Spondylolysis/Spondylolistheis: Management and Return to ...€¦ · 3. Albanese M, Pizzutillo PD. Family study of spondylolysis and spondylolisthesis. J Pediatr Orthop. 1982;2: 496-9

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Spondylolysis/Spondylolistheis:Management and Return to

Activity Guidelines

Hanbing Zhou MD

Disclosures

• I have no relevant financial relationships to disclose.

Spondylolysis/Spondylolistheis:1. Spine Anatomy

2. Pathophysiology

3. Natural History/Genetics

4. Clinical Presentation

5. Physical Exam

6. Imaging findings

7. Impact on athletes

8. Non-operative management

9. Operative management

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CCSU Sports Medicine Symposium - Tuesday, March 3, 2020

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Pars Interarticularis

Spondylolysis: Dissolution of, or a defect in the pars interarticularisof a vertebra

Spondylolisthesis:Slipping, or olisthesis, of a vertebra (spondylos in Greek) relative to an adjacent vertebra

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Types of spondylolisthesis

• Dysplastic (children)

• Isthmic (children, 85%)

• Degenerative

• Traumatic

• Pathologic

• Iatrogenic

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Genetics3

• 15-70% of first-degree relatives of individuals with the disorder

• 2-3x more frequent in boys than girls

• Slippage 2-3x more often than boys

Natural History• 5% of general population

• Fredrickson et al.4: 500 first-grade children in 1955• 4.4% at age of 6

• 6% in adulthood

• 2x common in males

• 15% with pars defect progressed to spondylolisthesis

• No slip >40%

• Back pain/SF-36 no different with age-matched general population group

• Progression secondary to degeneration of the L5-S1 vertebral disc

Clinical Presentation• 75% of back pain in children is “overuse” 5

• Most common identifiable cause is spondylolysis

• 40% recall traumatic injury event6

• Insidious or gradual onset

• Low back pain primarily worsening with extension related activities

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Physical Exam • Tenderness and pain on palpation of spinous process of affected

vertebra

• Lordotic lumbar spine

• Muscle guarding either unilateral or bilateral of erector spinae

• Weakness in gluteals and abdominals

• Pain on extension

• Positive single leg hyperextension test14

• Hamstring tightness

AP/Lateral/Obliques Radiographs“Scotty dog”: Broken neck→spondylolysis

Bone Scan/SPECT• Increased signal: bony activity and healing potential

Absence of signal: non-union, minimal healing potential12

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CT MRI

Athletes

• Symptomatic spondylolysis in athletes with low back pain is 15-47%7-8

(general population 6-8%)

• Professional soccer: 38.1%9

• Baseball players: 44.1%9

• Divers: 43%

• Wrestlers: 30%

• Weightlifters: 23%

Butterfly style and breaststroke swimmers are reported to have the highest incidence of spondylolysis when compared to other swimming styles10

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Non-Operative Treatment• Activity Modification

• Cessation of inciting sports activities

• Non-steroidal anti-inflammatory agents

• Reduction of lumbar lordosis

• Physical Therapy• Hamstring stretching

• Trunk strengthening

• Avoidance of inciting activities

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Spinal Orthotics • Patients with unacceptable symptoms

• Positive findings on SPECT scan: healing potential

• Compliance is more important than type of brace

• No difference between bracing and no bracing at 1 year17

TLSO LSO

Outcome of Non-operative Management

• >80% have resolution of symptoms

• 75%-100% of acute lesions heal

• All unilateral acute lesion heal

• 50% of bilateral lesions heal

• No chronic defects heal

• 90% return to previous levels of activity8

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Surgical options

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Buck’s repair Scott’s wiring Morscher technique

Surgical options• L5-S1 in-situ fusion with autogenous iliac crest bone graft

• No bracing needed

Surgical options (Low grade spondylolisthesis)• L5-S1 fusion with instrumentation with or without interbody

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Surgical options (High grade spondylolisthesis)

Surgical options (High grade spondylolisthesis)

Return to Play after Surgery

• Radcliff et al.18:• Core strengthening and non- impact activity 2 weeks postoperatively

• First 3 months, all exercises are done with a neutral spine

• After 3 months, higher impact training may start

• At 4-6 months sport specific training begins

• Athletes may return to play when they demonstrate normal strength, normalrange of motion and no pain with sport specific activity; 6-12 months after surgery

• Wide variability: • Ranging from 62-66% allowing RTP for noncontact sports at 6 months→one year

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Return to Play

19 yo M, football player, several months of intractable lower back pain

CT Scan

L3: Bilateral chronic spondylolysis/pars fracture

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What the…..?Second pars fracture discovered intraop

Two weeks postop

One year postop

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32 year F, in situ fusion in MexicoGrade II Isthmic spondylolisthesis

Two weeks Postop L5-S1 Anterior lumbar interbody fusion with posterior instrumentation

Spondylolysis/Spondylolistheis:Management and Return to Activity Guidelines

1. Case-by-case basis

2. Resolution of symptoms

3. Full pre-injury range of motion and strength

4. Completion of structured rehabilitation program

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References:1. Meyerding H. Spondylolisthesis. Surg Gynecol Obstet. 1932; 54:371-7

2. Jackson DW, Wiltse LL, Cirincoine RJ. Spondylolysis in the female gymnast. Clin Orthop Relat Res. 1976; 117:68-73

3. Albanese M, Pizzutillo PD. Family study of spondylolysis and spondylolisthesis. J Pediatr Orthop. 1982;2: 496-9

4. Fredrickson BE, Baker D, McHollick WJ, Yuan HA, Lubicky JP. The natural history of spondylolisthesis and spondylolysis. J Bone Joint Surg AM. 1984;66:669-707

5. Feldman DS, Hedden DM, Wright JG. The use of bone scan to investigate back pain in children and adolescents. J Pediatr Orthop. 2000;20:790-5

6. El Rassi G, Takemitsu M, Woratanarat P, Shah SA. Lumbar spondylolysis in pediatric and adolescent soccer players. Am J Sports Med. 2005;33:1688-93

7. Micheli LJ, Wood R: Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 1995; 149(1):15-18

8. Hsu W, Jenkins T. Management of Lumbar conditions in elite athlete. J Am Acad Orthop Surg 2017; 25:489-498

9. Sakai T, Sairyo K, Suzue N, Kosaka H, Yasui N: Incidence and etiology of lumbar spondylolysis: Review of the literature. J Orthop Sci 2010; 15(3): 281-288

10. Nyska, M., Constantini, N., Calé-Benzoor, M., Back, Z., Kahn, G., & Mann, G. (2000). Spondylolysis as a cause of low back pain in swimmers. International Journal of Sports Medicine, 21(5), 375–379.

11. Donaldson LD. Spondylolysis in elite junior-level ice hockey players. Sports Health. 2014 Jul;6(4):356-9.

12. Van den Oever M, Merrick MV, Scott JHS. Bone Scintigraphy in symptomatic spondylolysis. J Bone Joint Surg Br. 1987;69:453-6

13. McCleary, M. and Congeni, J. (2007). Current Concepts in the Diagnosis and Treatment of Spondylolysis in Young Athletes. Current Sports Medicine Reports, 6(1), pp.62-66.

14. Masci, L., Pike, J., Malara, F., Phillips, B., Bennell, K., Brukner, P., Standaert, C. and Micheli, L. (2006). Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. British Journal of Sports Medicine, 40(11), pp.940-946.

15. https://www.uwhealth.org/files/uwhealth/docs/sportsmed/Spondy_Rehab_Guide.pdf

16. Tawfik, S., Phan, K., Mobbs, R. and Rao, P. (2019). The Incidence of Pars Interarticularis Defects in Athletes. Global Spine Journal, p.219256821882369.

17. Klein G, Mehlman CT, McCarty M: Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: A meta-analysis of observational studies. J Pediatr Orthop 2009; 29(2): 146-156

18. Radcliff KE, Kalantar SB, Reitman CA: Surgical management of spondylolysis and spondylolisthesis in athletes: Indications and return to play. Curr Sports Med rep 2009; 8 (1): 35-40

19. Panteliadis P, Boszczyk Bronek. (2016). Athletic population with spondylolysis: review of outcomes following surgical repair or conservative management. Global spine Journal 2016;6:615-625

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Documents

Spondylolysis/Spondylolistheis: Management and Return to ...€¦ · 3. Albanese M, Pizzutillo PD. Family study of spondylolysis and spondylolisthesis. J Pediatr Orthop. 1982;2: 496-9