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Spondylolysis: What is spondylolysis?

Spondylolysis: What is spondylolysis?

Spondylolysis is a fracture of the pars interarticularis of a vertebra (most commonly L5) that is seen in pediatric and adolescent athletes. It is generally a stress fracture that can be unilateral or bilateral.

It is more common in sports that involve repetitive hyperextension and axial loading of the spine such as gymnastics, dance, weightlifting, football, tennis, baseball. The prevalence in the general pediatric and adolescent population ranges from 4.4-4.7%.

Image taken from review article by Goetzinger. et. al. 1

Why is it important to recognize this injury?

Spondylolysis can be a common cause of back pain in the pediatric athletic population. Up to 30-40% of pediatric athletes who presents to sports medicine or orthopedic clinics with lower back pain > 2 weeks have spondylolysis. Spondylolysis, when left untreated, can lead to non-union of the defect and chronic symptoms. It can also progress to develop spondylolisthesis (slipping of the affected vertebrae over the one below it), which can lead to neurological injury to the nerve roots.

How do you diagnose spondylolysis?

History:

Spondylolysis should be strongly considered in a child who presents with sports related lower back pain, especially if the child participates in activities that involve repetitive hyperextension or axial loading of the spine. Typical symptoms include insidious onset lower back pain, with occasional radiation to the buttock or proximal/lower extremities. Pain often increases with strenuous activity or hyperextension and improves with rest. Neurological symptoms (numbness/tingling) are rare.

It is also important to ask about risk factors for metabolic etiologies of fracture such as vitamin D intake, GI absorption issues, and relative energy deficiency syndrome.

Physical exam:

  • Inspection: examine for hairy patches, sacral dimples, or cutaneous discolorations as spinal bifida occulta is a congenital risk factor for this condition. Exaggerated lumbar lordosis may also be a risk factor. Observe general posture, spinal alignment, presence of directional preferences.
  • Palpation: there may be tenderness of paraspinal muscles or localized midline tenderness. Step-off deformity may be palpated if there is spondylolisthesis.
  • Range of motion: there may be pain with extension, or limited thoracolumbar range of motion
  • Lower extremity musculature: Examine forhamstring and hip flexor tightness, as well as gluteal, hamstring, abdominal/trunk strength.
  • Neurological exam: Examine for dermatomes, myotomes, and reflexes of lower extremities to rule out the presence of radiculopathy.
  • Stork test: Standing on a single leg, hyperextension of spine may produce ipsilateral or bilateral lumbar pain

Imaging:

  • AP and lateral x-rays of lumbar spine have a sensitivity of about 75%, so this may be ordered at initial work up. Other views (such as oblique) do not improve sensitivity, and therefore are not necessary.
  • MRI is the preferred imaging method in most cases if suspicion is moderate to high and x-rays are negative.

Management:

Non-operative treatment:

  • Discontinuation of sport and avoidance of aggravating activities (especially back extension) should be instituted at the time of diagnosis to allow for bony healing  
  • A physiotherapy program may be started early if tolerated or after a period of rest if there’s significant symptoms. Physiotherapy should focus on core, pelvic and lower extremity strengthening as well as lower extremity flexibility. Lumbar extension should be initially restricted, and gradually advanced based on symptoms and healing.
  • Lumbar brace that prevent hyperextension can be considered for a period of 4-6 weeks
  • Return to play may take anywhere from 2 to 6 months, and patient should only return to competitive play if they have met physiotherapy milestones, and if they no longer have symptoms.

Surgical treatment:

Most patients improve with conservative treatment. In a small fraction of athletes who fail non-operative management, surgical referral is indicated for consideration of direct repair.

Summary:

Spondylolysis is a defect of the pars interarticularis of a vertebra (most commonly L5) that should be strongly suspected in a pediatric or adolescent athlete presenting with extension aggrevated back pain. MRI is often needed for accurate diagnosis. Treatments include cessation of sports, physiotherapy, and lumbar brace until healing of the defect. Surgical referral is indicated if there is failure of non-operative management for > 6 months.

Yuhao Shi, MD

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References 1–3

1.        Goetzinger, S. et al. Spondylolysis in Young Athletes: An Overview Emphasizing Nonoperative Management. J. Sports Med. 2020, 1–15 (2020).

2.        Berger, R. G. & Doyle, S. M. Spondylolysis 2019 update. Current Opinion in Pediatrics vol. 31 61–68 (2019).

3.        Ebraheim, N., Elgafy, H., Gagnet, P., Andrews, K. & Kern, K. Spondylolysis and spondylolisthesis: A review of the literature. Journal of Orthopaedics vol. 15 404–407 (2018).

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