Spondylolysis

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Spondylolysis (spon-dee-low-lye-sis) is defined as a stress defect or fracture of the interarticular pars of the vertebral arch. Most cases occur in the lower lumbar vertebrae (L5), but spondylolysis may also occur in the cervical vertebra.

Video Spondylolysis

Signs and symptoms

In most cases, spondylolysis appears asymptomatic that can make the diagnosis difficult and incidental. When a patient presents with symptoms, there are general signs and symptoms that the doctor will seek:

Clinical Signs:
- Pain on completion of stork test (placed in hyperextension and rotation)
- Excessive lordotic posture
- unilateral tenderness on palpation
- Visible on diagnostic imaging (Scottie dog fracture)
Symptoms:
- Unilateral lower back pain
- Pain that spreads to the buttocks or feet
- Pain can be acute or gradual
- Pain that can limit daily activity
- Pain that worsens after strenuous activity
- Pains get worse with lumbar hyperextension

Maps Spondylolysis

Cause

The cause of spondylolysis remains unknown, but many factors are thought to contribute to its development. This condition is present in up to 6% of the population, most of which are usually present with no symptoms. Research supports that there are hereditary and acquired risk factors that can make a person more vulnerable to disability. This disorder is more common in men than in women, and tends to occur earlier in men because of their involvement in more severe activities at a younger age. In young athletes, the spine is still growing which means there are many centers of hardening, leaving a point of weakness in the spine. This makes young athletes at increased risk, especially when engaging in recurrent hyperextension and rotation across the lumbar spine. Spondylolysis is a common cause of low back pain in adolescents and juvenile athletes, as it accounts for about 50% of all low back pain. It is believed that neither repetitive trauma nor innate genetic weakness can make a person more susceptible to spondylolysis.

Risk factors

Exercise involving recurrent hyperextension of the spine, especially when combined with rotation is the primary mechanism of injury to spondylolysis. The stress fracture of the interarticular pars occurs on the opposite side of the activity. For example, for a right-handed player, a fracture occurs on the left side of the vertebra.

Spondylolysis memiliki kejadian yang lebih tinggi dalam kegiatan berikut:

Baseball
Tennis
Menu
Cheerleading
Senam
Sepak Bola Gridiron
Sepak Bola Asosiasi
Gulls
Angkat Berat
Roller Derby
Cricket
Pole Vault
Rugby
Bola Flights
Gym
Ultimate Frisbee (you can get a benturan dari peletakan)
Ballet

Although this condition can be caused by recurrent trauma to the lumbar spine in strenuous exercise, other risk factors may also affect the individual to spondylolsis. Men are more often exposed to spondylolysis than women. In one study looking at adolescent athletes, it was found that the average age of individuals with spondylolistesis was 20 years. Spondylolysis also occurs in families that exhibit inherited components such as predisposing to weaker vertebrae.

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Pathophysiology

Spondylolysis is a bone or fracture defect in the interarticularis of the vertebral arch in the spine. Most spondylolysis occurs in the lumbar vertebrae, but can also be seen in the cervical vertebrae. The lumbar vertebra consists of the body, pedicles, laminae, interarticularis pars, transverse processes, spinous processes and superior and inferior articular facies, which form joints connecting the joint vertebrae. When examining the vertebrae, the pars interarticularis is a segment of the bone between the superior and inferior articular facet joints that lie anteriorly to the lamina and posterior to the pedicles. The separation of the interarticular pars occurs when spondylolysis is present in the spine.

Spondylolysis is usually caused by bone stress fractures, and is very common in adolescents who exercise too much in activities. Pars interarticularis are prone to fractures during spinal hypertension, especially when combined with rotation, or when experiencing strength during landing. This stress fracture is most common in which the concave lumbar spine transitions into the convex sac (L5-S1). A large number of individuals with spondylolysis will develop spondylolisthesis, which is true for 50-81% of this population.

Spondylolysis of the Lumbar Spine: Symptoms, Causes & Treatments

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Diagnosis

There are several imaging techniques used to diagnose spondylolysis. Common imaging techniques include X-ray, MRI, Bone Scintigraphy (Bone Scan), and Computed Tomography (CT Scan). Qualified health care practitioners are also capable of performing clinical tests such as a one-foot hiperekstensi test to diagnose active spondylolysis.

One-foot hyperextension test

This is a test performed by a qualified health practitioner in a clinical setting. This involves the patient standing on one leg and then leaning back. The test should result in pain on the side of the spine similar to the foot you use. If producing pain this shows spondylolysis on that side. The test is then performed on the other side to assess the pain again. The test can be positive on one side, either side or not.

X-Ray

X-rays (electromagnetic radiation) are projected through the body to produce images of their internal structures. Radiation is further attenuated by the dense tissue of the body (ie the bone) than the soft tissues (ie muscles, organs, etc.) creating images consisting of shades of gray ranging from white to black. The vertebrae with a fracture or defect in the interarticular pars will have dark markings in this bone area. Because it is difficult to see in the posterior anterior x-ray image, the oblique x-ray of the lumbar spine can usually identify spondylolysis. If there is no conclusion CT scans can further produce 3-dimensional images to more clearly show defects even though the exam increases the patient's radiation dose by at least an order of magnitude rather than the usual x-ray.

Bone skintigraphy

Also known as bone scanning, bone scintigraphy involves injecting a small amount of radioactive tracer into the bloodstream. This tracker decays and emits radioactive energy that can be detected by a special camera. The camera produces black and white images where the area shown as dark black indicates bone damage in some types. If there is a black dot in the lumbar vertebra (eg L5) it indicates damage and potentially spondylolysis. If the test is positive, CT scans are usually ordered to confirm spondylolysis.

Computed tomography

Commonly known as CT Scan or CAT scan, this form of imaging is very similar to x-ray technology but produces more images than x-rays. Some images produce cross-section is not possible with x-ray. This allows a doctor or radiologist to examine images from more angles than the x-rays allow. For this reason CT scans are much more accurate in detecting spondylolysis than x-rays. Bone scintigraphy combined with CT scans is considered a gold standard meaning that it is best to detect spondylolysis.

MRI

MRI is a newer technique used to diagnose spondylolysis and is advantageous for several reasons. MRI is much more accurate than x-rays and also does not use radiation. MRI uses powerful magnets and radio frequencies to produce very detailed images of various network densities including bone and soft tissue.

Spine Fracture Spondylolysis Spondylolisthesis Is A Defect ...

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Treatment

Conservative management

Treatment for spondylolysis ranges from strengthening, activity restriction, extension exercises, flexion exercises and deep abdominal strengthening, provided through physical therapy. The duration of physical therapy that patients receive varies based on the severity of spondylolysis, but usually ranges from three to six months. The purpose of physical therapy is to minimize the movement of the unstable defects of the interarticular pars. After a patient completes physical therapy, and shows no symptoms or inflammation in the lower back, they are cleansed to resume daily or athletic activities. However, patients may need to maintain various rehabilitation techniques after physical therapy to prevent recurrence of spondylolysis.

Abdominal co-contraction exercises in

The goal of deep abdominal co-contraction exercises is to train the muscles surrounding the lumbar spine that provide spinal stability. Spondylolysis produces spinal instability and disrupts the pattern of joint recruitment between muscle synergies. In particular, local muscles attached directly to the spine are affected. The lumbar multifidis and transversus abdominis play a direct role in stabilizing the lumbar spine. In contrast localized muscles in individuals with spondylolysis are susceptible to dysfunction, resulting in abnormal spinal stability that causes chronic back pain. To compensate, large torques that produce global muscles are used to stabilize the spine.

In one study, patients were taught to train inner abdominal muscle contraction and lumbar multifidus in static posture, functional tasks and aerobic activity. This technique is proven to reduce pain and functional disability when compared with other conservative treatments. These results also have long-term effects in reducing pain levels and functional disabilities. This is because motor programming eventually becomes automatic, and conscious control is no longer necessary to contract the abdominal muscles during activity.

Activity restrictions

Limiting the activity of spondylolysis is recommended for a short time after the patient becomes symptoms, followed by a guided physical therapy program. After spondylolysis has been diagnosed, treatment often consists of a short rest period of two to three days, followed by a physical therapy program. There should be weight lifting restrictions, excessive bending, twisting and avoiding any work, recreational activities or participation in sports that cause stress on the lumbar spine. Activity restrictions can help eliminate and control the patient's symptoms so they can continue their normal activities. Activity restrictions most commonly used in conjunction with other rehabilitation techniques include bracing.

Bracing

Acute spondylolysis is most often treated through the use of an anti-lordotic brace (Boston brace) to control and restrict spinal movement, and reduce stress on the injured spinal segment. Bracing paralyzes the spine in a position of flexion for a short time to allow healing of bone defects in the interarticular pars. An antilordotic brace typically uses a contoured plastic component to fit the body. Brace antilordotic then reduces athlete's symptoms by reducing the amount of stress on the lower back, and allows a quick return to the sport for athletes. Typically, bracing is used for 6-12 weeks.

In order for the amplifier to be effective, it must be worn daily for the amount of time it takes. Patients are given a clamp schedule determined by their physical therapist who explains the amount of time that should be used daily. The effectiveness of the brace increases with adherence to the bracing schedule. Patients who do not follow their support schedule are more likely to progress symptoms. Studies have shown that when braces are used as determined by full adherence, they successfully prevent the development of spondylolysis.

Surgery

Most patients with spondylolysis do not require surgery but, if symptoms do not go away with non-surgical treatment, or when conditions develop into high-level spondylolistesis, then the patient may require surgery. There are two main types of surgery for this condition:

Spinal Fusion: This procedure is recommended when a set of spine becomes loose or unstable. The surgeon combines two or more bones (vertebrae) together through the use of metal rods, screws, and bone graft. Bone grafts complete their fusion within 4-8 months after surgery, securing the spine in the correct position. This procedure is also used to treat spine instability, fractures in the lumbar spine and, severe degenerative disc disease. This process is relatively non-invasive, done through a small incision and has a high success rate.
Laminectomy: Often done when spinal stenosis occurs simultaneously with spondylolysis. This procedure removes part or all of the lamina from the vertebral bone ring to reduce the pressure on the spinal cord. Laminectomy is generally performed on the spine in the lower back and in the neck.

Dr Balaji Anvekar's Neuroradiology Cases: Spondylolysis

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Implications for rehabilitation

Spondylolysis can have a major impact on a young athlete's career, and can hamper their future ability to perform. It is important to understand how social and psychological factors can affect the rehabilitation of injured athletes.

Frustration, anger, confusion, fear and depression are some of the psychological factors experienced by injured athletes, therefore a debilitating injury can have a major impact on the mental well being of an athlete. These psychological factors can also affect the recovery and return to the sport for fear of back injuries often prevents athletes from following rehabilitation and return to their sport at full intensity.

Social factors can also affect cognitive, behavioral, and physical responses to injury. More specifically, the social isolation of the team can have profound psychological effects. This makes it important to provide social support through listening support, emotional support, personal assistance and reality conformation.

It is also important to educate athletes on the rehabilitation process so they know what to expect. For example, explaining what activities should be avoided and will cause pain and length of treatment process. In addition, it is important to choose the right treatment option for each individual. For compliance conservative methods of this exercise requires motivated patients as it can become tedious and time-consuming. For example, one study looking at deep abdominal coagulation contractions reported that it took 4-5 weeks to reach this co-contraction pattern.

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References