Spondylolysis To Brace or Not To Brace AMSSM 2014

Transcription

1 Spondylolysis To Brace or Not To Brace AMSSM 2014

2 Nothing to Disclose Disclosures

3 To Brace? Goals of Treatment History/ Literature of Bracing Mechanics of Bracing Benefits to Brace. Earlier to return to sport?

4 Goals of Treatment Pain Relief / Clinical Healing Radiographic Healing? Reduce Recurrence Minimize long range complications - spinal stenosis? Return to sport. Same level? Time Loss from sport?

5 Acknowledgement. Points of agreement? Rest/ activity modification/cessation of pain provoking activity. Duration? 3-6 months? Less? Core Strengthening/ Hamstring Flexibility Most Clinically do well. Long term sequela - Minimal.

6 To date, there have not been any controlled trials assessing bracing as a treatment for spondylolysis or spondylolisthesis. However, there are studies that support bracing in the setting of acute pars fracture. treatment with brace support is most often applicable to the skeletally immature athlete. bracing in the adult athlete is of limited utility and is typically reserved only for those recreational athletes who are highly symptomatic.

7 Studies/ Reviews that cite Brace Treatment 1980 s Micheli 1980 AJSM 1985 Spine 1985 Orthotics and Prosthetics

8 Studies/ Reviews that cite Brace Treatment 1993 J Spinal Disord. Blanda, et al. Defects of Pars Interarticularis in Athletes: A Protocoal for Nonoperative Treatment 1995 Arch Pediatr Adolesc Med. Micheli & Wood. Back pain in Young Athletes 1995 JBJS Br. Morita, et al. Lumbar spondylolysis in children and adolescents Military Medicine. Daniel, et al. A study of the efficacy of nonoperative treatment of presumed traumatic spondylolysis in a young population. 2001:10 European Spine Journal. Sys, et al. Nonoperative treatment of active spondylolysis in elite athletes with normal X-ray findings:

9 Studies/ Reviews that cite Brace Treatment 2002:25(6) Orthopedics. d Hemecourt, et al. Spondylolysis: returning the athlete to sports participation with brace treatment. 2004;14 Scand J Med Sci Sports. Iwamoto, et al. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. 2004:86 JBJS Br Fujii, et al. Union of defects in the pars interarticularis of the lumbar spine in children and adolescents. 2007:20(8) J Spinal Disord Tech. Kurd, et al. Nonoperative treatment of symptomatic spondylolysis. 2007:6 CSMR McCleary & Congeni. Current Concepts in the Diagnosis and Treatment of Spondylolysis in Young Athletes. 2008:9(2) ISMJ Wicker. FIMS Statement. Spondylolysis and spondylolisthesis in sports.

10 Studies/ Reviews that cite Brace Treatment 2008:16(1) Sports Med Arthrosc Rev. Tallarico, et al. Spondylolysis and Spondylolisthesis in the Athlete. 2008:20 Current Opinion in Pediatrics. Kim & Green. Adolescent Back Pain 2010:92(6) JBJS-B Tsirikos & Garrido. Spondylolysis and Spondylolisthesis in Children and Adolescents 2012: 13(7) Contemporary Spine Surgery Nguyen & Patel. Lumbar Spondylolysis. 2012:25 J Spinal Disord Tech. Sutton, et al. Acute Lumbar Spondylolysis in Intercollegiate Athletes.

11 Below the Belt Phys Med Rehabil Clin N Am Nov;11(4): Spondylolysis. Standaert CJ, Herring SA, Halpern B, King O. Author information Abstract! Spondylolysis is a relatively common incidental radiographic finding that, most frequently, is asymptomatic. Isthmic spondylolysis with a lesion in the pars interarticularis may be a significant cause of pain in a given individual, particularly in adolescent athletes involved in sports with repetitive spinal motions. The pars lesion likely represents a stress fracture of the bone caused by the cumulative effect of repetitive stress imposed by physical activity. The lesion frequently presents as focal LBP and can often be identified on plain radiography. Advanced imaging with SPECT, CT, and MR imaging may be needed to ascertain the acuity of the lesion, assist in identifying a particular pars lesion as potentially symptomatic, and to exclude other spinal pathology that may be present. Conservative treatment is usually successful in controlling symptoms and restoring function; only a small percentage of patients require surgical intervention for pain or progressive spondylolisthesis. Based on current evidence, treatment requires activity restriction (i.e., temporary discontinuation of the aggravating sport or activity) and may require bracing to achieve treatment goals, although healing, pain relief or both may occur without brace application. A full understanding of spinal biomechanics and pathophysiology, the role of diagnostic imaging, and treatment options is needed to care for these patients.! PMID: [PubMed - indexed for MEDLINE]

12 BRACES DO NOT RESTRICT MOTION

13 Articles Frequently Cited as evidence bracing DOES NOT inhibit motion. 1986:11(8) Spine. Lantz and Schultz. Lumbar Spine Orthosis Wearing. Effect on Trunk Muscle Myoelectric Activity. 1992:21(6) Orthopaedic Review. Miller, et al. Lower Spinal Mobility and External Immobilization in the Normal and Pathologic Condition Spine. Axelsson, et al. Effect of Lumbar Orthosis on Intervertebral Mobility.

14 Evidence to support NO BENEFIT? 1992 Orthopaedic Review, Miller x-ray study. 7 patients with listhesis 7 volunteers Average age - 37

15 Evidence to support NO BENEFIT? Cohort - Seven, post-op patients. Surgery for Listhesis grade 1-2. Ages Tantalum indicators were implanted at time of surgery - in the sacrum; and the most proximal vertebra fused. Exam comparisons - supine and erect x-ray exams. NO erect Active Motions performed!!! Results: decrease the overall load on the lumbar spine but no stabilizing effect on the intervertebral mobility.

16 Is this Evidence Applicable to Athletic use of Brace? Can this postop study apply. Negate any possible brace effect in an active athlete? Cohort differences? Post op patients; Listhesis cases. Mobility comparisons? Supine to Erect vs. Active motion of Sport Age (the younger athlete, participating in sport, and due to greater flexibility, is more likely to extend spine SIGNIFICANTLY more than these postop adults. Thereby a brace will probably restrict at least some of the extreme extension of sport). Authors comment: In the current investigation the inter individual variation in mobility as demonstrated by RSA with and without lumbar support was considerable. This might imply that patient characteristics are more important than corset characteristics in spinal immobilization

17 Can These Studies Apply to the Active Athlete??

18 Braces CAN restrict Motion Ultralign provided greater spinal restriction on ROM in all three trunk movements. ProLign LO offered less restriction on the lumbar movements compared to UltraLign LSO, but was still effective in the reduction of lumbar intervertebral segmental mobility compared to the no-brace trials.

19 Journal of Back and Musculoskeletal Rehabilitation Zhang, et al 2006

20 Braces Most Studies of Spine Movement by Braces are intended to assess effect on fracture management at levels higher than L5-S1. These studies HAVE NOT been designed to assess restriction of spine movement during active athletic movement. Mechanical restriction Reminder restriction

21 Bracing: Spine Movements Restricted. Sample of Articles cited. Axelsson P, er al. Effect of lumbar orthosis on intervertebral mobility; A rontgen stereophotogrammetric analysis. Spine 1992;17: Buchalter D, et al. Three-dimensional spinal motion measurements. Part 2: A noninvasive assessment of lumbar brace immobilisation of the spine. J Spinal Disord 1998;1: Fidler MW, et al. The effect of four types of support on the segmental mobility of the lumbosacral spine. JBJS AM 1983;65-A: Lantz SA, et al. Lumbar spine orthosis wearing. I. Restriction of gross body motions. Spine 1986;11:834-7 Mellin G, et al. Effects of subject position on measurements of flexion, extension, and lateral flexion of the spine. Spine 1991;16: Nachemson A, et al. Mechanical effectiveness studies of lumbar spine orthoses. Scand J Rehabil Med Suppl 1983;9: Portek I, et al. Correlation between radiographic and clinical measurement of lumbar spine movement. Br. J Rheumatol 1983;22: Tanz SS, et al. Motion of the Lumbar spine. A roentgenologic study. Am J Roentgenol 1953;69:

22 Studies/ Reviews Questioning Brace Effectiveness for Bone Healing 2009:29(2) J Pediatr Orthop. Klein, et al. Nonoperative Treatment of Spondylolysis in Children and Young Adults. A meta-analysis of Observational Studies. 2011:19 Knee Surg Sports. Alvarez-Diaz., et al. Traumatol Arthrosc. Conservative treatment of lumbar spondylolysis in young soccer players. 2013:92(12) Am J Phys Med Rehab. Rassi et al. Effect of Sports Modification on Clinical Outcome in Children and Adolescent Athletes with Symptomatic Lumbar Spondylolysis.

23 Studies/ Reviews Questioning Brace Effectiveness for Bone Healing Publication liberties??? 2009:29(2) J Pediatr Orthop. Klein, et al. Nonoperative Treatment of Spondylolysis in Children and Young Adults. A meta-analysis of Observational Studies. In this 2009 meta-analysis, the authors cite a 2006 publication by Sairyo. In the text the authors state the use of a corset was discontinued in later studies by the same group BUT, Sairyo s publication on the use of MRI states, The conservative treatment involved asking the patient to stop any sporting activity and to wear a thoracolumbosacral-type trunk brace THERE IS NO MENTION of..corset was discontinued.. in Sairyo s article as was stated by Klein in the 2009 article.

24 Multiple Variables Affect Outcomes Significant factors which affect union following conservative treatment of pars defects of the lumbar spine in 134 children. Local factors Stage of defect Vertebral level Stage of Contralateral defect! Location of defect (L5) - Near Pedicle vs. Isthmus

25 Union of defects in the pars interarticularis of the lumbar spine in children and adolescents. JBJS-Br Fujii, et al. Lumbosacral factors Lumbar lordosis angle (L5 early stage) Lumbar inclination angle (early and progressive stage) Systemic factors Chronological age (L4 progressive stage)

26 Is the benefit of bracing Earlier Return to Sport? 2002:25(6) Orthopedics. d Hemecourt, et al. Spondylolysis: returning the athlete to sports participation with brace treatment. 73 athletes used Boston Brace 6.9 +/- 3.1 months 85% compliance with brace. Return to sport in 4-6 weeks.? lose less muscle mass.

27 Summary Rest/ Activity Modification is Cornerstone of Treatment. No Randomized Clinical Trials Old and Recent Literature suggest bracing. Studies suggesting brace does not restrict MAY NOT apply to sport use. Mechanical AND Reminder Effect.

28 Summary Bracing MAY allow earlier return to sport without compromising outcomes - clinical or radiographic. Timing may significantly influence an athlete s sport progression. The Act of Intervening engages patient and parents in a treatment plan. Compliance with Brace vs. Compliance with Rest? No physical risks/ Modest expense.