Sashil Kapur, MD Sports medicine fellow Lutheran General

Transcription

1 Sashil Kapur, MD Sports medicine fellow Lutheran General 1

2 Spondy-what? Presentation Diagnosis Treatment Return to play 2

3 Very common musculoskeletal complaint 10-15% of children and adolescents Adults vs. pediatrics Discogenic pain, lumbar strains Spondylolysis 3

4 Fracture of the pars interarticularis of the neural arch Separate from spondylolisthesis 4

5 Incidence of approximately 6% Greater in Caucasians, males Most common at L5 level Greater than 90% Second most common level- L4 Higher incidence in pediatrics population Pediatric athletes % 5

6 Immature skeleton Excessive lordosis Repetitive stress loading 6

7 Immature skeleton Maturation of ossification centers at ~ 25 years Growth spurt Excessive lordosis Tight iliopsoas, abdominal weakness, thoracolumbar fascia tightness Greater stress at lower lumbars Stress loading Hyperextension, rotation Much higher incidence in athletics Gymnastics, volleyball, weightlifting, dance, etc. 7

8 Type I- hyperlordotic female with hypermobility of joints Gymnast, dancer Type II- muscular male athlete, recent growth spurt, poor flexibility, tight paraspinals Football, weight lifters Type III- male or female new to sport, likely starting new and vigorous routines, usually start deconditioned 8

9 Continuum 9

10 Adolescent Gradually worsening low back pain without trauma Worsens with activity and improves with rest Localized, occasionally radiates to the buttocks or thighs Limited ROM and discomfort, especially with extension No neurologic complaints 10

11 Tight lumbar paraspinal muscles Tight hamstrings Pain with back extension, side bending, or rotation Stork test Neurological signs! 11

12 What do we start with? 12

13 Plain films Moderate accuracy Low cost Little radiation 13

14 14

15 Single-photon emission computed tomography (SPECT) Computed Tomography (CT) Magnetic Resonance Imaging (MRI) 15

16 Higher resolution than regular bone scan Low radiation Invasive- intravenous Highly sensitive Differentiate between active vs. inactive lesion Not specific 16

17 Great detail of bony anatomy Very good specificity Large amount of radiation Cannot differentiate if lesion is active or not Can help follow healing 17

18 No radiation Bony anatomy limited by technique 5mm vs. 2mm Expensive Great visualization of additional anatomy Can differentiate between active lesion or not 18

19 No consensus Institution dependent Further studies needed 19

20 Conservative vs. surgical No controlled studies The vast majority should be treated conservatively 20

21 Consensus Initial period of rest- but how long? 3 months? Rehab, work on deficiencies Sport-specific Gradual increase of activities To brace or not to brace? Which brace to use? Modified Boston brace- antilordotic TLSO Zero degrees of extension Worn 23 hours a day May have improved compliance 21

22 Indications Persistent pain at 9-12 months Without union Progression of spondylolisthesis to grade III or worse Persistent neurological symptoms Posteriolateral fusion of transverse processes Direct fracture repair 90% success rate 22

23 Rest from exacerbating activities Start PT Modified Boston brace Return to play in 4-6 weeks with brace if pain free Check CT in four months If healing, wean off brace If persistent pain or poor healing at 9-12 months, consider surgery 23

24 No evidence-based guidelines Skeletal maturity Symptoms Good outcomes Greater than 90% success rate 24

25 Chronic back pain Spondylolisthesis 25

26 The young athlete is more vulnerable to spondylolysis due to a number of factors. Common problem. Early diagnosis is important. Treatment consists of rest from exacerbating activities, rehab. No consensus on definitive treatment or return to play. Good outcomes with conservative therapy. 26

27 Standaert CJ, Herring SA. Spondylolysis: a critical review. Br J Sports Med 2000;34: McCleary MD, Congeni JA. Current concepts in the diagnosis and treatment of spondylolysis in young athletes. Curr Sports Med Rep Jan;6(1):62-6. Kim HJ, Green DW. Spondylolysis in the adolescent athlete. Curr Opin Pediatr Feb;23(1):68-72 Leone A, Cianfoni A. Lumbar spondyloysis: a review. Skeletal Radiol Jun;40(6): Epub 2010 May 4 Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil 2007;88: