Spondylolysis and spondylolisthesis in the athlete

Long-Term Risk of Adjacent-Segment Disease in Isthmic Spondylolisthesis Treated with Posterior Interbody Fusion

OBJECTIVE

Posterior interbody fusion can be associated with adjacent-segment disease (ASD) some years after surgery. The aim of this study is to confirm the rate of ASD in isthmic spondylolisthesis treated by posterior fusion.

METHODS

The records of patients treated by posterior lumbar fusion between January 2014 and June 2022 were collected. Inclusion criteria encompassed adults diagnosed with isthmic spondylolisthesis and available preoperative, postoperative, and follow-up radiologic images.

RESULTS

Of the 140 patients included in the study, the majority were female (53.6%) with a mean age of 48.5 years. In 111 (79.3%) patients the spondylolisthesis was located at L5-S1; in 20 (14.3%) patients at L4-L5; 5 (3.6%) cases presented the defect at L4-L5-S1, and in 4 (2.8%) cases at L3-L4. In 75 (53.6%) patients, the listhesis was classified as grade I (Meyerding); in 50 (35.7%) cases as grade II; in 12 (8.6%) cases as grade III; and in 3 (2.1%) cases as grade IV. The average follow-up of this study was 67 (10-111) months. Two cases (1.43%, 95% confidence interval 0.17%-5.07%) of ASD were observed. Evaluations of clinical symptoms revealed a notable reduction in the average Numeric Rating Scale score from 8 to 1.9 at the last follow-up. Postoperative pelvic incidence-lumbar lordosis mismatch <10 correlating with a favorable outcome (Numerical Rating Scale ≤3).

CONCLUSIONS

This study confirms data already present in the literature regarding the low incidence of ASD in patients who underwent surgery for isthmic spondylolisthesis. The posterior approach seems to remain a safe and effective technique in these patients.

Case Report: Lumbar spondylolisthesis with unilateral pedicle cleft and contralateral spondylolysis: a report of two cases and literature review

Background

The causes of pedicle cleft include congenital dysplasia and stress fractures, both of which are rare conditions. Secondary lumbar spondylolisthesis with combined unilateral pedicle cleft and contralateral spondylolysis is extremely rare and can be easily misdiagnosed. We report two cases with these conditions from different causes and discuss the diagnostic and therapeutic features in the context of the literature review.

Case description

Case 1 was a 58-year-old female with a stress fracture change at the left L5 pedicle. Case 2 was a 47-year-old female with a pedicle cleft due to hypoplasia of the left L5 pedicle. Both patients had a combined contralateral spondylolysis and Meyerding grade one lumbar spondylolisthesis, while neither had a clear history of lumbar trauma. After initial conservative treatments failed, both patients underwent a single-segment posterior lumbar interbody fusion with bilateral pedicle screw fixation. Both patients were followed up for more than 1 year postoperatively with clinical symptom relief and bony fusion at the pedicle cleft suggested by a CT scan.

Conclusion

Lumbar spondylolisthesis with unilateral pedicle cleft and contralateral spondylolysis is rarely reported and can be clinically misdiagnosed as simple spondylolisthesis with bilateral spondylolysis. There is no widely accepted surgical option for patients for whom conservative treatment has failed. Our experience suggests that good clinical results may be achieved by single-segment posterior interbody fusion and bilateral pedicle screw fixation. Precise screw placement into the deficient pedicle and sufficient exiting nerve decompression are prerequisites for the success of this surgical option.

Percutaneous Direct Pars Repair in Young Athletes

BACKGROUND

Lumbar pars defects are common in adolescent athletes and are often due to recurrent axial loading and traumatic stressors.

OBJECTIVE

To present an updated case series of young athletes who underwent percutaneous direct pars repair after failure of conservative management.

METHODS

A single-center, nonrandomized, retrospective observation study of athletes who were referred for minimally invasive direct pars repair after failure of at least 6 months of conservative management was performed. Summary demographic information, clinical features of presentation, perioperative and intraoperative radiographic imaging, and visual analog scale back pain scores were collected and analyzed.

RESULTS

A total of 21 patients were included (mean age [± SD] 17.47 ± 3.02 years, range 14-25 years), 6 of whom were female (29%). All patients presented with bilateral pars fractures, with L5 being the most frequent level involved (n = 13). The average follow-up time was 31.52 ± 9.38 months (range 3-110 months). The visual analog scale score for back pain was significantly reduced from 7.62 ± 1.83 preoperatively to 0.28 ± 0.56 at the final postoperative examination (P < .01). Fusion was noted in 20 of the 21 patients on final follow-up (95%).

CONCLUSION

Percutaneous direct pars repair is a safe and effective means in treating young adolescents who have failed conservative management. The advantages included minimized muscle and soft tissue dissection, reduced blood loss, and early mobilization and recovery. In young athletes who desire return to high-level physical activity, this surgical technique is of particular benefit and should be considered in this patient population.

Spondylolysis

Spondylolysis is a bony defect of the pars interarticularis and most often results from repetitive stress. Although spondylolysis is usually asymptomatic, symptomatic spondylolysis is the most common cause of identifiable back pain in children and adolescent athletes. A thorough history and physical exam, as well as appropriate imaging studies are helpful in diagnosis. General first-ine therapy for spondylolysis is conservative and consists of rest from sports, core strengthening, as well as spinal bracing. Patients who have failed conservative therapy may consider surgical repair. This article aims to review the epidemiology, pathophysiology, presentation, and treatment options of spondylolysis.

Use of Recombinant Human Bone Morphogenetic Protein-2 With Iliac Crest Bone Graft Instead of Iliac Crest Bone Graft Alone in Lumbar Spondylolysis

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to evaluate the clinical and radiographic effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) in pars repair of lumbar spondylolysis.

SUMMARY OF BACKGROUND DATA

BMP-2 is a growth factor that plays a role in the formation of bone and promotes bone healing. However, few studies of using rhBMP-2 in pars repair have been reported.

METHODS

Direct pars repair and pedicle screw fixation was performed, which were added with 1 mg of rhBMP-2 and iliac crest bone graft in the study group (rhBMP-2 group, n=32) and iliac crest bone graft alone in the autograft group (n=36). Patients completed the visual analog scale and the Oswestry Disability Index preoperation, 3, 6, and 12 months after the operation. Computed tomography scans with axial and sagittal reconstructions were performed at 6, 9, 12, 18, and 24 months postoperatively.

RESULTS

Baseline demographic data showed no significant difference between 2 groups. There were significant differences for the Oswestry Disability Index score at 3 and 6 months postoperatively, which were higher in the autograft group. There was no significant difference between the groups with respect to the overall union status. As for union speed, the trabecular bone appeared earlier and union rates were higher in rhBMP-2 group than in the autograft group at 9, and 12 months postoperatively. No complications were identified in either group. One case in the rhBMP-2 group and 2 cases in the autograft group underwent revision surgery.

CONCLUSION

Compared with iliac crest bone graft alone, the use of rhBMP-2 can accelerate fusion in pars repair for young patients with spondylolysis. The union rates were significantly different at 9 and 12 months after surgery. This study showed no clinical difference when adding rhBMP-2 compared with iliac crest bone graft alone.

Physical characteristics of patients with symptomatic lumbar spondylolysis who have recurrent low back pain after returning to sports

INTRODUCTION

To determine the physical characteristics of patients with symptomatic lumbar spondylolysis (LS) who have recurrent low back pain after returning to sports.

METHOD

Fifty-three adolescent patients with symptomatic LS participated in this study. Patients with symptomatic LS were assessed for flexibility, trunk muscle strength, and Functional Movement Screen (FMS) score, and then divided into two groups according to the degree of pain experienced one month after returning to sport.

RESULTS

Twenty-four patients returned to their pre-injury sports level without pain (excellent group), while the remaining 29 patients had pain and decreased activity level during sports (pain group). The excellent group had a significantly higher shoulder mobility score on the FMS than the pain group, and the effect size was larger. However, there were no significant differences in body flexibility, muscle tightness, trunk muscle strength, or other FMS items.

DISCUSSION

The most important finding of this study is that patients with LS who have recurrent low back pain after returning to sports are characterized by poor functional upper body movement.

CONCLUSIONS

Because upper body functional movement pattern may be an important factor in the management of patients with symptomatic LS, preventive rehabilitation to enhance upper body mobility and motor control should be considered for these patients.

Lumbosacral Spondylolysis and Spondylolisthesis

Repetitive stress on the lumbosacral spine during sporting activity places the athletic patient at risk of developing symptomatic pars defect. Clinical history, physical examination, and diagnostic imaging are important to distinguish spondylolysis from other causes of lower back pain. Early pars stress reaction can be identified with advanced imaging, before the development of cortical fracture or vertebral slip progression to spondylolisthesis. Conservative management is first-line for low-grade injury with surgical intervention indicated for refractory symptoms, severe spondylolisthesis, or considerable neurologic deficit. Prompt diagnosis and management of spondylolysis leads to good outcomes and return to competition for most athletes.

Minimally Invasive Approach Toward Percutaneous Direct Pars Repair: An Observational Study

BACKGROUND

Spondylolysis refers to a defect of the vertebral pars interarticularis. Percutaneous direct pars repair using a minimally invasive technique was performed in a group of young patients to maintain their spinal segment movement and to restore their normal anatomy. The aim of this study was to present the clinical, functional, and radiologic outcomes of pars defects that were repaired percutaneously via the minimally invasive technique.

METHODS

This was a single-center, nonrandomized, prospective study of the demographic, clinical, functional, and radiographic outcomes of 18 patients (age range, 18-32 years). The visual analog scale for back pain and the Oswestry Disability Index were used to evaluate the functional outcomes. The Macnab criteria were applied to evaluate patient satisfaction after surgery.

RESULTS

All patients were admitted with bilateral pars fracture at the level of L4 (n = 4) or L5 (n = 14). The average duration of clinical follow-up was 16.04 months (range, 12-28 months). With reference to the Macnab criteria, 17 patients (94%) showed perfect or good outcomes. Fusion or bridging of bones was observed on computed tomography in 14 patients (77%) at the last radiological examination.

CONCLUSIONS

Minimally invasive surgery to treat symptomatic spondylolysis is a safe option that minimizes muscle and soft tissue dissection. In this study, good clinical and functional outcomes were achieved in young patients with low complications and high fusion rates using completely percutaneous treatment.

Back Pain in Children and Adolescents

Back pain has long been considered an uncommon complaint in the pediatric population. When present, teaching had been that pediatric back pain almost always has a diagnosable cause, many of which are progressive and potentially debilitating. Recent evidence has suggested that pediatric back pain is not only more common than once thought but also, within certain populations, benign and idiopathic. This, in turn, places an increasing amount of pressure on pediatricians to accurately assess and manage their patients presenting with complaints of back pain. The aim of this article is to serve as a review of the current literature on pediatric back pain. The article reviews the epidemiology, basic anatomy, and important elements of a history and examination, which should be considered when a child presents complaining of back pain. Last, a common differential diagnosis with evaluation and management is also given to help guide pediatricians through their medical decision making.

Low back pain and golf: A review of biomechanical risk factors

Golf is an international sport played by a variety of age groups and fitness levels, and although golf has a low to moderate aerobic intensity level, injuries are common among professional and amateur golfers. High amounts of force experienced during the golf swing can lead to injury when golfers lack appropriate strength or technique with the lower back most commonly injured. Research has indicated that trunk muscle activation, hip strength and mobility, and pelvis and trunk rotation are associated with low back pain (LBP). Based on anecdotal evidence, golf practitioners specifically address issues in weight shift, lumbar positioning, and pelvis sequencing for golfers with LBP. This review aims to elucidate the effects of proper and improper golf swing technique on LBP and to help golf practitioners understand how to approach the alleviation of LBP in their clientele.

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.

Quantitative analysis of paraspinal muscle atrophy after oblique lateral interbody fusion alone vs. combined with percutaneous pedicle screw fixation in patients with spondylolisthesis

BACKGROUND

There is no available literature for comparison on muscle atrophy between the "stand-alone" oblique lateral interbody fusion (OLIF) and regular OLIF (i.e., combined with percutaneous pedicle screws fixation (PPSF) in patients with spondylolisthesis). This study aimed to identify changes in back muscle atrophy between the two surgeries.

METHODS

This was a retrospective cohort study of patients who underwent OLIF or OLIF+PPSF at Beijing Jishuitan Hospital and Shanghai ChangZheng Hospital between 07/2014 and 10/2017. Computed tomography (CT) was used to measure functional cross-sectional area (FCSA) and fat infiltration percentage (FIP) of the multifidus and erector spinae before and 24 months after surgery.

RESULT

There were no differences in FCSA and FIP between OLIF (n = 32) and OLIF+PPSF (n = 41) groups before surgery. In the OLIF group, the multifidus and erector spinae FCSA and FIP did not change at 24 months (FCSA: multifidus: from 8.59 ± 1.76 to 9.39 ± 1.74 cm2, P = 0.072; erector spinae: from 13.32 ± 1.59 to 13.55 ± 1.31 cm2, P = 0.533) (FIP: multifidus: from 15.91 ± 5.30% to 14.38 ± 3.21%, P = 0.721; erector spinae: from 11.63 ± 3.05% to 11.22 ± 3.12%, P = 0.578). In the OLIF+PPSF group, the multifidus and erector spinae FCSA decreased (multifidus: from 7.72 ± 2.69 to 5.67 ± 1.71 cm2, P < 0.001; erector spinae: from 12.60 ± 2.04 to 10.15 ± 1.82 cm2, P < 0.001), while the FIP increased (multifidus: from 16.13 ± 7.01% to 49.38 ± 20.54%, P < 0.001; erector spinae: from 11.93 ± 3.22% to 22.60 ± 4.99%, P < 0.001). The differences of FCSA and FIP between the two groups at 24 months were significant (all P < 0.001). The patients in the standalone OLIF group had better VAS back pain, and JOA scores than the patients in the OLIF combined group (all P < 0.05) at 1 week and 3 months after surgery. There were two cases (4.9%) of adjacent segment degeneration in the OLIF combined group, while there was no case in the OLIF alone group.

CONCLUSIONS

Standalone OLIF had better clinical outcomes at 1 week and 3 months than OLIF+PPSF in patients with spondylolisthesis. OLIF may not result in paraspinal muscle atrophy at 24 months after surgery.

Is radiographic lumbar spondylolisthesis associated with occupational exposures? Findings from a nested case control study within the Wakayama spine study

Background

To explore the relationship between radiographic spondylolisthesis and occupational factors in a case-control study nested within the Wakayama Spine Study (WSS).

Methods

The WSS is a cross-sectional observational study amongst Japanese adults. All participants completed a lifetime occupational history and underwent X-rays of the lumbar spine (L1-S1) according to a pre-defined protocol. One trained surgeon graded the presence of a spondylolisthesis based upon ≥5% anterior or posterior slip at one or more levels. Cases, with lumbar spondylolisthesis, were compared with controls without, for their principal occupation and occupational exposures.

Results

In total, data were available for 722 adults (245 men and 477 women), mean age 70.1 (range 53–93) years. According to the pre-defined radiographic criteria, 117 were defined with spondylolisthesis (cases), leaving 605 controls. Cases were not significantly different from controls for age, gender, BMI, smoking or alcohol intake. However, cases were more than twice as likely to report occupational driving ≥4 h/day (OR 2.39, 95% CI 1.08–5.27) after adjustment for age, gender and BMI. Additionally, after stratification by age using 75 years as a cut-point, cases were more than 3-fold more likely to report having worked in the agricultural/ fishing industries (OR 3.47, 95% CI 1.29–9.29) among those aged < 75 years. A reduced risk of being a case was associated with climbing slopes/steps and walking.

Conclusions

A history of occupational driving and working in the agricultural/fishing industry were associated with radiographic spondylolisthesis in this cross-sectional population study. This finding requires further evaluation in longitudinal studies.

Modern Medical Consequences of the Ancient Evolution of a Long, Flexible Lumbar Spine

Modern human bipedality is unique and requires lumbar lordosis, whereas chimpanzees, our closest relatives, have short lumbar spines rendering them incapable of lordosis. To facilitate lordosis, humans have longer lumbar spines, greater lumbosacral angle, dorsally wedged lumbar vertebral bodies, and lumbar zygapophyseal joints with both increasingly coronal orientation and further caudal interfacet distances. These features limit modern lower lumbar spine and lumbosacral joint ailments, albeit imperfectly. The more coronal zygapophyseal orientation limits spondylolisthesis, while increasing interfacet distance may limit spondylolysis. Common back pain, particularly in people who are obese or pregnant, may result from increased lumbar lordosis, causing additional mass transfer through the zygapophyseal joints rather than vertebral bodies. Reduction in lumbar lordosis, such as in flatback syndrome from decreased lumbosacral angle, can also cause back pain. Human lumbar lordosis is necessary for placing the trunk atop the pelvis and presents a balancing act not required of our closest primate relatives.

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.

The effectiveness and safety of nonsurgical integrative interventions for symptomatic lumbar spinal spondylolisthesis: A randomized controlled multinational, multicenter trial protocol

BACKGROUND

Surgery is generally accepted as the main therapeutic option for symptomatic lumbar spondylolisthesis. However, new nonsurgical therapeutic options need to be explored for this population.

OBJECTIVES

The objective of this study is to assess the effectiveness and safety of a 5-week Mokhuri treatment program compared with conventional nonsurgical treatments for symptomatic lumbar spondylolisthesis.

METHODS

This is a study protocol for a multinational, multicenter clinical randomized controlled trial comparing the effectiveness and safety of 5 weeks of nonsurgical integrative treatments (a Mokhuri treatment program consisting of Chuna, acupuncture, and patient education) with nonsurgical conventional treatments (drugs for pain relief, epidural steroid injections, and physical therapy). Clinical outcomes including visual analogue scale (VAS) scores ranging from 0 to 100 for low back pain and leg pain, EQ-5D scores, Oswestry disability index (ODI) scores, Roland-Morris Disability Questionnaire (RMDQ) scores, Zurich Claudication Questionnaire (ZCQ) scores, walking duration and distance without leg pain, and a 5-minute treadmill test, and the ratio between the actual duration of participation and the originally scheduled duration in each group, the presence of any additional spondylolisthesis treatments, the types of concomitant treatments during the follow-up period, and adverse events (AEs) will be assessed at 7 weeks, 18 weeks, 30 weeks, 54 weeks, and 102 weeks after the end of the treatments.

CONCLUSION AND DISCUSSION

The results of this study will provide clinical evidence on nonsurgical integrative interventions for patients with symptomatic lumbar spondylolisthesis. CLINICAL TRIAL REGISTRY:: clinicaltrials.gov (NCT03107468).

Vertebral body bone mineral density in patients with lumbar spondylolysis: a quantitative CT study

PURPOSE

Spondylolysis is known to be a part of a disease process, which describes a defect in the pars interarticularis of vertebra. We aimed to use quantitative computed tomography (QCT) to measure vertebral body bone mineral density (BMD) in patients with lumbar spondylolysis and compare it with readings in controls.

METHODS

Forty symptomatic patients with lumbar spondylolysis aged 18-52 years and 40 matched controls of same sex and approximate age (±2 years) were included in the study. Measurements of BMD were performed by QCT analysis for each vertebral body from T12 to L5 and mean BMD was calculated for each case.

RESULTS

Of 40 patients, 22 (55%) demonstrated L5 spondylolysis, 14 (35%) L4 spondylolysis, three (7.5%) L3 spondylolysis, and one (2.5%) L2 spondylolysis. Spondylolisthesis was found in 29 patients (73%). Patients with spondylolisthesis were significantly older than patients without spondylolisthesis (42±6.9 vs. 37.2±5.4, P = 0.024). Mean BMD value of the patient group was significantly lower than that of the controls (105±24 mg/cm³ vs. 118.7±25.6 mg/cm³, P = 0.015). Subgroup analysis of 19 patients and 19 controls under the age of 40 revealed that the mean BMD value of the patients was significantly lower than that of the controls in the younger age group as well (108.7±23.5 mg/cm³ vs. 130±25.8 mg/cm³, P = 0.009).

CONCLUSION

This study demonstrated that patients with spondylolysis had significantly lower mean vertebral body BMD compared with controls.

Minimally invasive direct pars repair with cannulated screws and recombinant human bone morphogenetic protein: case series and review of the literature

OBJECTIVE

The objective of this study was to describe the use of a minimally invasive surgical treatment of lumbar spondylolysis in athletes by a fluoroscopically guided direct pars screw placement with recombinant human bone morphogenetic protein–2 (rhBMP-2) and to report on clinical and radiographic outcomes.

METHODS

A retrospective review was conducted of all patients treated surgically for lumbar spondylolysis via a minimally invasive direct pars repair with cannulated screws. Demographic information, clinical features of presentation, perioperative and intraoperative radiographic imaging, and postoperative data were collected. A 1-cm midline incision was performed for the placement of bilateral pars screws utilizing biplanar fluoroscopy, followed by placement of a fully threaded 4.0-mm-diameter titanium cannulated screw. A tubular table-mounted retractor was utilized for direct pars fracture visualization and debridement through a separate incision. The now-visualized pars fracture could then be decorticated, with care taken not to damage the titanium screw when using a high-speed drill. Local bone obtained from the curettage was then placed in the defect with 1.05 mg rhBMP-2 divided equally between the bilateral pars defects.

RESULTS

Nine patients were identified (mean age 17.7 ± 3.42 years, range 14–25 years; 6 male and 3 female). All patients had bilateral pars fractures of L-4 (n = 4) or L-5 (n = 5). The mean duration of preoperative symptoms was 17.22 ± 13.2 months (range 9–48 months). The mean operative duration was 189 ± 29 minutes (range 151–228 minutes). The mean intraoperative blood loss was 17.5 ± 10 ml (range 10–30 ml). Radiographic follow-up was available in all cases; the mean length of time from surgery to the most recent imaging study was 30.8 ± 23.3 months (range 3–59 months). The mean hospital length of stay was 1.13 ± 0.35 days (range 1–2 days). There were no intraoperative complications.

CONCLUSIONS

Lumbar spondylolysis treatment with a minimally invasive direct pars repair is a safe and technically feasible option that minimizes muscle and soft-tissue dissection, which may particularly benefit adolescent patients with a desire to return to a high level of physical activity.

A minimal soft tissue damage approach of spondylolysis repair in athletes: preliminary report

Purpose and hypothesis

Both spondylolysis and spondylolisthesis come in second place in the causes of pain among athletes. Treatment options include both conservative management and different operative methods. Athletes and adolescents are groups where the priority is to protect tissues from perioperative damage.

Objective

We present our modification of the Buck’s, direct pars repair method, which we believe offers maximum protection of tissues. We used the modified surgical method in young, competitive athletes, in whom non-surgical treatment was not effective.

Method

Eight pars defects in five patients were treated using suggested method. All of them were young males (aged between 13 and 18 years), who practice soccer professionally. We use modified method of direct repair pars through the cannulated screw fixation, first proposed by Buck. Preoperative preparation consists of proper analysis of computer tomography images in multiplanar reconstruction mode: measuring screw length, measurement of inclination angle of the optimal screw trajectory in the frontal and sagittal plane. During the operation, the wire proper direction is performed by usage of the predetermined angles. Starting point for guide wire was also changed to the lower end of the facet. The fusion takes place with a screw of 3 mm diameter. After the operation patient need to use thoracolumbar spinal orthosis as a primary immobilization for 6 weeks and appropriate rehabilitation for another 6 weeks. We used these methods in eight pars fixations.

Results

All of the patients were painless in first week after surgery. All of them underwent total rehabilitation programme and returned to sport.

Conclusions

Direct pars repair using Buck’s method with proposed modification, including adequate radiographic preparation, the use of a thin cannulated screw and changing the point of screw entry, allows precise and safe screw placement, regardless of the size of the bone at the defect site.

Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence

The epidemiology of lumbar degenerative spondylolisthesis (DS) remains controversial. We performed a systematic review with the aim of gaining a better understanding of the prevalence of DS in the general population. The results showed that the prevalence of DS is very gender- and age-specific. Few women and men develop DS before they are 50 years old. After 50 years of age, both women and men begin to develop DS, with women having a faster rate of development than men. For elderly Chinese (≥ 65 years, mean age: 72.5 years), large population-based studies MsOS (Hong Kong, females: n = 2000) and MrOS (Hong Kong, males: n = 2000) showed DS prevalence was 25.0% in women and 19.1% in men. The female:male (F:M) prevalence ratio was 1.3:1. The published data for MsOS (USA) and MrOS (USA) studies seem to show that elderly Caucasian Americans have a higher DS prevalence, being approximately 60-70% higher than elderly Chinese; however, the F:M prevalence ratio was similar to the elderly Chinese population. Patient data showed that female patients more often received surgical treatment than male and preliminary data showed the ratio of female to male patients receiving surgical treatment did not differ between Northeast Asians (Chinese, Japanese, and Korean), Europeans, and American Caucasians, being around 2:1 in the elderly population. The existing data also suggest that menopause may be a contributing factor for the accelerated development of DS in postmenopausal women. The translational potential of this article: A better understanding of epidemiology of lumbar degenerative spondylolisthesis can support patient consultation and treatment planning.

Functional radiography in examination of spondylolisthesis

OBJECTIVE

Despite the predominant use of standing flexion-extension radiography for quantifying instability in isthmic and degenerative spondylolisthesis, other functional radio-graphic techniques have been presented in the literature.

CONCLUSION

The current evidence reported in the literature is insufficient to influence how the results of these other functional radiographic techniques should affect clinical management; however, it does raise doubts regarding the accuracy and reliability of standing flexion-extension radiography in this setting. Based on the currently available evidence and until randomized studies are performed to assess the efficacy of functional radiographic techniques in directing clinical decision making, positioning schemes other than traditional standing flexion-extension may be considered as options in the evaluation of patients with symptomatic isthmic and degenerative spondylolisthesis in which standard flexion-extension radiographs fail to show pathologic instability.

A review of the value of MRI signs in low back pain

Low back pain is a common symptom that can lead to disability and major socio-professional repercussions. Despite advances in imaging, the etiology of the pain often remains unknown. Morphological changes related to normal ageing of the disc appear on MR imaging without any symptoms. The potential impact of changes seen on imaging, especially MRI, also warrants discussion. The purpose of this work is to review the state-of-the-art of this subject, underlining relevant key features for routine radiological practice. We will first discuss anterior and posterior segments of the spine with a focus on anatomical, physiopathological and semiological findings. Secondly we will discuss the diagnostic value of each sign.

What is the optimum fusion technique for adult isthmic spondylolisthesis--PLIF or PLF? A long-term prospective cohort comparison study

STUDY DESIGN

Long-term prospective observational cohort study.

OBJECTIVE

The objective of the study was to compare the long-term functional outcomes of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) for the treatment of adult isthmic spondylolisthesis (IS).

SUMMARY OF BACKGROUND DATA

PLIF has the theoretical advantage of improving sagittal alignment and providing a larger, more consistent fusion mass in patients with IS compared with PLF. Studies to date though have not shown a clinical difference, with follow-up of 2 years.

METHODS

An prospective cohort study was performed of a single surgeon's patients with IS treated surgically over a 10-year period. Average follow-up was 7 years and 10 months. Preoperative patient characteristics between the 2 groups were not significantly different. The return rate of the long-term questionnaires was 83%. Outcome measures were the Roland Morris Disability Questionnaire (RMDQ), Low Back Outcome Score (LBOS), Short Form (SF)-12v2, and SF-6D R2.

RESULTS

PLIF provided better short-term and long-term results than PLF. The PLIF group had significantly better LBOS scores in the long term, and nonsignificantly better RMDQ scores. As measured by the RMDQ Minimal Clinically Important Difference set at 4 and 8, the LBOS Minimal Clinically Important Difference set at 7.5 points and by SF-12v2 Physical Component Score, PLIF patients performed better than PLF patients. When analyzing single-level fusions alone, the difference is more pronounced, with Physical Component Score, Mental Component Scores, and SF-6D R2 all being significantly better in the PLIF group rather than the PLF group.

CONCLUSIONS

This study strongly supports the use of PLIF to obtain equivalent or superior clinical outcomes compared with PLF for spinal fusion for lumbar IS. Although there are considerable issues when commenting on the results of observational studies, the results of this study are the first to report long-term follow-up beyond 2 years, and further larger long-term randomized studies are suggested.

A treatment-based classification approach to examination and intervention of lumbar disorders

CONTEXT

Low back injuries are a common occurrence in athletes and often result in missed competition and practice time. The examination of athletes with low back pain commonly involves diagnostic imaging, which rarely guides the clinician in selecting the appropriate interventions.

DATA ACQUISITION

All years of PubMed, CINAHL, PEDro, and SPORTDiscus were searched in December 2010. Keywords included treatment based classification and lumbar with the following terms: rehabilitation, treatment, athlete, low back pain, sports, and outcomes.

RESULTS

A treatment-based classification approach is preferred for the management of the athlete with low back pain. The treatment-based classification approach involves 3 steps. First is to screen the patient for potentially serious conditions that are not appropriate for conservative management. Second is staging the athlete (based on current disability ratings and ability to perform functional activities). Finally, treatment interventions are selected on the basis of the athlete's signs and symptoms.

CONCLUSION

The treatment-based classification scheme provides the clinician with a reliable algorithm for matching an athlete's symptom presentation to the optimal intervention, potentially reducing participation loss. Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards.

Return to sports activity by athletes after treatment of spondylolysis

AIM

To clarify the efficacy of conservative and surgical treatment of spondylolysis in athletes.

METHODS

PubMed was used to perform a search of the literature for studies published during the period from 1990 to 2009 that reported data on the outcome of conservative or surgical treatment of spondylolysis in athletes. The articles were examined for data on the percentage of athletes who returned to sports activities and the interval between the start of treatment and their return.

RESULTS

Five studies were identified. Two studies were concerned with conservative treatment and the other three with surgical treatment (wire fixation or screw fixation with bone graft). The percentages of athletes who returned to sports activities ranged from 80.0% to 89.3% and from 81.9% to 100%, respectively, and the intervals until their return ranged from 5.4 to 5.5 mo and from 7 to 12 mo, respectively.

CONCLUSION

The percentages of athletes who returned to sports activities after conservative and surgical treatment appeared to be satisfactory, but the interval until their return to sports activities was longer after surgery than after conservative treatment.

Association of modic changes, Schmorl's nodes, spondylolytic defects, high-intensity zone lesions, disc herniations, and radial tears with low back symptom severity among young Finnish adults

STUDY DESIGN

A cross-sectional magnetic resonance imaging (MRI) study.

OBJECTIVE

We investigated the association among Modic changes, Schmorl's nodes, spondylolytic defects, high-intensity zone lesions, radial tears, herniations, and low back symptom severity.

SUMMARY OF BACKGROUND DATA

Disc degeneration is associated with low back pain in early adulthood, but the associations between other MRI findings and low back pain are not well known.

METHODS

Questionnaire data and MRI scans (1.5-T) were available for 554 subjects derived from a birth cohort at 21 years of age. Data on low back pain and back-related functional limitations at 18, 19, and 21 years of age were used for clustering of subjects, using latent class analysis. We used logistic regression with adjustment for the degree of disc degeneration to evaluate the associations between specific imaging findings and low back symptom severity.

RESULTS

The prevalence of herniations was 20%, Schmorl's nodes 17%, radial tears 9.9%, high-intensity zone lesions 3.2%, spondylolytic defects 5.8%, and Modic changes 0.7%. Latent class analysis produced 5 clusters: "Always Painful" (n = 65) meant painful at all time points and "Recent Onset Pain" (n = 56) meant increasing symptom severity, whereas subjects in the "Moderately Painful" (n = 73), "Minor Pain" (n = 193), and "No Pain" (n = 167) clusters had fewer symptoms. Compared with the "No Pain" cluster, Schmorl's nodes were more likely to occur in the "Always Painful" cluster (P = 0.017) and herniations in the 3 most painful clusters (P < 0.001). Herniations were associated with low back symptom severity (odds ratio, 2.5; 95% confidence interval, 1.4-4.4). Schmorl's nodes and radial tears were associated with symptoms in crude analyses only, whereas high-intensity zone lesions and spondylolytic defects occurred in similar frequencies in all clusters.

CONCLUSION

Herniations were most likely in the subjects with recent onset or persistent (3-yr period) low back symptoms, although they were also detected in subjects with no symptoms. The clinical relevance of herniations on MRI remains to be evaluated in the context of symptoms.

Spontaneous reduction of spondylolisthesis during growth: a case report

Isthmic spondylolisthesis is a common cause of low back pain in children. It is associated with a defect in the pars interarticularis of the vertebra. The treatment depends on the clinical course and degree of spondylolisthesis. Low-grade isthmic spondylolisthesis usually shows a benign course without significant progression and therefore, conservative treatment is advised. Although isthmic pars defect can heal, initial existing degree of slippage persists. A complete reversion of deformity was never described yet. We present the case of a 7½-year-old girl with symptomatic grade 2 isthmic spondylolisthesis according to the Meyerding classification. Without any specific therapy, there was a radiologically documented near total reversion of slippage and total relief of clinical symptoms during 8 years of follow-up. Computed tomography scan after this period showed persisting pars interarticularis defect without signs of healing. This case report indicates that during growth, spontaneous reversion of vertebral slip in isthmic spondylolisthesis can occur, even without healing of the pars defect.

Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report

OBJECTIVE

This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic.

CLINICAL FEATURES

The 43-year-old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis.

INTERVENTION AND OUTCOME

A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire.

CONCLUSIONS

Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

Effect of hyperconcavity of the lumbar vertebral endplates on the playing careers of professional american football linemen

BACKGROUND

Hyperconcavity of the lumbar spine has been found in a disproportionate percentage of college football lineman evaluated at the National Football League (NFL) Combine compared with age-matched controls.

HYPOTHESIS

College football linemen with hyperconcavity of the lumbar spine are more likely to play in the NFL and to have a longer career in professional football.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Ninety three linemen from the 1992 and 1993 NFL Combines with hyperconcavity of the lumbar spine were compared with 191 linemen from the same combines without these changes in the lumbar spine. The percentage of athletes who played at least 1 game for an NFL team and the average length of career was calculated for both groups. In addition, the length of career for players with these changes was compared with those of matched controls based on other injuries and surgeries, year drafted, and round drafted.

RESULTS

There was no difference in the likelihood of playing professional football between linemen with lumbar spine changes (54 of 93 [58%]) and those without (101 of 191 [53%]) (P = .41). There was no significant difference between the 2 groups in length of career in terms of years played, games played, or games started.

CONCLUSION

Hyperconcavity of the lumbar spine does not appear to have any effect on the potential professional American football careers of college football linemen entering the NFL. Endplate changes on radiographs are not a significant screening tool for elite American football linemen. Further study of larger populations is needed to definitively answer whether these adaptive changes in the lumbar spine have any clinical relevance to these athletes.

The value of SPECT in the detection of stress injury to the pars interarticularis in patients with low back pain

The medical cost associated with back pain in the United States is considerable and growing. Although the differential diagnosis of back pain is broad, epidemiological studies suggest a correlation between adult and adolescent complaints. Injury of the pars interarticularis is one of the most common identifiable causes of ongoing low back pain in adolescent athletes. It constitutes a spectrum of disease ranging from bone stress to spondylolysis and spondylolisthesis. Bone stress may be the earliest sign of disease. Repetitive bone stress causes bone remodeling and may result in spondylolysis, a non-displaced fracture of the pars interarticularis. A fracture of the pars interarticularis may ultimately become unstable leading to spondylolisthesis. Results in the literature support the use of bone scintigraphy to diagnose bone stress in patients with suspected spondylolysis. Single photon emission computed tomography (SPECT) provides more contrast than planar bone scintigraphy, increases the sensitivity and improves anatomic localization of skeletal lesions without exposing the patient to additional radiation. It also provides an opportunity for better correlation with other imaging modalities, when necessary. As such, the addition of SPECT to standard planar bone scintigraphy can result in a more accurate diagnosis and a better chance for efficient patient care. It is our expectation that by improving our ability to correctly diagnose bone stress in patients with suspected injury of the posterior elements, the long-term cost of managing this condition will be lowered.

Predictive value of prior injury on career in professional American football is affected by player position

BACKGROUND

The National Football League holds an annual combine where individual teams evaluate college football players The abstract goes here and covers two columns. likely to be drafted for physical skills, review players' medical history and imaging studies, and perform a physical examination.

PURPOSE

The purpose of this study was to test the effect of specific diagnoses and surgical procedures on the likelihood of playing and length of career in the league by position.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A database for all players reviewed at the annual National Football League Combine by the medical staff of 1 National Football League team from 1987 to 2000 was created, including each player's orthopaedic rating, diagnoses, surgical procedures, number of games played, and number of seasons played in the National Football League. Athletes were grouped by position as follows: offensive backfield, offensive receiver, offensive line, quarterback, tight end, defensive line, defensive secondary, linebacker, and kicker. The percentage of athletes who played in the National Football League was calculated by position for each specific diagnosis and surgery.

RESULTS

The effect of injury on the likelihood of playing in the league varied by position. Anterior cruciate ligament injury significantly lowered the likelihood of playing in the league for defensive linemen (P = .03) and linebackers (P = .04). Meniscal injury significantly reduced the probability of playing (P < .05) and length of career (P = .002) for athletes in the defensive secondary. Shoulder instability had a significant effect on playing in the league for offensive (P = .03) and defensive linemen (P = .02), and shortened the length of career for defensive linemen (P = .016). Spondylolisthesis did not significantly reduce the chance of playing in the league for any position, while a history of spondylolysis had a significant effect for running backs (P = .01). Miscellaneous injuries (eg. acromioclavicular joint, knee medial collateral ligament, carpal fractures) had isolated position-specific effects.

CONCLUSION

The significant injuries and diagnoses appear congruent with the position-specific demands placed on the athletes. This information is useful to physicians and athletic trainers caring for college football athletes as well as those assessing these athletes at the National Football League Combine.