Spondylolysis. Ziva Petrin, MD March 3 rd, 2018

Transcription

1 Spondylolysis Ziva Petrin, MD March 3 rd, 2018

2 Terminology SpondyloLYSIS: Defect in the pars articularis

3 Terminology

4 Spondylolysis àspondylolisthesisà Spondyloptosis Yochum TR: Reactive sclerosis of a pedicle due to unilateral spondylolysis A case study. ACA J Chiro, 1980.

5 Spondylolysis: Types Dysplastic Isthmic Degenerative Traumatic Pathological

6 Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine Dec (24): Epidemiology Incidental & asymptomatic in up to 10% of population Variable by population: Up to 40% in American Eskimo skeletons Familiar predisposition None found in newborns, progressively found after walking Cause unclear/controversial Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am. 2000;84:

7 Epidemiology: Athletes Active lysis: symptomatic lysis Higher incidence in athletes Causes approx. 50% of back pain in young athletes Incidence varies by sport Traditionally: gymnastics, diving Further study: various sports Rotation and hyperextension More common on non-dominant side

8 L1 L2 2% L3 3% L4 5-15% L %

9 Presentation Unilateral low back pain Focal or poorly defined May radiate into buttocks Muscle spasm +/- No associated neurological signs Insidious onset vs acute Stress fracture pain: achy at rest, progressively worse with exercise Aggravated with lumbar hyperextension

10 Diagnosis: History History: Sensitive and Specific Age: <20 Sex: Male Grødahl LH, Fawcett L, Nazareth M, Smith R, Spencer S, Heneghan N, Rushton A.Diagnostic utility of patient history and physical examination data to detect spondylolysis and spondylolisthesis in athletes with low back pain: A systematic review. Man Ther Aug;24:7-17. doi: /j.math Epub 2016 Apr 1.

11 Diagnosis: Exam Masci L, Pike J, Malara F, Phillips B, Bennell K, Brukner P. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. British Journal of Sports Medicine. 2006;40(11): doi: /bjsm Grødahl LH, Fawcett L, Nazareth M, Smith R, Spencer S, Heneghan N, Rushton A.Diagnostic utility of patient history and physical examination data to detect spondylolysis and spondylolisthesis in athletes with low back pain: A systematic review. Man Ther Aug;24:7-17. doi: /j.math Epub 2016 Apr 1. Alqarni AM, Schneiders AG, Cook CE, Hendrick PA. Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review. Phys Ther Sport Aug;16(3): doi: /j.ptsp Epub 2015 Jan 8.

12 Diagnosis: Imaging Trout AT, Sharp SE, Anton CG, Gelfand MJ, Mehlman CT. Spondylolysis and Beyond: Value of SPECT/CT in Evaluation of Low Back Pain in Children and Young Adults. RadioGraphics :3,

13 XR: Lat vs Oblique

14 CT vs MRI

15 CT vs Scintigraphy vs SPECT Trout AT, Sharp SE, Anton CG, Gelfand MJ, Mehlman CT. Spondylolysis and Beyond: Value of SPECT/CT in Evaluation of Low Back Pain in Children and Young Adults. RadioGraphics :3,

16 Imaging: Radiation Lumbar Spine Xray AP 0.7 msv Lumbar Spine XR lateral 0.3 msv Peds LSpine XR AP/Lat 0.72 msv Peds LSpine XR AP/Lat/Obliq 1.26 msv Lumbar Spine complete 1.5 msv 6m SPECT 2.3 msv CT spine 6 msv 2y CT Abdomen 10 msv

17 Treatment Rest / Activity Modification: 4-12 weeks Bracing Bone Stimulator Biomechanics Neutral Core Strength Anterior pelvic tilt/ lumbar hyperlordosis Abdominal Co-contraction Hamstring flexibility Sport-specific biomechanics Surgery

18 magecache/product_full/bivalve%20hip%20s pica%20%28back%29.jpg

19 Surgery 9-15% of cases of symptomatic spondylolysis Indications: intractable pain progressive slip: 50-80% of spondylolysis progress to listhesis development of neurological deficits segmental spine instability Return to play outcome similar to non-op, however prolonged rehabilitation period

20 Return to Play Return to play: not until asymptomatic Greater than 80% of non-op patients return to play 7-12 months Most defects DO NOT heal, but become asymptomatic Bracing does not influence outcome or healing EXCEPT with early stage lysis 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 Mar;29(2): doi: /BPO.0b013e fc5. Huang P, Anissipour A, McGee W, Lemak L. Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries: A Comprehensive Review. Sports Health. 2016;8(1): doi: / Iwamoto J, Sato Y, Takeda T, Matsumoto H. Return to sports activity by athletes after treatment of spondylolysis. World Journal of Orthopedics. 2010;1(1): doi: /wjo.v1.i1.26.

21 Take home: Spondylolysis 50% of back pain in young athletes > 80% improve with conservative treatment Bracing effective only with early stages Stork test is non-specific Concept of Active vs Inactive : High prevalence of asymptomatic lysis and listhesis

22 References Beck NA, Miller R, Baldwin K, Zhu X, Spiegel D, Drummond D, Sankar WN, Flynn JM. Do oblique views add value in the diagnosis of spondylolysis in adolescents? J Bone Joint Surg Am May 15;95(10):e65. doi: /JBJS.L Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a metaanalysis. BMC Pediatr 2013;13:14. Gelfand MJ, Sharp SE. Bone SPECT with low dose co-registered CT in pediatric patients. J Nucl Med 2010;37 (suppl 2):211. Standaert CJ. Spondylolysis in the adolescent athlete. Clin J Sport Med 2002;12(2): Gelfand MJ, Parisi MT, Treves ST; Pediatric Nuclear Medicine Dose Reduction Workgroup. Pediatric radiopharmaceutical administered doses: 2010 North American consensus guidelines. J Nucl Med 2011;52(2): Sharp SE, Gelfand MJ, Anton CG. Bone SPECT/CT compared to bone SPECT and conventional radiographs in pediatric spondylolysis evaluation. J Nucl Med 2012;53(suppl 1):262. Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology 1991;180(2): Cavalier R, Herman MJ, Cheung EV, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents. I. Diagnosis, natural history, and nonsurgical management. J Am Acad Orthop Surg 2006;14(7): Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L. Lumbar spondylolysis: a review. Skeletal Radiol 2011; 40(6): Yang J, Servaes S, Edwards K, Zhuang H. Prevalence of stress reaction in the pars interarticularis in pediatric patients with new-onset lower back pain. Clin Nucl Med 2013;38(2): Huang P, Anissipour A, McGee W, Lemak L. Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries: A Comprehensive Review. Sports Health. 2016;8(1): doi: / Trout AT, Sharp SE, Anton CG, Gelfand MJ, Mehlman CT. Spondylolysis and Beyond: Value of SPECT/CT in Evaluation of Low Back Pain in Children and Young Adults. RadioGraphics :3,

23 References Cont. Masci L, Pike J, Malara F, Phillips B, Bennell K, Brukner P. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. British Journal of Sports Medicine. 2006;40(11): doi: /bjsm Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am. 2000;84: Moller H, Hedlund R. Surgery versus conservative management in adult isthmic spondylolisthesis a prospective randomized study: part 1. Spine (Phila Pa 1976). 2000;25: Syrmou E, Tsitsopoulos PP, Marinopoulos D, Tsonidis C, Anagnostopoulos I, Tsitsopoulos PD. Spondylolysis: A review and reappraisal. Hippokratia. 2010;14(1): Iwamoto J, Sato Y, Takeda T, Matsumoto H. Return to sports activity by athletes after treatment of spondylolysis. World Journal of Orthopedics. 2010;1(1): doi: /wjo.v1.i1.26. 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 Mar;29(2): doi: /BPO.0b013e fc5. Helenius I, Lamberg T, Osterman K, et al. Scoliosis research society outcome instrument in evaluation of long-term surgical results in spondylolysis and low-grade isthmic spondylolisthesis in young patients. Spine (Phila Pa 1976). 2005;30: 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: d Hemecourt PA, Zurakowski D, Kriemler S, Micheli LJ. Spondylolysis: returning the athlete to sports participation with brace treatment. Orthopedics. 2002;25: Haus BM, Micheli LJ. Back pain in the pediatric and adolescent athlete. Clin J Sports Med. 2012;31: Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am. 1984;66: Grødahl LH, Fawcett L, Nazareth M, Smith R, Spencer S, Heneghan N, Rushton A.Diagnostic utility of patient history and physical examination data to detect spondylolysis and spondylolisthesis in athletes with low back pain: A systematic review. Man Ther Aug;24:7-17. doi: /j.math Epub 2016 Apr 1. Alqarni AM, Schneiders AG, Cook CE, Hendrick PA. Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review. Phys Ther Sport Aug;16(3): doi: /j.ptsp Epub 2015 Jan 8.