Overview
Definition:
Spondylolysis is a stress fracture or defect in the pars interarticularis of a vertebra, most commonly L5
Spondylolisthesis is the forward slippage of one vertebra over the one below it, often a consequence of bilateral spondylolysis
Both are common causes of low back pain in active adolescents.
Epidemiology:
Spondylolysis affects approximately 5-7% of the general population, with higher prevalence (up to 15-20%) in athletes involved in sports with repetitive hyperextension and rotation, such as gymnastics, football, and weightlifting
Spondylolisthesis occurs in about 3-5% of individuals with spondylolysis.
Clinical Significance:
Understanding the distinction and relationship between spondylolysis and spondylolisthesis is crucial for accurate diagnosis and effective management in pediatric patients
Missed or delayed diagnosis can lead to chronic pain, functional limitations, and potentially neurological deficits, impacting a young athlete's career and quality of life.
Clinical Presentation
Symptoms:
Dull, aching low back pain, often exacerbated by activity, especially hyperextension or twisting motions
Pain may radiate to the buttocks or thighs
Hamstring tightness is common
In some cases, neurological symptoms like leg weakness or numbness may occur if nerve roots are compressed.
Signs:
Tenderness over the affected spinous process or paraspinal muscles
Palpable step-off at the lumbosacral junction in higher-grade spondylolisthesis
Limited range of motion in the lumbar spine, particularly extension
Positive straight leg raise test
Tight hamstrings are a frequent finding.
Diagnostic Criteria:
There are no formal diagnostic criteria for spondylolysis/spondylolisthesis in the same way as some infectious diseases
Diagnosis relies on a combination of suggestive clinical presentation, physical examination findings, and characteristic radiographic evidence.
Diagnostic Approach
History Taking:
Detailed history of the onset and duration of pain
Specific activities that aggravate or relieve pain
History of repetitive sports participation
Any prior trauma to the back
Red flags include bowel/bladder dysfunction, fever, weight loss, or nocturnal pain, which suggest other serious pathologies.
Physical Examination:
Assess gait and posture
Palpate the lumbar spine for tenderness and step-offs
Evaluate lumbar spine range of motion (flexion, extension, lateral bending, rotation)
Assess hamstring flexibility
Perform neurological examination including motor strength, sensation, and reflexes in the lower extremities
Perform tests like the prone hyperextension test and straight leg raise test.
Investigations:
Initial imaging typically involves plain radiography (AP, lateral, oblique views of the lumbar spine)
Oblique views are crucial for visualizing the "Scottie dog" sign of spondylolysis (a fracture in the pars interarticularis)
Lateral views assess for slippage (spondylolisthesis)
If plain radiographs are equivocal or neurological symptoms are present, MRI is indicated to assess for associated soft tissue injury, nerve root compression, or bone marrow edema
CT scan can provide more detailed bone anatomy, especially for complex fractures.
Differential Diagnosis:
Muscular strain, lumbar disc herniation, vertebral body fractures (other than pars), Scheuermann's kyphosis, scoliosis, spinal infections (osteomyelitis, discitis), tumors, inflammatory arthropathies, and hip pathology.
Management
Initial Management:
Discontinuation of aggravating activities
Relative rest
Pain control with analgesics
Modalities like ice or heat can provide symptomatic relief
Education about the condition and prognosis is vital.
Medical Management:
Conservative management is the mainstay
It includes physical therapy focusing on core strengthening, flexibility exercises for hamstrings and hip flexors, and postural correction
Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain and inflammation control, typically for short durations
Activity modification is key, with gradual return to sports as symptoms improve.
Surgical Management:
Surgery is generally reserved for cases with persistent, debilitating pain despite conservative management, or for those with progressive neurological deficits or high-grade slips (grades III-IV)
Procedures include pars repair (in select cases of active lysis) or spinal fusion (posterolateral fusion or interbody fusion) to stabilize the segment
The goal is to relieve pain and prevent further slippage.
Supportive Care:
Psychological support for young athletes struggling with pain and activity limitations
Nutritional assessment to ensure adequate calcium and Vitamin D intake for bone health
Close monitoring for recurrence or progression of symptoms.
Complications
Early Complications:
Infection, bleeding, nerve root injury, dural tear, non-union of pars repair, or pseudarthrosis of fusion
Persistent pain is a common "complication" of conservative management if not adhered to.
Late Complications:
Chronic low back pain, degenerative disc disease at adjacent levels (if fusion is performed), adjacent segment disease, radiculopathy, and spinal stenosis in severe or untreated cases
Chronic pain can significantly affect psychological well-being and participation in physical activities.
Prevention Strategies:
Proper training techniques in sports involving hyperextension and rotation
Gradual increase in training intensity and duration
Adequate warm-up and cool-down routines
Strengthening of core and back muscles
Encouraging proper posture and biomechanics
Avoiding overtraining.
Prognosis
Factors Affecting Prognosis:
Severity of the slip (grade of spondylolisthesis), presence of bilateral pars defects, persistence of pain, patient compliance with conservative treatment, and surgical success
Younger age at diagnosis may portend a better prognosis for recovery.
Outcomes:
Most adolescents with spondylolysis and low-grade spondylolisthesis (grades I-II) can return to full activity with conservative management, though some may experience intermittent pain
Surgical outcomes for selected patients with persistent pain or significant instability are generally good, with pain relief and return to sports.
Follow Up:
Regular follow-up with orthopedic specialists is recommended, particularly during periods of return to sport
Imaging may be repeated if symptoms recur or worsen
Long-term monitoring for adjacent segment degeneration is important, especially after fusion procedures.
Key Points
Exam Focus:
The "Scottie dog" sign on oblique radiographs is pathognomonic for spondylolysis
Spondylolisthesis is slippage of one vertebra over another, often due to bilateral spondylolysis
Conservative management with rest, physical therapy, and NSAIDs is the first line of treatment
Surgical intervention is reserved for refractory pain or neurological deficits
Common levels are L5-S1 and L4-L5.
Clinical Pearls:
Always consider spondylolysis/spondylolisthesis in an adolescent with persistent, activity-related low back pain
Tight hamstrings are a classic finding
Don't miss the oblique view on X-rays
it's your best friend for spotting the pars defect
MRI is essential for evaluating neural involvement.
Common Mistakes:
Dismissing adolescent back pain as simple muscle strain without adequate investigation
Relying solely on AP/lateral X-rays and missing oblique views for spondylolysis
Inadequate conservative management duration before considering surgery
Underestimating the psychological impact of chronic pain on young athletes.