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Spondylolysis
From WikiSM
Other Names
- Scotty Dog Fracture
- Fracture in the pars interarticularis
- "Spondy"
- Pars stress fracture
- Pars stress reaction
- Spondylolytic stress fracture
Background
- This page refers to a fracture or bony defect of the pars interarticularis of the vertebral arch, most commonly referred to as spondylolysis
Definitions
- Stress reaction: sclerosis, incomplete disruption of pars
- Spondylolysis: radiolucent defect in pars
History
- Spondylolysis derivation: spondylos (vertebra) and lysis (defect)
Epidemiology
- Prevalence is up to 6% in the general population[1]
- One of the most common causes of back pin in children, adolescents (need citation)
- In athletes with low back pain, it is responsible for between 50% - 80% of cases[2][3]
- Ratio of male to female is 2:1
- Risk increasing from adolescence to adult hood, but does not appear to increase in patients as they continue to age[4]
Pathophysiology
- Pathogenesis is controversial
- Most widely accepted theory is repetitive micrtrauma in a congenitally weak or dysplastic pars
- Often related to repetitive hyperextension, rotation of the lumbar spine
- Cadaveric studies have shown the repetitive flexion-extension motions can contribute due large stress reversals on the pars interarticularis[5]
- This leads to failure due to fatigue of the pars
- Can also be due to acute trauma
- Approximate 85-95% occur at the L5 level, 5=15% at the L4 level[6]
- Bilateral defects are more common than unilateral[7]
Etiology
- Dysplastic
- Involve congenital abnormalities (attenuated pars)
- Isthmic
- lesions in the pars interarticularis resulting from stress fractures or acute fractures
- Degenerative
- Degeneration of of intervertebral discs leading to segmental instability, alterations in articular process
- Traumatic
- Acute fractures in various areas of the neural arch, other than the pars
- Pathological
- involve various bone diseases, tumours or infections
Pathoanatomy
- Pars Interarticularis
- Represents the junction of the pedicle, articular facets and lamina
- Anterior-superior segment consists of vertebral body, pedicle, transverse process, superior articular process
- Posterior-inferior segment consists of inferior articular process, laminae and spinous process
Associated Injuries
- Spondylolisthesis
- Especially in patients with bilateral spondylolysis due to anterior slippage of vertebrae
- 50-80% of patients with spondylolysis have spondylolisthesis
Risk Factors
- Sports involving repetitive back extension
- Female athletic triad/relative energy deficiency in sport
- Imbalance between activity and rest
- Occupation
- Drivers
Differential Diagnosis
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
Clinical Features
- History
- Often asymptomatic and found incidentally
- When symptomatic, patients endorse low back pain
- Can radiate into buttocks, proximal lower limb
- Onset is usually insidious but can be acute if history of trauma
- Pain is intense and worse after activity, hyperextension
- Physical Exam: Physical Exam Back
- Special Tests
- One Legged Hyperextension: Patient stands on one leg, leans back
Evaluation
Radiographs
- Standard Radiographs Lumbar Spine
- Can be seen on PA, lateral views
- Dynamic and oblique views can also be helpful[12]
- AP, lateral, 45° left/right oblique and collimated lateral view identify 96.5% of pars defects[13]
- Oblique view identifies about 20% of pars defects
- This is where the term "collar on the Scottie dog" originates
- May be radiographically occult if stress fracture or reaction
- Additional findings suggesting spondylolysis
- Vertebral anisocoria
- Lateral deviation of SP
- Sclerosis of contralateral pedicle
- Co-occuring Spondylolisthesis is common
- Degree of spondylolisthesis correlates with degree of widening in the pars interarticularis
CT
- Best for evaluating fracture size, extent
- Valuable as a follow up imaging modality
MRI
- May detect changes in signal intensity even before fracture is visible on plain radiographs
SPECT
Classification
Standaert and Herring Classification
- Early
- Progressive
- Terminal
Management
Prognosis
- Most symptomatic cases do well with conservative care only
- Between 9% and 15% of symptomatic spondylolysis require surgery (need citation)
- Panteliadis et al review of outcomes in athletes following conservative or surgical management[14]
- Duration of management ranges from 1.5 to 24 months
- 344/390 patients reported good or excellent outcomes
- Mean return to play was 3.7 months in conservative treatment
- Michielsen et al found that among athletes, osseous healing is more likely to occur in unilateral active spondylolysis as compared to bilateral and pseudo-bilateral active spondylolysis[15]
- 87% of athletes with unilateral defect healed
- 87% of athletes with nonunion had bilateral defect
Nonoperative
- Cessation of aggravating activities
- Especially true in athletes
- Medications
- NSAIDS might be considered controversial due to impaired bone growth, healing
- In patients with osteoporosis or osteopenia, consider Bisphosphonate
- Therapeutic modalities
- Physical Therapy
- Emphasis on isometric contractions of back muscles to promote increased blood flow
- Core strengthening aimed at reducing lumbar lordosis
- Treatment of tight/ contracted hamstrings
- Bone Stimulator
- Two case reports of excellent results[14]
- Orthotics for 3-6 months
- Goal is to prevent motion at the stress fracture, allow healing
- One cited example is 3 months full time wear without followed by 3 months full time wear with sports[16]
- Thoracolumbosacral Orthosis more commonly used
- Lumbosacral Orthosis can also be considered
Operative
- Indications
- Failure of conservative measures after at least 6 months
- Intractable pain
- Progressive slip
- Myelopathy
- Segmental instability
- Younger patient
- Relative contraindications
- Technique
- Translaminar screw fixation
- Cerclage wiring loop
- Pendiculolaminar hook screws
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Patients with spondylolysis should rest 4 to 6 weeks and then demonstrate full range of motion and pain-free extension before RTP[17]
Complications
- Nonunion
- Neurologic deficits or myeloppathy
- Pseudoarthrosis
- Operative
- Wound infection
- Nonunion
- Hardware malfunction
See Also
- Internal
- External
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
References
- ↑ Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. Instr Course Lect. 2008;57:431–445.
- ↑ McTimoney CA, Micheli LJ. Current evaluation and management of spondylolysis and spondylolisthesis. Curr Sports Med Rep. 2003;2:41–46.
- ↑ Iwamoto J, Sato Y, Takeda T, Matsumoto H. Return to sports activity by athletes after treatment of spondylolysis. World J Orthod 2010;1(1):26–30
- ↑ Brooks BK, Southam S, Mlady GW, Logan J, Rosett M. Lumbar spine spondylolysis in the adult population: using computed tomography to evaluate the possibility of adult onset lumbar spondylosis as a cause of back pain. Skeletal Radiol 2009;
- ↑ . Green TP, Allvey JC, Adams MA (1994) Spondylolysis. Bending of the inferior articular processes of lumbar vertebrae during simulated spinal movements. Spine 19:2683–2691
- ↑ Standaert DC, Herring S. Spondylolysis: a critical review. Br J Sports Med. 2000;34:415–422.
- ↑ Teplick JG, Lafley PA, Berman A, Haskin ME. Diagnosis and evaluation of spondylolisthesis and/or spondylolysis on axial CT. AJNR Am J Neuroradiol. 1986;7:479–91.
- ↑ Vrable A, Sherman AL. Elite male adolescent gymnast who achieved union of a persistent bilateral pars defect. Am J Phys Med Rehabil 2009;88(2):156–160
- ↑ Hardcastle PH. Repair of spondylolysis in young fast bowlers. J Bone Joint Surg Br 1993;75(3):398–402
- ↑ Anderson SJ. Assessment and management of the pediatric and adolescent patient with low back pain. Phys Med Rehabil Clin N Am. 1991;2:157–85.
- ↑ Garry JP, McShane J (1988) Lumbar spondylolysis in adolescent athletes. J Fam Pract 46:145–149
- ↑ Rodts MF. Disorders of the spine. Orthop Nurs. 2002;3:515–550.
- ↑ Amato M, Totty WG, Gilula LA. Spondylolysis of the lumbar spine: demonstration of defects and laminal fragmentation. Radiology. 1984;153:627–9.
- ↑ 14.0 14.1 Panteliadis, Pavlos, et al. "Athletic population with spondylolysis: review of outcomes following surgical repair or conservative management." Global spine journal 6.06 (2016): 615-625.
- ↑ Sys, J., et al. "Nonoperative treatment of active spondylolysis in elite athletes with normal X-ray findings: literature review and results of conservative treatment." European Spine Journal 10.6 (2001): 498-504.
- ↑ Steiner ME, Micheli LJ. Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace. Spine. 1985;10:937–43.
- ↑ Eck JC, Riley LH., III Return to play after lumbar spine conditions and surgeries. Clin Sports Med. 2004;23:367-379
Created by:
John Kiel on 17 June 2019 16:44:34
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Last edited:
5 October 2022 23:59:55
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