Hi, everyone! Today I'm going to talk to you about Spondylolysis. So, what is it exactly? Spondylolysis is a condition which affects the lumbar spine. It is defined as a defect or stress fracture in the pars interarticularis of a lumbar vertebra and can occur unilaterally (meaning on one side) as seen in 25 to 50 percent of cases or bilaterally (meaning on both sides). The majority of cases occur at the fifth lumbar vertebra or L5 with much of the remainder occurring at L4. Pars defects can also be noted at more than one level but according to David Hersh and colleagues "defects involving multiple vertebral levels, [...], are extremely rare." This brings me to what causes Spondylolysis. Other than acute trauma, Spondylolysis is typically caused by repetitive microtrauma to the bone stemming from excessive hyper-extension and rotation of the spine. A genetic predisposition, environmental factors, and improper sports technique also play a role.
An interesting point, stated by multiple authors including Carl Stanitski, Robert Metzger, and Susan Chaney is that Spondylolysis is not found in infants or those who have never walked So, the condition also seems to be linked with the onset of walking. Now, who is most at risk? Men are twice as likely to have a pars defect than women although women have a greater likelihood of progression to Spondylolisthesis which is a related but independent condition. Spondylolisthesis is when one vertebra slips over the next one. In terms of sports, symptomatic Spondylolysis appears in approximately 8 to 14 percent of adolescent athletes although some sports see much higher incident rates of up to 35 percent. Particularly vulnerable populations include... Wrestlers, gymnasts, ballet dancers, weight lifters, football players, golfers, and track and field throwers.
All of these sports require frequent loading, hyperextension, and/or rotation of the spine. How does it present? A person with Spondylolysis will present as having low back pain which worsens upon hyperextension and rotation. Tight hamstrings can be found in up to 80 percent of cases as well as weak abdominals, possible lumbar muscle spasms, localized tenderness, increased lumbar lordosis, and decreased range of motion. How is it diagnosed? A diagnosis is reached after a detailed physical exam and imaging tests have been completed. A one leg hyperextension (or stork standing) test is routine. The patient will be asked to stand on one leg and then hyperextend the spine. If pain is elicited in the lumbar spine upon this action it is indicative of spinal injury and further imaging tests should be completed.
In terms of imaging, the first approach is often a plain radiograph (or x-ray) taken of the lumbar spine of the back and side views. The lateral view may show the cardinal sign of the Scotty Dog with a collar. It is called a Scotty Dog sign because the lateral view of the vertebra takes the shape of a little Scottish Terrier. An image in which the Scotty Dog appears to be wearing a collar is abnormal and suggests there is a break in the bone at that location. If x-rays are insufficient for a diagnosis, a CT scan or SPECT bone scan is generally the second course of action. A CT scan is best for the visualization of bone but a bone scan may be preferred since it is sensitive to any bony areas in the active healing process. However, bone scans subject patients to much more radiation than CT scans. Therefore, both tests should be considered carefully.
An MRI often misses a Spondylolysis defect but it may still be warranted for patients with more complex issues such as Spondylolisthesis with disc or nerve involvement. So, how do you treat Spondylolysis? Most treatments are conservative or non-operative and often include a period of rest, the use of a back brace from anywhere between 2 to 6 months, physical therapy, core strengthening, flexibility training, and the identification of risk factors in order to modify activity upon return to play and prevent recurrence. NSAIDs are also helpful to reduce pain during recovery. For patients who do not improve after six months of conservative treatment, or for patients with a high degrees of Spondylolisthesis, surgical treatments should be explored. Surgical interventions include direct repair of the pars through instrumentation techniques such as using wires, hooks, and screws, or fusion (usually of L5 to S1) through a posterior iliac crest bone graft. Non-surgical patients can gradually return to non-contact sports while using a brace after 4 to 6 weeks Contact sports should be avoided until full range of motion and pain free extension returns. For patients who have had spinal fusion surgery, non-contact sports can be resumed after 6 months and contact sports after 1 year. Exercises which should be used during rehab include low weight bearing activities such as swimming and cycling, strength training exercises in a seated or lying supine position such as the bridge, plank, and sit ups with knees bent, and exercise ball activities.
Pull downs and overhead work is discourage during rehab as are any exercises involving increased stress to or hyperextension of the spine. And, lastly, what are the complications of Spondylolysis? As mentioned earlier, Spondylolisthesis can be a complication of Spondylolysis. Other complications are a pars non-union (or fracture that doesn't heal), postural changes due to pain which can predispose someone to further injury, and psychological distress. This last point has a significant impact on dancers. Findings from a study of 154 dancers seeking treatment for injury at the Medical Centre for Dancers and Musicians in the Netherlands indicated that 60.1 percent of the patients met the criteria for referral to a psychiarist and 46.6 percent had "above average" distress levels. This suggests that psychological distress may be brought on or worsened by sustaining a dance related injury.
Therefore, special care needs to be taken to treat the whole person when presenting with an injury such as Spondylolysis. And, that's it! Thanks for watching!.
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