Athletic Population with Spondylolysis: Review of Outcomes following Surgical Repair or Conservative Management

Factors associated with return to play following conservative treatment for lumbar spondylolysis among young athletes: A retrospective case series using structural equation modeling

INTRODUCTION

Lumbar spondylolysis is the most common underlying cause of lower back pain (LBP) in young athletes. Conservative treatment methods are often used to reduce pain and promote healing. Several parameters may affect the duration of conservative treatment, such as the time to return to play (RTP), patient behavior, and physical parameters; however, no study has comprehensively assessed the factors that affect the time to RTP.

OBJECTIVES

This study aimed to determine the factors associated with the time required for RTP among young athletes with early-stage spondylolysis receiving conservative treatment using structural equation modeling (SEM).

METHODS

In this retrospective case series, 137 young athletes (128 males and 9 females, aged 9-18 years) with early-stage lumbar spondylolysis were enrolled. All patients were examined using plain radiography and magnetic resonance imaging and treated conservatively (sports cessation, wearing a corset, therapeutic exercises, and low-intensity pulsed ultrasound radiation). SEM was used to investigate the factors affecting the time to RTP in these patients.

RESULTS

The final model included the following factors: spondylolysis laterality, symptom duration, lower-extremity flexibility, treatment interval, patient adherence, and residual LBP. SEM revealed that patient adherence to physician orders (p < 0.01), treatment interval (p < 0.001), and spondylolysis laterality (p < 0.001) contributed directly to shortened RTP.

CONCLUSION

Patient adherence is essential for reducing the time to RTP among young athletes receiving conservative treatment for early-stage spondylolysis.

Spondylolysis of the Thoracic Spine with Instability: A Rare Cause for Myelopathy

CASE

A 51-year-old lady with multiple comorbidities presented with T11 spondylolysis in association with thoracic stenosis and myelopathy. Our patient underwent T11-T12 laminectomy, T10-L1 posterior instrumented stabilization, and T11-T12 transforaminal interbody fusion. She had a good neurological recovery, and the radiographs at 1-year follow-up showed good fusion and implant position.

CONCLUSION

Spondylolysis is an anatomical defect or stress fracture of the pars interarticularis and usually reported in the lumbar region. This case of T11 spondylolysis in association with thoracic stenosis, spinal instability, and myelopathy is highlighted for its rarity and to reiterate the need for high index of suspicion among surgeons for the timely diagnosis.

Surgical repair of lumbar stress fractures in professional cricketers

Background

Professional cricket fast bowlers sustain high rates of lumbar stress fractures (spondylolysis). Limited research exists around the success of surgical repair when these injuries fail conservative treatment. We present an ambispective cohort study of spondylolysis surgical repair in a consecutive group of multi-national professional cricket fast bowler using a technique not previously reported in this unique sporting group.

Methods

Between 2004 and 2019, a consecutive series of male professional fast bowlers with lumbar spondylolysis who had repeatedly failed conservative treatment and subsequently received surgical repair using a cable-screw construct were reviewed. Analysis comprised of ambispective outcome and radiological data collection and a survey at final follow-up.

Results

The cohort included 13 elite (7 state and 6 international) cricket fast bowlers from 3 countries (New Zealand, Australian and India) with an average age of 26 years (range, 20.3-29.5 years). All returned to play professional cricket at a median time of 8 months (IQR, 7-11 months) post surgery. All ten players surveyed at final follow-up [median, 38 (IQR, 31-103) months, range, 15-197 months] rated their bowling performance as the 'same or better' compared with prior to surgery. At final follow-up, 10 players continue to play cricket professionally ranging from 15 to 107 months post-surgery [median 35 (IQR, 24-43) months].

Conclusions

Our cohort demonstrated favorable return to play rates and career longevity following surgical repair of spondylolysis. To our knowledge it is the largest published surgical series of spondylolysis repair in cricketers, and the first to document the success of a cable-screw surgical technique in this sporting group.

Inter-Disciplinary Conservative Management of Bilateral Non-United Lumbar Pars Defects in a Junior Elite Golfer

The prevalence of spondylolysis amongst adolescent athletes presenting with low back pain has been reported as high as 47-55%. Youth athletes participating in sports involving movements combining compression, extension and rotation appear most susceptible. As such, young golfers are a high-risk group, particularly given the high shear and compressive forces associated with the golf swing action. This is compounded by a culture which encourages very high practice volumes, typically poorly monitored. Although non-operative interventions are deemed the gold-standard management for this condition, surgery is indicated for more severe presentations and cases of 'failed' conservative management. The case presented herein outlines an inter-disciplinary, non-operative management of a 17-year old elite golfer with a moderate to severe presentation. A 4-stage model of reconditioning is outlined, which may be of use to practitioners given the paucity of rehabilitation guidelines for this condition. The report highlights the benefits of a graded program of exercise-based rehabilitation over the typically prescribed "12 weeks rest" prior to a return to the provocative activity. It also supports existing evidence that passive therapeutic approaches should only be used as an adjunct to exercise, if at all in the management of spondylolysis. Finally, and crucially, it also underlines that to deem non-surgical rehabilitation 'unsuccessful' or 'failed', clinicians should ensure that (long-term) exercise was included in the conservative approach.

LEVEL OF EVIDENCE

4-Case Report.

Return to play after spondylolysis: An overview

Spondylolysis is increasingly associated with specific sports, timely and effective management of which underpins successful return to sports. Hence, the main purpose of this systematic review of reviews [RoR] is to summarize data from published reviews exploring the return to play in athletes with spondylolysis managed conservatively or surgically, thereby providing for recommendations for future practice and research. A systematic review of review of articles published in English and since 2015 was conducted online using PubMed and Google Scholar, as per Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines. Predefined eligibility criteria were applied, and the data thus compiled were analyzed. Study quality was assessed using the AMSTAR-2 checklist. A total of 7 systematic reviews and meta-analysis consisting of 51 primary studies were included in the review. The result of this RoR highlights the knowledge gap and limitations in RTP research post spondylolysis with existing heterogeneity in methods and reporting amid other factors within primary studies. Further quality of the study was found to be of low to critically low confidence based on the AMSTAR-2 scale, suggesting that the results should be interpreted with great caution. Though both conservative and surgical approaches increase the percentage of athletes returning to play, the evidence remains largely limited and inconclusive as to which is better. However, it appears that surgical interventions give those who failed a trial of conservative approach, a better shot at return to play. There is a need for further high-quality, appropriately powered, well-designed, multicentered studies, and also for consensus regarding "returning to play" definition and outcome measures.

Adolescents with spondylolysis have lower SRS-22 scores than controls and peers with pre-operative idiopathic scoliosis

PURPOSE

The Scoliosis Research Society Outcomes Questionnaire (SRS-22) is a health-related quality-of-life (HRQL) tool for scoliosis patients. Since no equivalent questionnaire exists for spondylolysis patients, we characterized patient-reported scores in pediatric spondylolysis patients using the SRS-22, and compared these scores to previously published values for age-matched controls and patients with pre-operative adolescent idiopathic scoliosis (AIS).

METHODS

A single-institution cross-sectional observational study was performed using SRS-22 data from spondylolysis patients aged 12-18 years. Mean SRS-22 domain scores were compared to the existing literature values for adolescent control and AIS cohorts via unpaired Student t tests (α = 0.05) and against minimal clinically important differences (MCIDs).

RESULTS

Thirty-five patients met inclusion criteria. Mean (± SD) spondylolysis patients' scores met the MCID across all domains except Mental Health (α= 0.05). Spondylolysis patient scores for Pain, Function, and Self-Image were significantly lower (p < 0.01) than AIS patients (Pain; 2.99 ± 0.66 vs 4.14 ± 0.79; Function; 3.81 ± 0.61 vs 4.09 ± 0.54; Self-Image; 3.45 ± 0.70 vs 3.80 ± 0.68).

CONCLUSION

The adolescent spondylolysis population has clinically significantly lower SRS-22 scores compared to age-matched controls and AIS patients, suggesting that the SRS-22 questionnaire should be given to this population to assess patients' HRQL. Further research is needed to assess the utility of the SRS-22 in measuring treatment effects.

LEVEL OF EVIDENCE

III.

The Incidence of Pars Interarticularis Defects in Athletes

STUDY DESIGN

Literature review.

OBJECTIVE

To conduct a literature review of studies reporting the incidence of pars interarticularis defects in athletes of specific sports, in order to allow more targeted prevention and treatment strategies to be implemented for the groups at highest risk.

METHODS

Electronic searches were performed using PubMed, Ovid Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Cochrane Database of Controlled Trials from their dates of inception to September 2017, with the following keywords: "spondylolysis," "sports," "low back pain," and "pars defects."

RESULTS

A total of 509 total articles were retrieved, of which 114 were used in the final review. The incidence of pars interarticularis defects was found to be highest in diving (35.38%), cricket (31.97%), baseball/softball (26.91%), rugby (22.22%), weightlifting (19.49%), sailing (17.18%), table tennis (15.63%), and wrestling (14.74%). Only 5 studies reported the management instituted for their participants, and these were all case reports. Of 74 players with spondylolysis in these studies, 70 (94.59%) underwent conservative treatment and 4 (5.41%) underwent surgical treatment. 61 (82.43%) returned to their previous level of play, 6 (8.11%) retired, and the disposition of the final 7 was not reported.

CONCLUSION

The current medical literature provides good evidence that the incidence of pars interarticularis defects is higher in the athletic population, with the highest incidence in diving. There remains no gold standard protocol for the management of pars interarticularis defects. Further research is required to compare conservative therapy to surgical therapy and to compare the various surgical techniques to each other.

Symptomatic stress reaction of the humerus in a professional cricketer

A symptomatic bone stress reaction is an early pathological feature, which can lead to stress fractures. It typically affects bones of the lower limbs in response to unaccustomed disproportional compressive loading. Professional sportspeople are susceptible to both bone stress reaction and stress fractures, where training regimes and competition predispose to overuse injuries. We discuss a unique case of a professional cricketer developing pain in the throwing arm due to bone stress reaction in the distal humerus, as confirmed on MRI. Modification of the patient's training regime, presented in this case, facilitated complete recovery within 6 weeks. The positive response to modified training suggests a biomechanical origin of the pain. This case illustrates that tensile stress associated with throwing activities can result in a symptomatic bone stress reaction of the humerus in elite cricketers.

Artistic Gymnastics Injuries; Epidemiology, Evaluation, and Treatment

Artistic gymnastics is a physically demanding sport that requires flexibility, agility, and extreme upper and lower body strength. The specific biomechanics of the sport leads to a unique injury profile. Gymnastic skills require intense upper body weight-bearing, placing unusual forces across the upper extremity joints and predisposing them to injury. In addition, the required body control during air aerobatics (tumbling, twisting, flipping) necessitates precise landing techniques to avoid spine and lower extremity injury. Common gymnastic injuries include those of the spine and upper extremity such as spondylolysis, shoulder instability, ulnar collateral ligament injuries, capitellar osteochondritis dissecans, and several wrist pathologies. Understanding the injury etiology, prevention, and treatment protocols is important for a successful recovery and return to sport.

Low-Intensity Pulsed Ultrasound for Early-Stage Lumbar Spondylolysis in Young Athletes

OBJECTIVE

To examine the effect of low-intensity pulsed ultrasound (LIPUS) on early-stage spondylolysis in young athletes.

DESIGN

Case-control study.

SETTING

A single outpatient orthopedic and sports clinic.

PATIENTS

A total of 82 young athletes (80 boys and 2 girls; mean age, 14.8 years; range, 10-18 years) with early-stage lumbar spondylolysis were enrolled in this study. All patients were examined by plain radiography and magnetic resonance imaging.

INTERVENTIONS

Patients received either standard conservative treatment combined with LIPUS (n = 35) or without LIPUS (n = 47), according to the sequence of admission. The standard conservative treatment included thoracolumbosacral brace, sports modification, and therapeutic exercise.

MAIN OUTCOME MEASURES

The time required to return to previous sports activities was analyzed by using Kaplan-Meier methods with the log-rank test.

RESULTS

The baseline parameters of both groups were not significantly different. The median time to return to previous sports activities was 61 days [95% confidence interval (CI): 58-69 days] in the group treated with LIPUS, which was significantly shorter than that of the group treated without LIPUS (167 days, 95% CI: 135-263 days; P < 0.01).

CONCLUSIONS

These results suggest that LIPUS combined with conservative treatment for early-stage lumbar spondylolysis in young athletes could be a useful therapy for quick return to playing sports.

Return to play after conservative and surgical treatment in athletes with spondylolysis: A systematic review

PURPOSE

Analyze the return to sports rate and timing after conservative and surgical treatment in athletes with spondylolysis.

METHODS

Comprehensive search using Pubmed, Cochrane Library and SPORTDiscus databases to identify English language studies that assessed the return to sports after conservative or surgical treatment of symptomatic spondylolysis in athletes. The main outcome of interest was the return to sports rate and timing, as well as, the follow-up clinical and functional outcomes.

RESULTS

A total of 14 trials (592 participants) were included. Eight and seven studies reported the outcomes of conservative and surgical approach, respectively. A total of 92% (n = 492) and 88% (n = 100) of athletes return to sports at any level, and 89% (n = 185) and 81% (n = 103) returned to their pre-injury level of sports for conservative and surgical approaches, respectively. The time to return to sports was 4.6 and 6.8 months for conservative and surgical approaches, respectively.

CONCLUSIONS

Conservative management (bracing, sports modification and physiotherapy) of athletes with spondylolysis show excellent return to sports rates at any level and at the pre-injury level at a mean of 4.6 months. Those who fail the conservative treatment can be successfully managed with surgical treatment with a high rate of return to sports at 6.8 months.

LEVEL OF EVIDENCE

Level IV, Systematic review of level IV studies.