Thoracic Spondylolysis

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Definition

. Spondylosis = various forms of spinal degeneration that accompany the natural aging process
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.
“Spondylolysis” is also known as a blanket term used by physicians to describe general deterioration of the spine. This defect can be asymptomatic or associated with significant back pain (7). (Level of evidence 2A)
The literature confirmed several times that the thoracic spondylolysis, is not as common as cervical or lumbar spondylolysis. The vast majority of spondylolitic defects are seen at level L5 (85-95%),(15 LOE: 4) with level L4 being the second most likely to be affected. The higher levels of the lumbar spine are rarely affected. (15 LOE: 4)

Clinically Relevant Anatomy

The most important structures which are involved in a thoracic spondylolysis are: the thoracic vertebrae (T1-T12), the intervertebral disc of the thoracic vertebrae (These act like shock absorbers for the spine as it moves.), 12 pairs of spinal nerve roots, posterior rami (innervate the regional muscles of the back) and ventral rami (innervate the skin and muscles of the chest and abdominal area). (10) (level of evidence 3B)
The functions of the spine are:

• Stability; The costovertebral joints and rib cage are very important when it comes to stabilizing the thoracic spine. (11) (level of evidence 2B)
• housing of neurological structures and control.

The spine is supported by ligaments and muscles (1). When there’s a gap between the vertebral arches, a vertebra slipping or sliding can arise. In this condition are the nerves and spinal cord in danger (3).

Epidemiology/Etiology

The etiology of spondylolysis is considered to be a stress fracture at the pars interarticularis (12). (Level of evidence; 3B)
The reason that they call it a stress facture and not a congenital disorder is that they have never found a spondylolysis in neonates (newborns). Also spondylolysis don’t occurs in non-ambulatory patients. The last reason that this is a stress fracture is that the time line from spondylolysis to pseudoarthritis looks like the timeline from the long bone. (20; LOE: 1A)
This fracture can be the result of genetic predispositions (16 LOE: 4) including weak crossectional areas of the cortical bone area of the pars intervertebralis and relative cortical bone density (4,6) (4 LOE: 4) (6 LOE:1A). There is a possible genetic tendency for people with lower cortical bone density at the pars interarticularis.
Spondylolysis this is not spondylosis affects 3-6% of the population(17)(18)( 17: loe: 4) ( 18: loe: 1A), but the incidence of spondylolysis within the young athletic population is seen to be increased (47%) . (24 LOE: 2B) It is the most common cause in low back pain in pediatric patients. (22) ( loe: 2A) This condition appears in the first or second decade of life; the frequency of spondylolysis increases with age until 20 years. There is, however, no change in prevalence with increasing age from 20 to 80 years old. (19)(20)
Other risks are:
• structure of the pars interarticularis and the spine
• sport and activities that require repetitive flexion-extension movements, such as football, dance, gymnastics, wrestling, swimming (2,3,6,12).
• Excessive hyperextension forces is often associated with hypermobility.
• Muscle weakness
• long periods of static posture in extension and rotation (13) ( LOE: 2A)
• Men are affected twice as often as women (16)(17) ( 17 LOE: 4)
• 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. (16) (18) ( 16 LOE: 4) ( (18 LOE: 1A)

These factors affect the efficiency in which the neural arch absorbs forces (5 LOE: 1B).
The terms spondylolysis and spondylolithesis are often switched with one another. Spondylolythesis is actually a health problem that follows on a spondylolysis.

Another condition, called spondylolisthesis, can occur when there is a complete bilateral fracture of the pars interarticularis. This fracture results in the translation (in the anterior/posterior or anterior-caudal) direction of one vertebral body over the adjacent caudal vertebra, which could lead to neurologic problems (because of compression of the nerves and spinal cord between the bony structures). (6,9, 20,21) (level of evidence 1A)

Characteristics/Clinical Presentation

• The onset of pain can start after an acute injury or be gradual. Mild symptoms can last for a while and can after a particular event acute worsening (2).
• Focal back pain (2, 7).
• Symptoms increase during activities involving spinal extension and rotation (2).
• Reporting of acute or gradual pain after an intense activity (7).
• When the fracture is not recent: pain can be felt deep within the lower back and radiate to the buttock and thigh on the affected side (7).
• Pain through tout the full range of lumbar motion (8).

Differential Diagnosis

To demonstrate spondylolysis, plain radiographs of the lower back are used (2). To visualize the suspected bony defect CT scan can be helpful (image). SPECT (Single-Photon Emission Computed Tomography) and CAT scan (Computed Axial Tomography) are more sensitive to identify partial lesions (3,6). To define the status of the disc at and just above the level of slippage, MRI can be used (6)

Examination

• Neurologic exam is usually normal; except when vertebrae slips, neurogenic symptoms can arise (1).
• Pain when standing on the ipsilateral leg during the one legged hyperextension maneuver: the patient has to stand on one leg and lean backwards (2).
• Single leg raise test (link): the patient lifts one leg and places the trunk into hyperextension. This test is positive when there’s pain (unilateral or bilateral) determined in the sacroiliac area or lumbar spine, indicating shear forces on the pars interarticularis. (5).

Medical Management

There are two main types of surgery:
1. Laminectomy (link): nerve compression can be caused by an excess of cartilage where the broken bones try to heal. The loose lamina is removed to take the pressure off the nerve (5).
2. Posterior spinal fusion (link): this is recommended when a spinal segment is instable or loose. A spinal fusion results into one solid bone, because it allows that two or more bones grow together by means of small grafts in the problem area at het back of the spine. In some occasions the surgeon applies screws and metal plates to put two vertebrae together to avoid movement (5,8).
After the surgery the patients are recommended to use a supporting belt or a brace and they have to be careful with resuming activities in the first weeks (8).

Physical Therapy Management

The conservative treatment, to increase blood flow to the affected area, promote physical activity and healing and control pain in symptomatic spondylolysis, includes physical therapy, electrical stimulation, ultrasound, heat and ice (2: Level of Evidence: A2) ,(5: Level of Evidence: A1). Once the pain is under control, therapeutic isometric contractions of surrounding musculature and pulsed ultrasound may start to promote additional blood flow. An electrical bone stimulator (internally or external) is also used to promote the healing (7: Level of Evidence: A2).  Patients with symptomatic spondylolysis and postsurgical patients may benefit from rehabilitation to regain mobility to that particular region of the spine, as well to decrease the pain (5: Level of Evidence: A1). It is important to do daily aerobic physical activity during the rehabilitation. The main goals of rehabilitation program are to optimize physical function, regular participation in an exercise program, active relieve associated pain and bony healing promoting. Control pain and inflammation, daily stabilization, strength and flexibility, and functional movement are the four stages in which the rehabilitation program should progress. To take stress off the area of lesion, strengthening exercises, flexibility and modest stabilization are introduced. It can be necessary during the conservative phase to take extreme care to avoid rotational shearing motions and extensions, because they cause stress on the structures of the lamina (1: Level of Evidence: D),(5: Level of Evidence: A1). The maintenance of pelvic tilt is used during strength and flexibility activities to avoid this stress. Functional activities and more aggressive strengthening are added after the acute symptoms subside an when a certain base of stability establishing. The main goal of this exercise program is to increase functional abilities, promote the patient’s wellbeing and full function, improve spinal range of motion and maintenance pain alleviation. This program focuses on flexibility, stabilization, coordination and strengthening of the trunk (5: Level of Evidence: A1). Core stabilization must be added and include exercises for increasing the strength and stability of the M. Erector Spinae, M. Quadratus Lumborum, Mm. Internal/External Oblique Abdominis and M. Serratus Anterior. (8: Level of Evidence: A2). Activities of daily living and postural awareness has to be added to the program. Patients with acute symptoms should be instructed in comfortable positions and postures (during sleeping, sitting, lying, standing, walking and picking up objects) that are safe for the spinal structures and introduced to gentle trunk exercises (2: Level of Evidence: A2). To control the spondylolysis area, neuromuscular stabilization techniques, including activation of the M. Transversus Abdominis and other core stabilizer muscles must be emphasized (5: Level of Evidence: A1), (8: Level of Evidence: A2). To reduce pressure on the pars interarticularis, it is important to teach the patient to stand in a neutral spine position. To enhance control range of sensitivity and to gain strength, limited ranges of motion and isometric holds in various positions are recommended. To prepare the patient for future functional activities, strength, flexibility and endurance training must be progressed, as the inflammation and pain subside. Primarily, coordination, balance and coordination exercises are added as plyometric and proprioceptive parts. Secondarily, functional exercises are incorporated to allow the natural execution of functional daily activities, these are through home exercises supported using various equipment (hand weights, stability balls, foam rolers,..) (5: Level of Evidence: A1). The individuals have to be encourage to resume activities as tolerated (2: Level of Evidence: A2). Furthermore, the patient is recommend in a home exercise program for daily practice and continue independently after the completion of rehabilitation. In some cases the use of bracing is recommended momentarily in the early stage to control the pain and mobility (5: Level of Evidence: A1). It’s very important that the patient’s work place undergoes an ergonomic evaluation and that he/she is educated in proper body mechanics. These changes are meant to assist the employee’s return to work (2: Level of Evidence: A2).

References

1. David A., et al. Macnab’s Backache. P. 96- 102. (book with primary sources)
Level of evidence: D
2. Standaert C.J. and Herring S.A Herring. Spondylolysis: a critical review. Br J Sports Med. 2000;34:415-422.
Level of evidence: A2.
3. Robert Gunzburg and Marek Szpalski. Spondylolysis, spondylolisthesis, and degenerative spondylolisthesis. 2005. P.2-35. (book with primary sources)
Level of evidence: D
4. Morita T. et al. Lumbar Spondylolysis in children and adolescents. J. Bone Joint Surg. 1995;77-B-620-625.
Level of evidence: B1.
5. Peer K. S. and Fascione J. M. Spondylolysis – A Review and Treatment Approach. Orthopaedic Nursing. 2007,26: 104-111.
Level of evidence: A1.
6. Ruiz-Cotorro A. et al. Spondylolysis in young tennis players: Review. Br J. Sports Med. 2006;40:441-446.
Level of evidence: A2.
7. Syrmou E. et al. Spondylolysis: A review and reappraisal. Hippokratia. 2010;14:1:1721.
Level of evidence: A2.
8. 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.