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Spondylolysis

spondylitis

By Chris Linthwaite.

Introduction

Spondylolysis (SL) is an isolated defect at the Pars Interarticularis a lumbar vertebra. This can either be unilateral or bilateral. SL can be asymptomatic or symptomatic, manifested by LBP.

Prevalence of SL in paediatric and adolescent populations range from 4.4%-4.7%. This is affected by the activity of the child/ adolescent.

Cause

SL occurs due to chronic loading overuse or acute overload injury. The posterior aspect of the vertebrae is loaded with spinal hyperextension and rotation which weakens the par interarticularis, thus increases chance of fracture. The prevalence is 11% in young athletes and 3% in no young athletes. Pars defect ranges from a stress response to partial to complete fracture. A stress response is hard to see on imaging. SL can also result in spondylolisthesis. Chronic non-union (serious complicated fracture) occurs when cartilaginous, fibrous or osseous (bone/ turning to bone) materials bridge the pars lesion.

Also, biological factors cannot be ruled out. Rosenberg et al (2011) studied 143 non ambulatory (physically or mentally unable mobilise without aid) and found 0% prevalence of SL. This supports that SL progresses unilaterally or bilaterally with age.

3 favourable for complete resolution of SL (100% healed – Fujii et al):

  1. Early detection
  2. Unilateral involvement
  3. Location of L4

Epidemiology

Prevalence increases in children or adolescents who have increased participation in high intense sports. Prevalence of back pain is lower in an average child is much lower than young athletes. Prevalence varies on sex, growth, genetics, and sporting levels (especially weight lighting, gymnastics, swimming, and wrestlers).

Clinical presentation

80% of patients without symptoms had SL; however, 47% of Paediatric athletes who present with LBP had SL. Symptoms are LBP with occasional radiation to the buttock or proximal lower limbs. Pain will be greater than 3 weeks and pain onset is gradual. Pain increases with strenuous activity or hyper extension. Pain should subside with rest. If it does not, then the patient might have spondylolisthesis. Numbness and tingling are very rare. If they occur, other diagnosis should be considered.

3 “classic” types of patients:

  1. Female dancer or gymnast who is hyper lordotic and hyperflexible.
  2. Strong male athlete in their PHV who has limited flexibility and tight erector spinae.
  3. Athlete who has recently picked up a sport and no conditioning prior starting vigorous activities.

Morita (2011) Spondylolysis has been classified into:

  • early – clear hairline fracture
  • progressive – hairline fracture develops into a gap.
  • terminal stages – represents pseudoarthrosis.

Clinical Examination

  • Hx of LBP and consumption of anti-inflammatories are an indicator of SL. Questions should be asked about vit D intake, GI absorption and dairy allergies.
  • Tenderness on palpation
  • Isolated lumbosacral tenderness (unilateral or bilateral)
  • Pain on spine extension
  • Reduced thoracolumbar ROM
  • Ipsilateral or bilateral pain with Single leg hyperextension – Stork test
  • Tight hamstrings and flattened lumbar lordosis.
  • Forward flexion shouldn’t cause pain – resisted extension from forward flexion can cause pain.
  • Neurologic exam usually NAD.
  • Normal gait unless pain compromised à these pt walk leaning forward and reduced hip extension.

Diagnostic imaging

Computerised Tomography (CT) – high sensitivity but also patient will be exposed to radiation. This is a very accurate diagnosis of SL due to it being cross sectional. Accuracy is 97%.

Magnetic Resonance Imaging (MRI) – compared with CT, sensitivity is 80% with no radiation. Stress reactions can be missed occasionally with MRI’s also.

Treatment

Patients can be vit D deficient due to extensive indoor training, minimalizing sunlight exposure and compromising bone health.

Rest is the first part of treatment, 2-6 months. 100% bony healing rate for early-stage SL and treatment is commonly a period of 2 and a half months. Progressive SL healing was 93.8% and 80% terminal stage healing rates. After the fracture has healed, very low graded core exercises can be started

Summary

  • Children athletes will encounter excessive loading, repetition of hyper extension and rotation, placing disproportionate pressure on the spine.
  • Combination of poor bone health, overuse injuries = SL
  • MRI is the most appropriate diagnostic imagining with minimal radiation – for a more accurate confirmation, CT scans can be utilised.
  • Best treatment is Rest, vit D intake improvement and physical therapy.

If you are suffering with pain and would like any help or advice from our physiotherapists or sports injury therapists, please contact our reception team on 01454 838366 or book online at www.thethornburyclinic.co.uk.