Spondylolysis: Difference between revisions
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{{Qualityalert_Condition}} '''<font color="red">To edit: general grammar and spelling, info update, red bar removal </font>''' <br> | {{Qualityalert_Condition}} '''<font color="red">To edit: general grammar and spelling, info update, red bar removal</font>''' <br> | ||
<div class="editorbox"> | |||
'''Original Editors ''' - [[User:Andrea Nees|Andrea Nees]] [[User:Elien Vanderlinden|Elien Vanderlinden]][[User:Heleen Van Cleynenbreugel|Heleen Van Cleynenbreugel]][[User:Els Van Haver|Els Van haver]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. | '''Original Editors ''' - [[User:Andrea Nees|Andrea Nees]] [[User:Elien Vanderlinden|Elien Vanderlinden]][[User:Heleen Van Cleynenbreugel|Heleen Van Cleynenbreugel]][[User:Els Van Haver|Els Van haver]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. | ||
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== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
Vertebrae consist of the vertebral body and a bony ring or arcus which protects the spinal cord. The arcus is formed by | Vertebrae consist of the vertebral body and a bony ring or arcus which protects the spinal cord. The arcus is formed by two pedicles which attach to the dorsal side of the vertebral body and two laminae, which complete the arch. The area between the pedicle and the lamina is called the pars interarticularis and is in fact the weakest part of the arcus. It is the pars interarticularis that is affected in spondylolysis. | ||
<br> | <br> | ||
| Line 26: | Line 25: | ||
== Epidemiology /Etiology == | == Epidemiology /Etiology == | ||
Spondylolysis affects 3-6% of the population. <ref name="Elien 1" /><ref name="Elien 2" /><ref name="Elien 6">Haun D.W., Kettner N.W., Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management, J Chiropr Med 2005;4:206–217 (Level of evidence: A1)</ref> This condition appears in the first or second decade of life | Spondylolysis affects 3-6% of the population. <ref name="Elien 1" /><ref name="Elien 2" /><ref name="Elien 6">Haun D.W., Kettner N.W., Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management, J Chiropr Med 2005;4:206–217 (Level of evidence: A1)</ref> This condition appears in the first or second decade of life; the frequency of spondylolysis increases with age until 20 years. <ref name="Elien 3">Aufderheide A.C., Rodriguez-Martin C., The Cambridge Encyclopedia Of Human Paleopathology, Cambridge University Press, 1998, p. 63. (Level of evidence: D)</ref><ref name="Elien 4">Fast A., Goldsher D., Navigating The Adult Spine, Demos Medical Publishing, 2007, p. 55. (Level of evidence: D)</ref> There is, however, no change in prevalence with increasing age from 20 to 80 years old. Men are affected twice as often as women. <ref name="Elien 2" /><ref name="Elien 5">Depalma M.J., iSpine: Evidence-based interventional spine care, Demos Medical Publishing, 2011, p. 156-157. (Level of evidence: D)</ref> There is a possible genetic tendency for people with lower cortical bone density at the pars interarticularis. <ref name="Elien 2" /><ref name="Elien 6" /> There is increased prevalence in specific ethnic, sports and family groups. <ref name="Elien 7">Ruiz-Cotorro A., Spondylolysis in young tennis players, Br J Sports Med 2006;40:441–446 (Level of evidence: A1)</ref> Spondylolysis occurs more frequently in the young athletic population. There is an increased risk in gymnasts, football players, cricketers, swimmers, divers, weight lifters and wrestlers. <ref name="Elien 2" /><ref name="Elien 6" /> | ||
More information regarding | More information regarding spondylolysis in the young athletic population can be found on this [[Spondylolysis_in_Young_Athletes|page]].<br> | ||
Spondylolysis is considered to be a stress fracture that results from mechanical stress at the pars interarticularis. These stress fractures occur due to repetitive load and stress, rather than being caused by a single traumatic event. <ref name="Elien 2" /><ref name="Elien 6" /> The stress distribution at the pars interarticularis is the highest in extension and rotation movements. <ref name="Elien 1" /><ref name="Elien 2" /><ref name="Elien 6" /> Spondylolysis occurs mostly at '''L5''' (80-95%) due to repetitve hyperextension | Spondylolysis is considered to be a stress fracture that results from mechanical stress at the pars interarticularis. These stress fractures occur due to repetitive load and stress, rather than being caused by a single traumatic event. <ref name="Elien 2" /><ref name="Elien 6" /> The stress distribution at the pars interarticularis is the highest in extension and rotation movements. <ref name="Elien 1" /><ref name="Elien 2" /><ref name="Elien 6" /> Spondylolysis occurs mostly at '''L5''' (80-95%) due to repetitve hyperextension, <ref name="Elien 2" /><ref name="Elien 4" /><ref name="Elien 6" /> which increases the contact between the caudal edge of the inferior articular facet of L4 and the pars interarticularis of L5.<br> | ||
== Characteristics/Clinical Presentation == | == Characteristics/Clinical Presentation == | ||
| Line 38: | Line 37: | ||
*Onset of pain is gradual or acute (after intense athletic activity) <ref name="Andrea 1">Syrmou E., Tsitsopoulos P.P., Marinopoulos D., Tsnodis C., Anagnostopoulos I. Spondylolysis: A review and reappraisal. Hippokratia 2010,14,1,1:17-21 (Level of evidence: A2)</ref><ref name="Andrea 3">Standaert C.J., Herring S.A. Spondylolysis: a critical review. Br J Sports Med 2000;34:415–422. (Level of evidence: A2)</ref><ref name="Elien 1" /> | *Onset of pain is gradual or acute (after intense athletic activity) <ref name="Andrea 1">Syrmou E., Tsitsopoulos P.P., Marinopoulos D., Tsnodis C., Anagnostopoulos I. Spondylolysis: A review and reappraisal. Hippokratia 2010,14,1,1:17-21 (Level of evidence: A2)</ref><ref name="Andrea 3">Standaert C.J., Herring S.A. Spondylolysis: a critical review. Br J Sports Med 2000;34:415–422. (Level of evidence: A2)</ref><ref name="Elien 1" /> | ||
*There can be a recent or old history of local trauma <ref name="Andrea 1" /> | *There can be a recent or old history of local trauma <ref name="Andrea 1" /> | ||
*Intense pain | *Intense pain restricts ADL performance <ref name="Andrea 1" /><ref name="Elien 1" /> | ||
* | *Symptoms become aggravated after a stressful event <ref name="Andrea 1" /> | ||
*Rest usually relieves the symptoms <ref name="Elien 1" /> | *Rest usually relieves the symptoms <ref name="Elien 1" /> | ||
Specific symptons depend on the region of the spine that is affected. Lumbar spondylolysis | Specific symptons depend on the region of the spine that is affected. Lumbar spondylolysis will show other symptoms than thoracic or cervical spondylolysis. | ||
Symptoms for '''lumbar spondylolysis''' are: | |||
*Focal low back pain with radiation into the buttock or proximal lower limb <ref name="Andrea 1" /><ref name="Andrea 3" /><ref name="Elien 1" /> | *Focal low back pain with radiation into the buttock or proximal lower limb <ref name="Andrea 1" /><ref name="Andrea 3" /><ref name="Elien 1" /> | ||
*Symptoms can increase when a movement | *Symptoms can increase when a movement such as lumbar spinal extension or rotation is performed <ref name="Andrea 3" /><ref name="Elien 1" /> | ||
*Children under 13 years old show tenderness or pain on extension <ref name="Andrea 2">Tetsuki M, Takaaki I, Shinsuke K, Ryoji M. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg [Br] l995;77-B:620-5 (Level of evidence: B1)</ref> | *Children under 13 years old show tenderness or pain on extension <ref name="Andrea 2">Tetsuki M, Takaaki I, Shinsuke K, Ryoji M. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg [Br] l995;77-B:620-5 (Level of evidence: B1)</ref> | ||
*Children can present a postural deformity or abnormal gait pattern <ref name="Elien 1" /> | *Children can present a postural deformity or abnormal gait pattern <ref name="Elien 1" /> | ||
| Line 70: | Line 69: | ||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
The golden standard for the diagnosis of spondylolysis is the combination of SPECT and computed tomography (CT). When a pars fracture is present, computed tomography can clearly visualize the spondylolysis. On axial CT scans, the neural arch should be closed and continuous at the level of the pedicles. When there is a pars defect, there is a discontinuity at this level. Sagittal CT images | The golden standard for the diagnosis of spondylolysis is the combination of SPECT and computed tomography (CT). When a pars fracture is present, computed tomography can clearly visualize the spondylolysis. On axial CT scans, the neural arch should be closed and continuous at the level of the pedicles. When there is a pars defect, there is a discontinuity at this level. Sagittal CT images differentiate better between a pars defect and the facet joint and are also the most accurate in showing incomplete fractures. MRI shows promising results in detecting spondylolysis but can also be used to determine the state of the disc above and below the affected vertebra. <ref name="Elien 1" /><ref name="Elien 5" /><ref name="Heleen 3">Hyde TE. Spine-health. Profile and Diagnosis of Spondylolysis. http://www.spine-health.com/conditions/spondylolisthesis/profile-and-diagnosis-spondylolysis (accessed 5/05/2012)</ref><br> | ||
== Examination == | == Examination == | ||
| Line 76: | Line 75: | ||
The most common findings for lumbar spondylolysis are hyperlordotic posture and low back pain during lumbar extension. <ref name="Els 1">Leone et al. Lumbar spondylolydid: a review. Skeletal Radiol (2011) 40:683–700</ref><br> | The most common findings for lumbar spondylolysis are hyperlordotic posture and low back pain during lumbar extension. <ref name="Els 1">Leone et al. Lumbar spondylolydid: a review. Skeletal Radiol (2011) 40:683–700</ref><br> | ||
The Michelis' test or unilateral extension test can be performed to confirm diagnosis. | The Michelis' test or unilateral extension test can be performed to confirm diagnosis. The patient performs hyperextension of the lumbar spine while standing on one leg. In a positive test, pain is reproduced. Unilateral lesions often produce pain when standing on the ipsilateral leg. <ref name="Heleen 3" /><ref name="Elien 5" /> | ||
Neurologic exam is usually normal | Neurologic exam is usually normal but neurogenic symptoms can arise if the condition progresses to spondylolisthesis. | ||
== Medical Management <br> == | == Medical Management <br> == | ||
| Line 84: | Line 83: | ||
'''Conservative treatment''' is usually sufficient to treat symptomatic spondylolysis and aims to reduce pain and facilitate healing processes. Possible features of conservative treatment are: <ref name="Els 1" /><ref name="Els 2">McNeely M, Torrance G. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual Therapy 2003: 8(2); 80-91</ref> | '''Conservative treatment''' is usually sufficient to treat symptomatic spondylolysis and aims to reduce pain and facilitate healing processes. Possible features of conservative treatment are: <ref name="Els 1" /><ref name="Els 2">McNeely M, Torrance G. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual Therapy 2003: 8(2); 80-91</ref> | ||
* | *NSAIDs to provide pain relief | ||
*cessation of aggravating (sporting) activities<br> | *cessation of aggravating (sporting) activities<br> | ||
*the use of a spinal brace to prevent motion at the injured pars and allow bony repair <ref>Steiner ME, Micheli LJ. Treatment of symptomatic spondylol- ysis and spondylolisthesis with the modified Boston brace. Spine. 1985;10:937–43.</ref> | *the use of a spinal brace to prevent motion at the injured pars and allow bony repair <ref>Steiner ME, Micheli LJ. Treatment of symptomatic spondylol- ysis and spondylolisthesis with the modified Boston brace. Spine. 1985;10:937–43.</ref> | ||
*physical therapy | *physical therapy | ||
When severe pain is persistent and progression | When severe pain is persistent and progression to spondylolisthesis needs to be prevented, '''surgical treatment''' can be required. This only occurs in some patients and evidence of long-term benefit is still uncertain. Latest procedures attempt a repair of the affected pars with preservation of the segmental mobility whereas earlier methods sometimes included a spinal fusion procedure. <ref name="Els 2" /> | ||
== Physical Therapy Management <br> == | == Physical Therapy Management <br> == | ||
| Line 96: | Line 95: | ||
*Facilitating the healing processes by promoting additional blood flow and thus healing of the affected pars. This can be accomplished by isometric contractions of the surrounding muscles. | *Facilitating the healing processes by promoting additional blood flow and thus healing of the affected pars. This can be accomplished by isometric contractions of the surrounding muscles. | ||
*Avoiding aggravation or turning into a chronic state by handling underlying causes ( | *Avoiding aggravation or turning into a chronic state by handling underlying causes (e.g. hypermobility, hyperextension in specific sports such as wrestling, skating) | ||
*Optimization of physical function | *Optimization of physical function | ||
A rehabilitation | A rehabilitation program should progress in four stages: <ref name="Elien 1" /><ref name="Andrea 2" /><ref name="Els 1" /><ref name="Els 2" /> | ||
#'''Control pain and inflammation''': Taking stress | #'''Control pain and inflammation''': Taking stress off the injured area allows physiological healing processes to take place. Therefore, it can be necessary to avoid rotational shearing forces and extension movements by a temporary cessation of sporting activities and/or wearing a brace. | ||
#'''Daily stabilization''': Neuromuscular stabilization techniques, including activation of | #'''Daily stabilization''': Neuromuscular stabilization techniques, including activation of transversus abdominis and other core stabilizer muscles must be started after the acute symptons have decreased. This section includes education and postural training. | ||
#'''Strength and flexibility''': As paraspinal muscle spasms and hamstrings tightness are often seen in patients with spondylolysis, stretching exercises can be added to the rehabilitation programm. Flexibility training is usefull in patients with hypomobility of the back spine. | #'''Strength and flexibility''': As paraspinal muscle spasms and hamstrings tightness are often seen in patients with spondylolysis, stretching exercises can be added to the rehabilitation programm. Flexibility training is usefull in patients with hypomobility of the back spine. | ||
#'''Functional movement''': The main goal of physiotherapy is to increase functional abilities | #'''Functional movement''': The main goal of physiotherapy is to increase functional abilities through a home exercise program. As soon as primary pain decreases, patients have to be encouraged to resume activities as tolerated.<br> | ||
== Key Research == | == Key Research == | ||
| Line 112: | Line 111: | ||
== Clinical Bottom Line == | == Clinical Bottom Line == | ||
A detailed knowledge of spine anatomy and functioning is imperative. Objective interpretation of medical imaging is necessary in order to avoid making premature conclusions because there is a low correlation between clinical findings and symptoms. Because of the athletic background of most patients with spondylolysis, it is essential to be well informed about training principles and sports-specific exercises to provide the patient with the best care available.<br> | |||
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | ||
| Line 118: | Line 117: | ||
== References == | == References == | ||
<br> | |||
<references /> | <references /> [[//www.pinterest.com/pin/create/extension/|//www.pinterest.com/pin/create/extension/]] | ||
[[Category:Condition]] [[Category:Lumbar_Conditions]] [[Category:Lumbar]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Vrije_Universiteit_Brussel_Project]] | [[Category:Condition]] [[Category:Lumbar_Conditions]] [[Category:Lumbar]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Vrije_Universiteit_Brussel_Project]] [[//www.pinterest.com/pin/create/extension/|//www.pinterest.com/pin/create/extension/]] | ||
Revision as of 03:30, 9 August 2015
This condition/syndrome article requires improvement to meet Physiopedia's quality standards. The reasons have been specified below this alert box. Please help improve this page if you can. #qualityalert #qualityalert_condition
To edit: general grammar and spelling, info update, red bar removal
Original Editors - Andrea Nees Elien VanderlindenHeleen Van CleynenbreugelEls Van haver as part of the Vrije Universiteit Brussel's Evidence-based Practice project.
Top Contributors - Els Van Haver, Rani Vetsuypens, Abbey Wright, Admin, Melissa Coetsee, Laura Ritchie, Evan Thomas, James Greenwood, Dejonckheere Margo, WikiSysop and Kim Jackson -
Search Strategy[edit | edit source]
Search engines PubMed, Web of Knowledge, Pedro
Keywords Spondylolysis + Physiotherapy / Physical Therapy / Anatomy / Medical management / Diagnosis
Searches have been performed between 28/03/2012 and 20/05/2012
Definition/Description[edit | edit source]
Spondylolysis is a unilateral or bilateral bony defect in the pars interarticularis or isthmus of the vertebra. The term derives from the Greek words spondylos (vertebra) and lysis (defect). [1][2] It can cause a slipping of the vertebra, in which case the term spondylolytic spondylolysthesis is used.
Clinically Relevant Anatomy[edit | edit source]
Vertebrae consist of the vertebral body and a bony ring or arcus which protects the spinal cord. The arcus is formed by two pedicles which attach to the dorsal side of the vertebral body and two laminae, which complete the arch. The area between the pedicle and the lamina is called the pars interarticularis and is in fact the weakest part of the arcus. It is the pars interarticularis that is affected in spondylolysis.
Epidemiology /Etiology[edit | edit source]
Spondylolysis affects 3-6% of the population. [1][2][3] This condition appears in the first or second decade of life; the frequency of spondylolysis increases with age until 20 years. [4][5] There is, however, no change in prevalence with increasing age from 20 to 80 years old. Men are affected twice as often as women. [2][6] There is a possible genetic tendency for people with lower cortical bone density at the pars interarticularis. [2][3] There is increased prevalence in specific ethnic, sports and family groups. [7] Spondylolysis occurs more frequently in the young athletic population. There is an increased risk in gymnasts, football players, cricketers, swimmers, divers, weight lifters and wrestlers. [2][3]
More information regarding spondylolysis in the young athletic population can be found on this page.
Spondylolysis is considered to be a stress fracture that results from mechanical stress at the pars interarticularis. These stress fractures occur due to repetitive load and stress, rather than being caused by a single traumatic event. [2][3] The stress distribution at the pars interarticularis is the highest in extension and rotation movements. [1][2][3] Spondylolysis occurs mostly at L5 (80-95%) due to repetitve hyperextension, [2][5][3] which increases the contact between the caudal edge of the inferior articular facet of L4 and the pars interarticularis of L5.
Characteristics/Clinical Presentation[edit | edit source]
In most cases, spondylolysis is asymptomatic. If there are any symptoms, they often have following characteristics:
- Onset of pain is gradual or acute (after intense athletic activity) [8][9][1]
- There can be a recent or old history of local trauma [8]
- Intense pain restricts ADL performance [8][1]
- Symptoms become aggravated after a stressful event [8]
- Rest usually relieves the symptoms [1]
Specific symptons depend on the region of the spine that is affected. Lumbar spondylolysis will show other symptoms than thoracic or cervical spondylolysis.
Symptoms for lumbar spondylolysis are:
- Focal low back pain with radiation into the buttock or proximal lower limb [8][9][1]
- Symptoms can increase when a movement such as lumbar spinal extension or rotation is performed [9][1]
- Children under 13 years old show tenderness or pain on extension [10]
- Children can present a postural deformity or abnormal gait pattern [1]
- Pain through the full range of lumbar motion [11]
Differential Diagnosis[edit | edit source]
- Disc Injuries: Disc Herniation
- Lumbosacral Discogenic Pain Syndrome
- Facet Joint Syndrome
- Acute Bony Injuries
- Sprain/Strain Injuries
- Spondylolisthesis
- Myofascial Pain in Athletes
- Sacroiliac Joint Injury
- Lumbar radiculopathy
- Osteoid osteoma
- Osteomyelitis
- Spinal stenosis
- Stress fracture
Diagnostic Procedures[edit | edit source]
The golden standard for the diagnosis of spondylolysis is the combination of SPECT and computed tomography (CT). When a pars fracture is present, computed tomography can clearly visualize the spondylolysis. On axial CT scans, the neural arch should be closed and continuous at the level of the pedicles. When there is a pars defect, there is a discontinuity at this level. Sagittal CT images differentiate better between a pars defect and the facet joint and are also the most accurate in showing incomplete fractures. MRI shows promising results in detecting spondylolysis but can also be used to determine the state of the disc above and below the affected vertebra. [1][6][12]
Examination[edit | edit source]
The most common findings for lumbar spondylolysis are hyperlordotic posture and low back pain during lumbar extension. [13]
The Michelis' test or unilateral extension test can be performed to confirm diagnosis. The patient performs hyperextension of the lumbar spine while standing on one leg. In a positive test, pain is reproduced. Unilateral lesions often produce pain when standing on the ipsilateral leg. [12][6]
Neurologic exam is usually normal but neurogenic symptoms can arise if the condition progresses to spondylolisthesis.
Medical Management
[edit | edit source]
Conservative treatment is usually sufficient to treat symptomatic spondylolysis and aims to reduce pain and facilitate healing processes. Possible features of conservative treatment are: [13][14]
- NSAIDs to provide pain relief
- cessation of aggravating (sporting) activities
- the use of a spinal brace to prevent motion at the injured pars and allow bony repair [15]
- physical therapy
When severe pain is persistent and progression to spondylolisthesis needs to be prevented, surgical treatment can be required. This only occurs in some patients and evidence of long-term benefit is still uncertain. Latest procedures attempt a repair of the affected pars with preservation of the segmental mobility whereas earlier methods sometimes included a spinal fusion procedure. [14]
Physical Therapy Management
[edit | edit source]
Physiotherapy in spondylolysis has multiple goals: [9][13][14]
- Facilitating the healing processes by promoting additional blood flow and thus healing of the affected pars. This can be accomplished by isometric contractions of the surrounding muscles.
- Avoiding aggravation or turning into a chronic state by handling underlying causes (e.g. hypermobility, hyperextension in specific sports such as wrestling, skating)
- Optimization of physical function
A rehabilitation program should progress in four stages: [1][10][13][14]
- Control pain and inflammation: Taking stress off the injured area allows physiological healing processes to take place. Therefore, it can be necessary to avoid rotational shearing forces and extension movements by a temporary cessation of sporting activities and/or wearing a brace.
- Daily stabilization: Neuromuscular stabilization techniques, including activation of transversus abdominis and other core stabilizer muscles must be started after the acute symptons have decreased. This section includes education and postural training.
- Strength and flexibility: As paraspinal muscle spasms and hamstrings tightness are often seen in patients with spondylolysis, stretching exercises can be added to the rehabilitation programm. Flexibility training is usefull in patients with hypomobility of the back spine.
- Functional movement: The main goal of physiotherapy is to increase functional abilities through a home exercise program. As soon as primary pain decreases, patients have to be encouraged to resume activities as tolerated.
Key Research[edit | edit source]
McNeely M, Torrance G. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual Therapy 2003: 8(2); 80-91
Clinical Bottom Line[edit | edit source]
A detailed knowledge of spine anatomy and functioning is imperative. Objective interpretation of medical imaging is necessary in order to avoid making premature conclusions because there is a low correlation between clinical findings and symptoms. Because of the athletic background of most patients with spondylolysis, it is essential to be well informed about training principles and sports-specific exercises to provide the patient with the best care available.
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Gunzburg R., Szpalski M., Spondylolysis, Spondylolisthesis and Degenerative Spondylolisthesis, Lippincott Williams and Wilkins, 2006, p. 21. (Level of evidence: D)
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 MacAuley D., Best T., Evidence-based Sports Medicine, Blackwell Publishing, 2007, p. 282. (Level of evidence: D)
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Haun D.W., Kettner N.W., Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management, J Chiropr Med 2005;4:206–217 (Level of evidence: A1)
- ↑ Aufderheide A.C., Rodriguez-Martin C., The Cambridge Encyclopedia Of Human Paleopathology, Cambridge University Press, 1998, p. 63. (Level of evidence: D)
- ↑ 5.0 5.1 Fast A., Goldsher D., Navigating The Adult Spine, Demos Medical Publishing, 2007, p. 55. (Level of evidence: D)
- ↑ 6.0 6.1 6.2 Depalma M.J., iSpine: Evidence-based interventional spine care, Demos Medical Publishing, 2011, p. 156-157. (Level of evidence: D)
- ↑ Ruiz-Cotorro A., Spondylolysis in young tennis players, Br J Sports Med 2006;40:441–446 (Level of evidence: A1)
- ↑ 8.0 8.1 8.2 8.3 8.4 Syrmou E., Tsitsopoulos P.P., Marinopoulos D., Tsnodis C., Anagnostopoulos I. Spondylolysis: A review and reappraisal. Hippokratia 2010,14,1,1:17-21 (Level of evidence: A2)
- ↑ 9.0 9.1 9.2 9.3 Standaert C.J., Herring S.A. Spondylolysis: a critical review. Br J Sports Med 2000;34:415–422. (Level of evidence: A2)
- ↑ 10.0 10.1 Tetsuki M, Takaaki I, Shinsuke K, Ryoji M. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg [Br] l995;77-B:620-5 (Level of evidence: B1)
- ↑ Freeman B. J. C. and Debnath U. K. The management of Spondylolysis and Spondylolisthesis. Surgery for Low Back Pain. 2010:4:137-145. (Level of evidence: A2)
- ↑ 12.0 12.1 Hyde TE. Spine-health. Profile and Diagnosis of Spondylolysis. http://www.spine-health.com/conditions/spondylolisthesis/profile-and-diagnosis-spondylolysis (accessed 5/05/2012)
- ↑ 13.0 13.1 13.2 13.3 Leone et al. Lumbar spondylolydid: a review. Skeletal Radiol (2011) 40:683–700
- ↑ 14.0 14.1 14.2 14.3 McNeely M, Torrance G. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual Therapy 2003: 8(2); 80-91
- ↑ Steiner ME, Micheli LJ. Treatment of symptomatic spondylol- ysis and spondylolisthesis with the modified Boston brace. Spine. 1985;10:937–43.
