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Spondylolysis of lumbosacral region — Clinical Guidelines

Overview

Spondylolysis involves a stress fracture in the pars interarticularis of the vertebrae, commonly affecting the L5 vertebra in young athletes, leading to potential instability and lower back pain. 1 3 16

Diagnosis

Key Diagnostic Criteria: Persistent low back pain, especially with extension activities.

Recommended Tests:

- Plain Radiographs: Initial screening, often normal in early stages. - MRI: Highly sensitive, especially T1-weighted sequences for detecting posterior epidural fat interposition 1. - CT/SPECT: Useful for confirming defects not visible on plain films 1 11.

Grading: Often not formally graded but severity can be assessed by defect size and presence of spondylolisthesis 1 16.

Management

First-Line Treatments:

- Rest and Activity Modification: Reducing activities that exacerbate pain. - Bracing: To stabilize the spine and promote healing 1 11 15.

Adjunctive Treatments:

- Physical Therapy: Strengthening core muscles and flexibility exercises post-healing phase 16. - Vitamin D Supplementation: Given high rates of deficiency in affected patients 6.

Special Populations

Pediatrics: Early diagnosis via MRI crucial; high incidence in young athletes 1 3 6 16.

Comorbidities: Vitamin D deficiency prevalent; consider screening and supplementation 6.

Key Recommendations

Utilize MRI for early and accurate diagnosis of spondylolysis, particularly in young athletes 1 22 (Evidence: Strong).

Initiate conservative management with rest and bracing for most cases to promote healing 1 11 15 (Evidence: Moderate).

Screen for vitamin D deficiency in pediatric patients with spondylolysis due to high prevalence rates 6 (Evidence: Moderate).

Consider spinopelvic alignment variations in surgical planning for acquired spondylolysis post-surgery 8 (Evidence: Weak).

Monitor for facet joint degeneration and disc issues post-treatment, especially in long-term follow-up 4 9 10 13 (Evidence: Moderate).

References

1 Güdü BO, Karan B, Dilbaz S. Diagnostic Efficacy of Posterior Epidural Fat Interposition on Magnetic Resonance T1-Weighted Sequence in the Diagnosis of Spondylolysis. World neurosurgery 2024. link 2 Guo X, Li Z, Guo Z, Li W. Factors associated with non-fusion after direct pars repair of lumbar spondylolysis with pedicle screw and lamina hook: a clinical and CT-assessed study. BMC musculoskeletal disorders 2024. link 3 Hollabaugh WL, Foley Davelaar CM, McHorse KJ, Achar SA, MacDonald JP, Riederer MF. Clinical Practice Patterns of Isthmic Spondylolysis in Young Athletes: A Survey of Pediatric Research in Sports Medicine Members. Current sports medicine reports 2022. link 4 Meng H, Gao Y, Lu P, Zhao GM, Zhang ZC, Sun TS et al.. Risk factor analysis of disc and facet joint degeneration after intersegmental pedicle screw fixation for lumbar spondylolysis. Journal of orthopaedic surgery and research 2022. link 5 Enoki S, Kuramochi R, Nakajyuku S, Mitsuyama H. The prevalence of spondylolysis and intervertebral disc degeneration in male pole vaulters. Journal of back and musculoskeletal rehabilitation 2022. link 6 Amoli MA, Sawyer JR, Tyler Ellis R, Seymour J, Spence DD, Kelly DM et al.. Pediatric Patients with Spondylolysis Have High Rates of Vitamin-D Deficiency. Journal of surgical orthopaedic advances 2019. link 7 Celtikci E, Yakar F, Celtikci P, Izci Y. Relationship between individual payload weight and spondylolysis incidence in Turkish land forces. Neurosurgical focus 2018. link 8 Vazifehdan F, Karantzoulis VG, Igoumenou VG. Acquired spondylolysis and spinopelvic sagittal alignment. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 2018. link 9 Goda Y, Sakai T, Harada T, Takao S, Takata Y, Higashino K et al.. Degenerative Changes of the Facet Joints in Adults With Lumbar Spondylolysis. Clinical spine surgery 2017. link 10 McCunniff PT, Yoo H, Yu C, Bajwa NS, Toy JO, Ahn UM et al.. Spondylolysis and End Plate Arthrosis at L5-S1: A Cadaveric Study. Orthopedics 2017. link 11 Oren JH, Gallina JM. Pars Injuries in Athletes. Bulletin of the Hospital for Joint Disease (2013) 2016. link 12 McCunniff PT, Yoo H, Dugarte A, Bajwa NS, Toy JO, Ahn UM et al.. Bilateral Pars Defects at the L4 Vertebra Result in Increased Degeneration When Compared With Those at L5: An Anatomic Study. Clinical orthopaedics and related research 2016. link 13 Toy JO, Tinley JC, Eubanks JD, Qureshi SA, Ahn NU. Correlation of sacropelvic geometry with disc degeneration in spondylolytic cadaver specimens. Spine 2012. link 14 Amari R, Sakai T, Katoh S, Sairyo K, Higashino K, Tachibana K et al.. Fresh stress fractures of lumbar pedicles in an adolescent male ballet dancer: case report and literature review. Archives of orthopaedic and trauma surgery 2009. link 15 Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Archives of physical medicine and rehabilitation 2007. link 16 McCleary MD, Congeni JA. Current concepts in the diagnosis and treatment of spondylolysis in young athletes. Current sports medicine reports 2007. link 17 Micheli LJ, Curtis C. Stress fractures in the spine and sacrum. Clinics in sports medicine 2006. link 18 Standaert CJ. New strategies in the management of low back injuries in gymnasts. Current sports medicine reports 2002. link 19 Campbell RS, Grainger AJ. Routine thin slice MRI effectively demonstrates the lumbar pars interarticularis. Clinical radiology 2000. link 20 Garry JP, McShane J. Lumbar spondylolysis in adolescent athletes. The Journal of family practice 1998. link 21 Kennedy K. Acute spondylolysis in an adolescent. Orthopedic nursing 1994. link 22 Yamane T, Yoshida T, Mimatsu K. Early diagnosis of lumbar spondylolysis by MRI. The Journal of bone and joint surgery. British volume 1993. link 23 Jackson DW, Wiltse LL, Cirincoine RJ. Spondylolysis in the female gymnast. Clinical orthopaedics and related research 1976. link

Spondylolysis of lumbosacral region