluating spondylolysis in adolescent athletes. J Musculoskel Med 2000; 17: 123-129.
• Hirano A, Takebayashi T, Yoshimoto M. Characteristics of clinical and imaging findings in adolescent lumbar spondylolysis associated with sports activities. J Spine. 2012; 1:124.
• Arima H, Suzuki Y, Togawa D, Mihara Y, Murata H, Matsuyama Y. Low-intensity pulsed ultrasound is effective for progressive-stage lumbar spondylolysis with MRI high-signal change. Eur Spine J 2017:1-7. Thank You!