Spondylolysis: Difference between revisions

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More information regarding spondylolysis in the young athletic population can be found on this [[Spondylolysis in Young Athletes|page]].<br>  
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.&nbsp;<ref name="Elien 2" /><ref name="Elien 6" /> The stress distribution at the pars interarticularis is the highest in extension and rotation movements.&nbsp;<ref name="Elien 1" /><ref name="Elien 2" /><ref name="Elien 6" />&nbsp;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>  
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.&nbsp;<ref name="Elien 2" /><ref name="Elien 6" /> The stress distribution at the pars interarticularis is the highest in extension and rotation movements.&nbsp;<ref name="Elien 1" /><ref name="Elien 2" /><ref name="Elien 6" />&nbsp;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.
[[File:Spondylolysis x ray .docx.jpg|none|thumb|681x681px|XRay to show spondylolysis]]
<br>  


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
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*Onset of pain is gradual or acute (after intense athletic activity)&nbsp;<ref name="Andrea 1">Syrmou E, Tsitsopoulos PP, Marinopoulos D, Tsonidis C, Anagnostopoulos I, Tsitsopoulos PD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843565/ Spondylolysis: a review and reappraisal]. Hippokratia. 2010 Jan;14(1):17.</ref><ref name="Andrea 3">Standaert CJ, Herring SA. [https://bjsm.bmj.com/content/34/6/415.short Spondylolysis: a critical review]. British journal of sports medicine. 2000 Dec 1;34(6):415-22.</ref><ref name="Elien 1" />  
*Onset of pain is gradual or acute (after intense athletic activity)&nbsp;<ref name="Andrea 1">Syrmou E, Tsitsopoulos PP, Marinopoulos D, Tsonidis C, Anagnostopoulos I, Tsitsopoulos PD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843565/ Spondylolysis: a review and reappraisal]. Hippokratia. 2010 Jan;14(1):17.</ref><ref name="Andrea 3">Standaert CJ, Herring SA. [https://bjsm.bmj.com/content/34/6/415.short Spondylolysis: a critical review]. British journal of sports medicine. 2000 Dec 1;34(6):415-22.</ref><ref name="Elien 1" />  
*There can be a recent or old history of local trauma&nbsp;<ref name="Andrea 1" />  
*Possible history of local trauma (recent or historical)&nbsp;<ref name="Andrea 1" />  
*Intense pain restricts ADL performance <ref name="Andrea 1" /><ref name="Elien 1" />  
*Intense pain restricts activities of daily living or sporting performance <ref name="Andrea 1" /><ref name="Elien 1" />  
*Symptoms become aggravated after a stressful event&nbsp;<ref name="Andrea 1" />  
*Symptoms become aggravated after a stressful event&nbsp;<ref name="Andrea 1" />  
*Rest usually relieves the symptoms&nbsp;<ref name="Elien 1" />
*Rest usually relieves the symptoms&nbsp;<ref name="Elien 1" />
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*Focal low back pain with radiation into the buttock or proximal lower limb&nbsp;<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&nbsp;<ref name="Andrea 1" /><ref name="Andrea 3" /><ref name="Elien 1" />  
*Symptoms can increase when a movement such as lumbar spinal extension or rotation is performed <ref name="Andrea 3" /><ref name="Elien 1" />  
*Symptoms can increase with movement specifically lumbar extension or rotation<ref name="Andrea 3" /><ref name="Elien 1" />  
*Children under 13 years old show tenderness or pain on extension&nbsp;<ref name="Andrea 2">Ikata T, Miyake R, Katoh S, Morita T, Murase M. [http://journals.sagepub.com/doi/10.1177/036354659602400117 Pathogenesis of sports-related spondylolisthesis in adolescents: radiographic and magnetic resonance imaging study]. The American journal of sports medicine. 1996 Jan;24(1):94-8.</ref>  
*Children under 13 years old show tenderness or pain on extension&nbsp;<ref name="Andrea 2">Ikata T, Miyake R, Katoh S, Morita T, Murase M. [http://journals.sagepub.com/doi/10.1177/036354659602400117 Pathogenesis of sports-related spondylolisthesis in adolescents: radiographic and magnetic resonance imaging study]. The American journal of sports medicine. 1996 Jan;24(1):94-8.</ref>  
*Children can present a postural deformity or abnormal gait pattern&nbsp;<ref name="Elien 1" />  
*Children can present a postural deformity or abnormal gait pattern&nbsp;<ref name="Elien 1" />  
*Pain through the full range of lumbar motion&nbsp;<ref name="Andrea 6">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: 5)</ref>
*Pain throughout lumbar range of movment<ref name="Andrea 6">Freeman B. J. C. and Debnath U. K. [https://link.springer.com/chapter/10.1007/978-3-642-04547-9_19 The management of Spondylolysis and Spondylolisthesis]. Surgery for Low Back Pain. 2010:4:137-145. </ref>


== Differential Diagnosis  ==
== Differential Diagnosis  ==

Revision as of 15:25, 20 August 2018

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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.


Thoracic vertebrae

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.

XRay to show spondylolysis


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]
  • Possible history of local trauma (recent or historical) [8]
  • Intense pain restricts activities of daily living or sporting 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 with movement specifically lumbar extension or rotation[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 throughout lumbar range of movment[11]

Differential Diagnosis[edit | edit source]

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] Standaert C.J. et al.(2006) (LOE: 2A) [13] Leone et al.(2011) (LOE: 3A) [14] McNeely, et al. (2003) (LOE: 3A)

  • 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
  • Strength and stabilize the spine
  • Reduce pain

A rehabilitation program should progress in four stages:[1] Gunzburg et al.(2006) (LOE: 5) [10] Tetsuki M.(1995) (LOE: 1B) [13] Leone, et al. (2011) (LOE: 3A) [14] McNeely, et al. (2003) (LOE: 3A)

  1. 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. It reduces the pain intensity and functional disability levels.[1] Gunzburg et al. (LOE: 5) [13] Leone, et al. (2011) (LOE: 3A), [14] McNeely, et al. (2003) (LOE: 3A), [9] Standaert, et al. (2000) (LOE: 2A), [16] O'sullivan, et al. (1997) (LOE: 1A)
  2. 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. There is evidence suggesting that special trunk stabilizing exercises to spondylolysis.[1] Gunzburg et al. (LOE: 5) [14] McNeely, et al. (2003) (LOE:3A), [13] Leone, et al. (2011) (LOE: 3A)
  3. Strength and flexibility: As paraspinal muscle spasms and hamstrings tightness are 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. [17] Gareth, et al. (2013) (LOE: 1A), [14] McNeely, et al. (2003) (LOE: 3A), [13] Leone, et al. (2011) (LOE: 3A)
  4. 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. [1]Gunzburg et al.(2006) (LOE: 5)[14] McNeely, et al. (2003) (LOE: 3A), [10] Tetsuki M, et al. (1997) (LOE: 1B)

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. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Gunzburg R., Szpalski M., Spondylolysis, Spondylolisthesis and Degenerative Spondylolisthesis, Lippincott Williams and Wilkins, 2006, p. 21. (Level of evidence: 5)
  2. ↑ 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: 5)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Haun DW, Kettner NW. Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management. Journal of chiropractic medicine. 2005 Dec 1;4(4):206-17.
  4. ↑ Aufderheide A.C., Rodriguez-Martin C., The Cambridge Encyclopedia Of Human Paleopathology, Cambridge University Press, 1998, p. 63. (Level of evidence 5)
  5. ↑ 5.0 5.1 Fast A., Goldsher D., Navigating The Adult Spine, Demos Medical Publishing, 2007, p. 55. (Level of evidence: 5)
  6. ↑ 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: 5)
  7. ↑ Ruiz-Cotorro A, Balius-Matas R, Estruch-Massana AE, Angulo JV. Spondylolysis in young tennis players. British journal of sports medicine. 2006 May 1;40(5):441-6.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Syrmou E, Tsitsopoulos PP, Marinopoulos D, Tsonidis C, Anagnostopoulos I, Tsitsopoulos PD. Spondylolysis: a review and reappraisal. Hippokratia. 2010 Jan;14(1):17.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Standaert CJ, Herring SA. Spondylolysis: a critical review. British journal of sports medicine. 2000 Dec 1;34(6):415-22.
  10. ↑ 10.0 10.1 10.2 Ikata T, Miyake R, Katoh S, Morita T, Murase M. Pathogenesis of sports-related spondylolisthesis in adolescents: radiographic and magnetic resonance imaging study. The American journal of sports medicine. 1996 Jan;24(1):94-8.
  11. ↑ Freeman B. J. C. and Debnath U. K. The management of Spondylolysis and Spondylolisthesis. Surgery for Low Back Pain. 2010:4:137-145.
  12. ↑ 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) (Level of evidence 5)
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L. Lumbar spondylolysis: a review. Skeletal radiology. 2011 Jun 1;40(6):683-700.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 McNeely ML, Torrance G, Magee DJ. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual therapy. 2003 May 1;8(2):80-91.
  15. ↑ Steiner ME, Micheli LJ. Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace. Spine. 1985 Dec;10(10):937-43.
  16. ↑ O'sullivan, Peter B., et al. "Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis." Spine 22.24 (1997): 2959-2967. (Level of evidence: 1A)
  17. ↑ Garet, Matthew, et al. "Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review." Sports health 5.3 (2013): 225-232. (Level of evidence 1A)
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