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Treating Spondylolysis in the Adolescent Athlete

By: Maureen Leahy

Maureen Leahy

Spondylolysis is a common cause of back pain in adolescent athletes. The incidence of spondylolysis is especially high in athletes who engage in sports that involve frequent flexion and extension combined with rotation, such as diving, wrestling, weightlifting, and gymnastics.

“Spondylolysis is a defect in the pars interarticularis of the neural arches in the spine,” explained William C. Warner Jr, MD, of the University of Tennessee-Campbell Clinic. “It can be unilateral or bilateral. The most common location is at the L5 level, although it can also occur at L4 and L3.”

Dr. Warner made his comments during Thursday’s Instructional Course Lecture, “Head and Spine Injuries in Athletes: When to Worry.”

Pathophysiology, presentation
The pathophysiology of spondylolysis is multifactorial: repetitive mechanical stresses lead to fracture, according to Dr. Warner. “The direction of the fracture line is almost always from inferior medial to superior lateral,” he said.

Other contributing factors include the following:

  • increased lumbar lordosis
  • increased thoracic kyphosis
  • facet joint orientation that is more coronal than sagittal
  • spino-pelvic balance
  • Vitamin D deficiency

According to Dr. Warner, patients usually complain of back pain with acute onset that may also radiate into the buttock or posterior thigh. A single-leg hyperextension “stork test” may provocative, reproduce pain. Other symptoms of spondylolysis include hamstring tightness or spasm, forward flexed gait, decreased lumbar lordosis, and radiculopathy.

Courtesy of William C. Warner Jr, MD

Diagnostic tests
Diagnostic tests for spondylolysis include plain radiographs, bone scans, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans; each has its pros and cons, according to Dr. Warner. For example, anteroposterior (AP) and lateral radiographs may not show the fractures. In addition, recent literature indicates that oblique radiographs are also not beneficial, citing no difference in the sensitivity and specificity between 4-view (AP, lateral, and oblique) and 2-view (AP and lateral) studies.

Before the introduction of MRI, the bone scan was the standard diagnostic test for spondylolysis because “it told you metabolically what was going on,” Dr. Warner said.

Similarly, the CT scan is the gold standard for demonstrating the fracture. The disadvantages of using CT include radiation exposure and the inability to differentiate between a metabolically active fracture and a metabolically inactive fracture, he added.

“MRI is useful in identifying marrow edema; however, it is not as good as the CT scan for demonstrating the fracture line,” Dr. Warner said.

Treatment
Although spondylolysis is traditionally treated nonsurgically with rest and restriction of activities, the compliance rate is usually quite low. One way to increase compliance is to use a brace that can be worn either full- or part-time. Dr. Warner has his patients wear a brace for 8 to 12 weeks, primarily to reinforce the importance of restricting activity. He also uses electrical stimulation and checks Vitamin D levels on all spondylolysis patients, putting them on a supplement when necessary.

“My patients begin a physical therapy program when their pain level is 2 or 3 out of 10, and they must complete a structured 4-phase rehabilitation program before they can return to sport,” he said.

In Dr. Warner’s opinion, surgical intervention for spondylolysis is indicated when conservative treatment for 6 months fails, the patient is unwilling to modify sports activities, and the patient is having significant pain that it is interfering with daily activities.

Surgical options include fusion and repair. At the L5 level, fusion and repair will produce similar results; at the L4 and L3 levels, direct repair is recommended over fusion, according to Dr. Warner.

Techniques for repair of a pars defect include Scott wiring, a Buck screw, a pedicle screw and hook, or a U-rod (Fig. 1). After repair, radiographic healing rates range from 67 percent to 90 percent; asymptomatic and return to sports rates range from 80 percent to 90 percent, Dr. Warner pointed out. He also noted that although all four techniques restore normal vertebral displacement in flexion, rotation, and bending, the Buck screw is the only technique that restores normal motion at both the level of the pars defect and the adjacent level above. “I usually use a screw and hook, mainly because of my familiarity with the technique,” he said.

Return to play
Return to play for spondylolysis patients is not based on radiographic union, partial union, fibrous union, or nonunion, but instead is symptom-dependent. On average, he said, it takes patients who are treated nonsurgically 3 to 6 months to complete a dedicated rehabilitation program and become pain-free. Surgical patients usually return to play somewhere between 6 and 12 months.

Additional presenters for ICL 311 “Head and Spine Injuries in Athletes: When to Worry”were Alexander R. Vaccaro, MD, PhD; Patrick Cahill, MD; and Kern Singh, MD.

Details of the presenters’ disclosure as submitted to the Orthopaedic Disclosure Program can be found in the Final Program; the most current disclosure information may be accessed electronically at www.aaos.org/disclosure

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