Spondylolysis Flashcards
What is spondylolsis
unilateral or bilateral defect in the region of the pars interarticularis, (isthmus or bone bridge between the inferior and superior articular surfaces of a single vertebra) is most commonly the result of repetitive trauma to the growing immature skeleton of a genetically susceptible individual.
Prevalence
The prevalence of this condition is 4% by age 6 and 6% by age 14.
Symptoms of spondylolysis
Spondylolysis usually is asymptomatic, but approximately 10% of affected individuals present with symptoms including insidious onset, low back pain that is exacerbated with activity or lumbar hyperextension, and may or may not be associated with a radicular component. This activity outlines the evaluation and treatment of spondylolysis and highlights the role of the interprofessional team in managing patients with this condition.
Spondylolysis mostly remains asymptomatic, but approximately 10% of affected individuals manifest symptoms constituting of insidious onset, recurrent axial low back pain that increases with activity, is exacerbated by lumbar hyperextension, and may or may not be associated with a radicular component. The pain can range from mild to severe in intensity and is described as a dull, aching pain in the lower back, buttocks, and posterior thigh regions. If neurologic symptoms/signs are present, it is likely secondary to spondylolysis with spondylolisthesis or associated degenerative processes resulting in narrowing of the neuroforamina and the spinal nerve impingements. Since spondylolysis most commonly affects L5 on S1, the corresponding dermatomal and myotomal pattern clinical manifestations usually occur. It is important to note that if the patient’s spondylolysis has progressed to spondylolisthesis and they are presenting with pain, the degree of pain does not correlate with the degree of slippage, and this presents a diagnostic challenge and explains why the condition is often advanced at the time of diagnosis.
The neurological examination would specifically show increased lumbar lordosis, tight hamstrings, reduced trunk range of motion (particularly with extension), tenderness to palpation overlying the pars fracture site, a positive stork test (single leg hyperextension and rotation of the spine which reproduces the patient pain and is diagnostic of spondylolysis until proven otherwise), with the characteristic absence of any radiculopathy. Again, radicular symptoms can occur, but they are uncommon.
Etiology of Spondylolysis
Spondylolysis may be congenital or acquired. Although the exact pathogenesis remains unknown in all cases, it is most commonly secondary to a fatigue or stress fracture of the pars interarticularis that persists as a non-union. It typically develops in genetically susceptible children and adolescents with faulty biomechanics, and who also experience repetitive microtrauma on the pars interarticularis from repeated activities involving lumbar hyperextension with rotation.[3][4][5][6]
Spondylolysis Epidemiology
The prevalence of spondylolysis is 4% by age 6 and 6% by age 14 and thereafter remains constant throughout adulthood.
There is a genetic predisposition with an increased incidence seen in:
Males (male to female ratio of 2:1)
Alaskan Eskimo descendants
First-degree offspring of patients with the condition
Concurrent pathologies such as spina bifida occulta, Marfan syndrome, osteogenesis imperfecta, and osteopetrosis.
Adolescents involved in sports have a higher prevalence compared to those not involved in sports. The mean age of diagnosis is 15 years of age.
There is an increased incidence among participants of certain higher-risk sports which involve repeated axial loading and/or lumbar hyperextension with rotation. These sports include gymnastics, dance, football (particularly linemen), rugby, wrestling, martial arts, soccer, basketball, cheerleading, pitching, golf, tennis, volleyball servers, weightlifting, and butterfly and breaststroke swimming.[3][4][7][8]
Pathophysiology of spondylolysis
Ninety percent of the cases of spondylolysis occur at the L5 vertebra with decreasing incidence at progressively higher lumbar levels. Excessive lumbar lordosis is a risk factor for spondylolysis development. Most commonly, pars interarticularis defects occur bilaterally as opposed to unilaterally. Unhealed pars interarticularis defects may progress to lytic (isthmic) spondylolisthesis, which is an anterior displacement of the vertebral body in relation to the vertebra below. It is important to note unilateral lesions never progress to spondylolisthesis. However, in patients with bilateral spondylolysis, at the time of diagnosis, 50% to 75% will already have accompanying spondylolisthesis. Slip progression is more common in adolescents compared to adults, and although the incidence of spondylolysis is more common in males, the slip progression of spondylolisthesis occurs more frequently in females.
Additionally, multifidi muscles of the back attach to the mamillary process of the vertebra thereby stabilizing vertebral joints and providing stability at each segmental level. The mammillary process is not completely formed until 25 years of age. Full ossification of the neural arch is also not completed until the same age limit. These 2 factors play a pivotal role in the development of the condition during adolescence.[8][5][3]
Differential Diagnosis of spondylolsis
Muscular strains and sprains
Lumbar radiculopathy secondary to degenerative disc disease and resultant disc bulge and/or herniation
Spinal canal stenosis
Epidural abscess
Fracture of other components of the posterior vertebral arch
Osteoid sarcoma or other primary bone tumors
Pathologic fracture secondary to osteoporosis, malignancy, infections, or additional intrinsic bone-weakening etiologies
Degenerative spondylolisthesis of adulthood
Ankylosing spondylitis[7][4]
Prognosis spondylolysis
The prognosis in patients with spondylolysis is usually excellent. Asymptomatic individuals require no specific treatments or any modifications to activities of daily living or athletic activities. Even patients who present with symptomatic spondylolysis usually have a very favorable prognosis as validated by a recent meta-analysis which demonstrated that the 92% of the adolescent athletes were able to return to competitions when they are treated conservatively, and 90% of the time when managed surgically.[11][1][3][4]
Complications spondylolsis
In the majority of patients with spondylolysis, the condition is occult and remains asymptomatic throughout their lifetimes. However, degenerative disc disease and resultant spondylosis, which typically occurs as a sequela of the aging process, have a propensity to be accelerated in patients with spondylolysis. This may lead to spinal stenosis and lumbar radiculopathies. These deleterious effects may also occur secondary to vertebral body slippage in almost 50% to 75% of patients with bilateral spondylolysis. Potential surgical complications would include a failed fusion, infections, chronic persistent pain, neurological deteriorations, and the failed back surgery syndrome.[11][1][4]
Management
NSAIDS
Mostly pain guided
Should remain non-surgical for 6 to 12 months
Modified activity; no hyperextension
Core stabilisation (different to ab work), hamstring, hip flexors, quads and calf complex flexibility
Lumbo-pelvic control
Post op: non-impact aerobic exx can be started after 4/52. Return to sports when pain free, at the 4 to 6/12 mark
