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Adolescent Spondylolysis and Spondylolisthesis

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Adolescent Spondylolysis and Spondylolisthesis Adolescent Spondylolysis and Spondylolisthesis Steven J. Gould, D.C., D.A.C.B.R. Central Plains Radiologic Services Cheney, KS. 1 2 3 4 K. Bee. Competative Tennis/Running 5 6 1 Purpose Purpose Review a common but commonly Up date of information on this condition; unidentified/ overlooked cause of back ◼ Classification (including a new classification scheme) M.Herman and P. Pizzutillo; Clinical Ortho. And Related Research. No. 434; pp. pain in adolescent athletes 46-54. Treating chiropractors must be able to ◼ Incidence/ Etiology recognize the presence of this disorder, as ◼ Diagnosis (clinical and imaging) spinal manipulative therapy may be contra- ◼ Treatment options indicated. 7 8 Classification (Wiltse) Clinical Orthopedics and Related Research No. 117, June 1976 9 10 Classification Spondylolisthesis (Wiltse) Type III: Degenerative; long standing Spondylolisthesis Classification (Wiltse 1976) intersegmental instability Type I: Dysplastic; Genetic variety of dysplasia of the neural arch Type IV: Traumatic; acute traumatic fracture of the neural arch, other than the pars Type II: Isthmic; Type V: Pathologic; generalized or local bone ◼ IIA; lytic (spondylolysis) fatigue (stress) fx of pars, disease ◼ IIB; elongation of pars without separation ◼ IIC; acute pars fx; significant trauma 11 12 2 Classification Classification Marchetti-Bartolozzi System Marchetti-Bartolozzi System cont’d… ◼ Developmental ◼ Acquired High grade dysplastic Traumatic ◼ With lysis ◼ Acute Fx ◼ With elongation ◼ Stress Fx Low grade dysplastic Post-surgery ◼ With lysis ◼ Direct surgery ◼ With elongation ◼ Indirect surgery 13 14 Classification Marchetti-Bartolozzi System cont’d… ◼ Pathologic Local pathology Systemic pathology ◼ Degenerative Primary Secondary 15 16 NEW CLASSIFICATION SYSTEM New Classification System Type I - Dysplastic Type II – Developmental Type III – Traumatic ◼ Type III A; Acute ◼ Type III B; Chronic Stress Reaction Stress Fracture Spondylolytic defect (nonunion of pars) Type IV - Pathologic 17 18 3 Wiltse compared / Herman(new) Spondylolisthesis / Spondylolysis Wiltse ◼ Type II: Isthmic; Prevalence of spondylolysis varies depending on type and IIA; lytic (spondylolysis) fatigue (stress) fx of pars, population affected. IIB; elongation of pars without separation IIC; acute pars fx; significant trauma 1951 study of 4200 cadaver spines showed 4.2% Herman (new) prevalence ◼ White men(2.8%), Black men (2.8%), White women Type II – Developmental (2.3%), Black women (1.1%), Roche Type III – Traumatic 4.4% found in 1st grade children in New York. As the ◼ Type III A; Acute cohort group reached adulthood, incidence raised to 6%. ◼ Type III B; Chronic Study also showed that spondylolysis is not present at Stress Reaction birth, Fredrickson Stress Fracture Spondylolytic defect (nonunion of pars) 19 20 Athletic populations As high at 47% of young athletes present to sports injury Ferguson, studied back pain in college clinic with LBP, Micheli football linemen, found 24% had Rossi, retrospectively reviewed radiographs of elite spondylolysis and 8% incidence of athletes in Rome and found 16% prevalence of spondylolisthesis. spondylolysis in athletes in general with higher rates for specific sports. ◼ Divers (83%), Weight Lifters (45%), Wrestlers (33%), Gymnasts (38%), high jumpers (24%). Prevalence of spondylolisthesis is these patients was 32%. 21 22 Athletic populations Soler and Calderon; found spondylolysis in 8% of Spanish athletes ◼ (Throwing sports were highest at 27%, followed by artistic gymnastics (17%), and weightlifting (13%). ◼ Found higher incidence in women. 23 24 4 https://www.ncbi.nlm.nih.gov/pubmed/27040065 25 26 27 28 Athletic populations Jackson, studied gymnasts found 11% spondylolysis in asymptomatic women ◼ 54% of whom had spondylolisthesis. Free article link: https://www.jstage.jst.go.jp/article/jmi/63/1.2/63_119/_pdf 29 30 5 ◼ Lumbar spine MRI in the elite-level female gymnast with low back pain. Bennet DL, Nassar L, Delano MC Skeletal Radiol. 2006 Jul;35(7):503-9. Epub 2006 Mar Athletic Populations ◼ Hypothesis is that MRI will demonstrate the same type of abnormalities in both the symptomatic and asymptomatic gymnasts. Elliott reviewed studies of Fast bowlers and found prevalence of spondylolysis to be up to ◼ Studied 19 Olympic Level Gymnasts ages 12-20. 55%. ◼ RESULTS: Anterior ring apophyseal injuries (9/19) and degenerative disk disease (12/19) were common. Spondylolysis (3/19) and spondylolisthesis (3/19) were found. Focal bone-marrow edema was found in both L3 pedicles in one gymnast. ◼ History and physical exam revealed four gymnasts with current low back pain at the time of imaging. There were findings confined to those athletes with current low back pain: spondylolisthesis, spondylolysis, bilateral pedicle bone-marrow edema, and muscle strain. ◼ CONCLUSIONS: Our initial hypothesis was not confirmed, in that there were findings that were confined to the symptomatic group of elite-level female gymnasts. 31 32 Fast Bowlers OR Holy Rollers May 2004 May 2004 33 34 Fast Bowlers Stretch,Botha, Chandler, and Pretorius (South African Med. Journ.) Aug 2003, Vol. 93. No. 8 Studied 10 cricketers, with lower back pain. Dx via x-ray, SPECT, and CT scan. 2nd and 3rd CT scans done at 3 months and 12 months after initial. Radiographs normal in 8 subjects, 2 had evidence of sclerosis. SPECT showed uptake in all subjects. CT showed No Fx in 3, Partial Fx in 3, complete Fx in 2 and old Fx bilaterally in 2. 35 36 6 Fast bowlers; FAST BOWLERS Tx; conservative via physiotherapy modalities, postural correction and specific individually graded flexibility, stabilization, strengthening and cardiovascular programs Complete healing was achieved in all subjects at 12 months, a. SPECT c. partial fx, exception of 1 that showed near-complete union, with a small area of fibrous union at inferior border. 2 old bilateral fractures remained un-united. b. no fx on CT d. union w/ sclerosis 12 mnth followup 37 38 Fast Bowlers Cont’d… Etiology Repetitive Stress injury of the pars interarticularis. A. sag. Partial fx c. significant healing at 3 mnth Extension/Hyperextension and Extension with Rotation. b. fx before partial d. x-ray at initial ct healing show no fx 39 40 41 42 7 Etiology Etiology Familial tendency noted. (Native Weakness from dysplastic elements. Alaskans/Eskimos; Frequency approaches 60% in ◼ Spina bifida occulta related to relatives of affected individual.) spondylolysis ~ 22- 92%. McTimoney and Wynne-Davies and Scott; 19% in first-degree Micheli. relatives. Isthmic lesions (33%) more commonly ◼ Spina Bifida occulta without spondylolysis associated compared to dysplastic types. is about 7%. Fredrickson; similar results and noted spondylolysis ◼ Gracile, thin pars in dysplastic cases. not present at birth. 43 44 Spondylolysis Stress Fx Risk Factors for Spondylolysis Clinical presentation Heredity Signs and symptoms; Male sex ◼ Adolescent age range, commonly preadolescent Type of sport growth spurt. ◼ Asymptomatic or Symptomatic, May be ◼ Presence of spina bifida occulta is associated discounted as “growing pains” Pain in low back that occasionally radiates to the iliac region, buttocks, or posterior thigh. ◼ Repetitive hyperextension and rotational activities. 45 46 Spondylolysis Stress Fx Spondylolysis Stress Fx Clinical presentation Clinical presentation ◼ Pain with running and/or jumping ◼ Positive extension test of lumbar spine ◼ Pain relieved some with rest ◼ Positive “Stork Test”. Single leg standing ◼ Pain may be of several months duration with spinal extension (validity in ?) that changes intensity with activity changes. ◼ Positive “Jump or Hop Test”. Hop in place and land on flat feet or on heels with legs ◼ May have single episode that brings patient straight to jolt the spine. for care. (over the threshold from annoyance to more severe pain). 47 48 8 Spondylolysis Stress Fx The use of the one-legged hyperextension test and Clinical presentation magnetic resonance imaging in the diagnosis of active spondylolysis Lorenzo Masci 1*, John Pike 2, Frank Malara 2, et.al. Q: Differentiate stress reaction/fx vs. facet syndrome or Br J Sports Med. Published Online First: 15 September 2006. mechanical back pain? doi:10.1136/bjsm.2006.030023 Conclusions: These results suggest that there is a high rate of active spondylolysis in active athletes with low A: back pain. The one-legged hyperextension test is not ◼ Imaging; Changes in posterior arch useful in detecting active spondylolysis and should not be ◼ +/- radiographs relied on to exclude the diagnosis. Also concluded that MRI less sensitive compared to ◼ edema on MRI, but +/- for pars lysis SPECT w/ CT ◼ increased activity on SPECT ◼ sclerosis or lysis on CT 49 50 Magnetic Resonance Imaging in Diagnosis and Juvenile Spondylolysis: a comparative analysis of Follow-up of impending spondylolysis in CT, SPECT and MRI. Cambell RS, Grainger children and adolescents: Early treatment AJ, Hide IG, et al. Skeletal Radiol. 2005, may prevent pars defects. Cohen E., Stuecker RD. Feb;34(2):63-73. Epub 2004 Nov. 25. ◼ J. Pediatr.Ortho B. 2005 Mar; 14(2):63-7. Conclusion: MRI can be used as an effective and ◼ 14 pts (mean 12.4 yoa) unspecific activity related back pain >3 reliable first-line image modality for dx of wks with normal x-rays. juvenile spondylolysis. However, localized CT is ◼ Impending spondylolysis dx by typical signal abnormalities were recommended as a supplementary exam in confined to the pars interarticularis
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