|
https://upload.orthobullets.com/topic/2058/images/lysis.jpg
https://upload.orthobullets.com/topic/2058/images/spect scan.jpg
https://upload.orthobullets.com/topic/2058/images/slip_angle.jpg
Introduction
  • Common cause of low back pain in children and adolescents. 
  • Conditions represent a continuum of disease including
    • pars stress reaction
    • spondylolysis
    • spondylolithesis
  • Definitions
    • pars stress reaction
      • sclerosis with incomplete bone disruption of pars
    • spondylolysis
      • term used to describe anatomic defect (radiolucent gap) in pars interarticularis with adjacent bone sclerosis
      • epidemiology
        • one of most common causes of back pain in children and adolescents
        • defects are not present at birth and develop over time (seen in 4-6% if population)
      • mechanism
        • usually activity related and occurs from repetitive hyperextension
        • prevalence as high as 47% in certain athletes (gymnasts, weightlifters, football linemen)
    • spondylolisthesis
      • defined as forward translation of one vertebral segment over the one beneath it
      • epidemiology
        • approximately 15% of individuals with a pars interarticularis lesion have progression to spondylolisthesis
        • most common at L5-S1 (90%) in adolescents and adults
      • risks of progression
        • the larger the slip the more likely it is to progress
        • dysplastic slips (Wiltse Type I) are more likely to progress
      • severity of current slip
        • correlates most strongly with pelvic incidence
Spondylolisthesis Classification
 
Wiltse-Newman Classification
Type I Dysplastic
• Secondary to congenital abnormalities of lumbosacral articulation including maloriented or hypoplastic facets, sacral deficiency, poorly developed pars
• Posterior elements are intact (no spondylolysis)
• More significant neurologic symptoms
 Type II-A  • Isthmic - Pars Fatigue Fx
 Type II-B  • Isthmic - Pars Elongation due to healed stress fx
 Type II-C  • Isthmic - Pars Acute Fx
 Type III  • Degenerative
 Type IV  • Traumatic
 Type V  • Neoplastic
 
Marchetti-Bartolozzi classification
 Developmental  • Includes Wiltse I and II
 Acquired  • Traumatic, postsurgical, pathologic, degenerative
 
Myerding Classification
 Grade I  • < 25%
 Grade II  • 25-50%
 Grade III  • 50-75%
 Grade IV  • 75-100%
 Grade V  • Spondyloptosis
 
Presentation
  • Symptoms
    • most cases of spondylolysis are asymptomatic
    • symptoms include insidious onset of activity related low back pain and/or buttock pain
    • neurologic symptoms include
      • hamstring tightness (most common) and knee contracture
      • radicular pain (L5 nerve root)
      • bowel and bladder symptoms
      • cauda equina syndrome (rare)
    • listhetic crisis
      • severe back pain aggravated by extension and relieved by rest
      • neurologic deficit
      • hamstring spasm - walk with a crouched gait
  • Physical exam
    • palpation and motion 
      • flattened lumbar lordosis 
      • palpable step off of spinous process
      • limitation of lumbar flexion and extension
        • pain with single-limb standing lumbar extension  
      • measure popliteal angle to evaluate for hamstring tightness 
    • neurologic exam
      • straight leg raise may be positive
      • rectal exam if bowel and bladder symptoms present
Imaging
  • Pars Stress Reaction & Spondylolysis
    • radiographs
      • lateral radiograph
        • may show defect in pars in 80% 
      • oblique radiograph
        • views may show sclerosis and elongation in pars interarticularis (scotty dog sign) 
      • AP
        • may see sclerosis of the stress reaction 
    • bone scan
      • most sensitive (however lesion may be cold) 
      • excellent screening tool for low back pain in children or adolescents
    • CT 
      • best study to diagnose and delineate anatomy of lesion 
      • pars stress reaction will show up as sclerosis on xrays and CT scan 
    • Single photon emission computer tomography (SPECT)  
      • best diagnostic adjunct when plain radiographs are negative  
  • Spondylolisthesis
    • radiograph
      • views
        • lateral xray used to measure slip angle and grade.
        • flexion and extension radiographs used to evaluate instability
      • measurements
        • slip grade  
          • slippage on plain lateral radiographic imaging measured in accordance to the vertebra below
            •  The caudal vertebra is divided into four parts
              •  Grade I means a translation of the cranial vertebra of up to 25%
              • Grade II of up to 50% 
              • Grade III of up to 75%
              • Grade IV up to 100%
              • Grade V describes the ptosis of the cranial vertebra
        • slip angles
          • methodology to determine slip angle  
        • pelvic incidence    
          • pelvic incidence = pelvic tilt + sacral slope
          • a line is drawn from the center of the S1 endplate to the center of the femoral head
          • a second line is drawn perpendicular to a line drawn along the S1 endplate, intersecting the point in the center of the S1 endplate
          • the angle between these two lines is the pelvic incidence (see angle X in figure above)
          • correlates with severity of disease   
          • pelvic incidence has direct correlation with the Meyerding–Newman grade  
        • pelvic tilt    
          • pelvic tilit =  pelvic incidence - sacral slope
          • a line is drawn from the center of the S1 endplate to the center of the femoral head
          • a second vertical line (parallel with side margin of radiograph) line is drawn intersecting the center of the femoral head
          • the angle between these two lines is the pelvic tilt (see angle Z in figure above)
        • sacral slope    
          • sacral slope = pelvic incidence - pelvic tilt
          • a line is drawn parallel to the S1 enplate
          • a second horizontal line (parallel to the inferior margin of the radiograph) is drawn
          • the angle between these two lines is the sacral slope (see angle Y in the figure above)
    • CT
      • best study to diagnose and delineate anatomy of pars defect
    • MRI
      • indicated if neurologic symptoms present
      • useful to diagnose associated stenosis central and foraminal
NonOperative Treatment
  • Nonoperative
    • observation with no activity limitations
      • indications
        • asymptomatic patients with low-grade spondylolisthesis or spondylolysis 
      • may participate in contact sports 
    • physical therapy and activity restriction
      • indications
        • symptomatic isthmic spondylolysis
        • symptomatic low grade spondylolisthesis
      • technique
        • physical therapy should be done for 6 months and include 
          • hamstring stretching
          • pelvic tilts
          •  abdominal strengthening 
        • watch low grade dysplastic carefully as there is a higher chance of progression
    • TLSO bracing for 6 to 12 weeks
      • indications
        • acute pars stress reaction spondylolysis
        • isthmic spondylolysis that has failed to improve with physical therapy
        • low grade spondylolisthesis that has failed to improve with physical therapy
      • outcomes
        • brace immobilization is superior to activity restriction alone for acute stress reaction  spondylolysis 
  • Operative
    • par interarticularis repair 
      • indications
        • L1 to L4 isthmic defect that has failed nonoperative management
        • multiple pars defects
    • L5-S1 in-situ posterolateral fusion with bone grafting
      • indications
        • L5 spondylolysis that has failed nonoperative treatment
        • low grade spondylolisthesis (Myerding Grade I and II) that
          • has failed nonoperative treatment
          • is progressive
          • has neurologic deficits
          • is dysplastic due to high propensity for progression
    • L4-S1 posterolateral fusion, +/- reduction,  (+/- ALIF)
      • indications
        • high grade isthmic spondlylisthesis (Meyerding Grade III, IV, V) q
        • reduction is extremely controversial with no accepted guidelines 
Surgical Technique
  • Par interarticularis repair 
    • approach
      • posterior midline approach to lumbar spine 
    • technique
      • repair pars defect with screw fixation, tension wiring, or screw and sublaminar hook technique
      • decompression indicated if clinical symptoms of stenosis
  • L5-S1 in-situ posterolateral fusion with bone grafting
    • approach
      • posterior midline approach to lumbar spine 
    • reduction
    • technique
      • in-situ fusion with bone grafting / with or without instrumentation 
      • postoperative immobilization in a TLSO
      • decompression only indicated if clinical symptoms of stenosis or radiculopathy
  • L4-S1 posterolateral fusion +/- reduction
    • approach
      • posterior midline approach to lumbar spine 
    • reduction
      • reduction may be done with instrumentation or positioning
      • pros of reduction
        • can restore sagittal alignment and reduce lumbosacral kyphosis
      • cons
        • risk of significant complications (8-30%) including
          • L5 is the most common nerve root injury with reduction 
          • sexual dysfunction
          • catastrophic neurologic injury
    • fusion
      • usually instrumented
Complications
  • Neurologic deficits
  • Pseudoarthrosis
  • Progression of slippage
  • Hardware failure 
 

Please rate topic.

Average 4.2 of 45 Ratings

Questions (12)
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase

(OBQ09.15) A 17-year-old high school football lineman was diagnosed with the condition shown in the Figure A radiograph. He continues to have pain despite 6 months of wearing a custom lumbar spine orthotic (LSO) and avoiding all sports activities. His physical exam is notable for pain with single-limb standing lumbar extension and a normal neurologic exam. How would the surgical management differ if this condition occurred at L3 instead of L5? Review Topic

QID: 2828
FIGURES:
1

Pars interarticularis repair is indicated

76%

(1398/1850)

2

Lumbosacral fusion is indicated

6%

(105/1850)

3

Gill procedure is indicated

8%

(157/1850)

4

Combined anterior interbody fusion and posterior decompression is indicated

6%

(118/1850)

5

Iliac crest bone grafting is indicated

3%

(59/1850)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase

(OBQ08.55) A 14-year-old soccer player has a history of intermittent low back pain. He reports for the last 4 months he has had no symptoms or limitations in his athletic activity. Treatment should include? Review Topic

QID: 441
FIGURES:
1

a thoracolumbar orthosis

4%

(73/2046)

2

in situ L5-S1 bilateral posterolateral fusion

1%

(14/2046)

3

repair of pars defect wih screw fixation

2%

(32/2046)

4

limitation of athletic activity

10%

(207/2046)

5

observation with no restriction of physical activity

84%

(1714/2046)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ11.61) A 12-year-old gymnast has had progressive low back and buttock pain refractory to conservative management for two years. A sagittal MRI is shown in Figure A. Surgical management with reduction of L5 on S1 would most likely lead to which of the following neurologic complications? Review Topic

QID: 3484
FIGURES:
1

Decreased patellar reflexes

1%

(20/3982)

2

Weakness to hip flexion

1%

(22/3982)

3

Weakness to great toe extension

84%

(3347/3982)

4

Weakness to knee extension

1%

(30/3982)

5

Weakness to ankle plantar flexion

14%

(551/3982)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ06.10) A 13-year-old gymnast reports the acute onset of low back pain that began four weeks ago. Radiographs are unremarkable. A single-photon-emission-computer-tomography (SPECT) is shown in Figure A. Initial treatment should consist of? Review Topic

QID: 21
FIGURES:
1

Bracing with a molded lumbosacral orthosis

79%

(1634/2064)

2

Aggressive physical therapy

16%

(337/2064)

3

CT guided biopsy

3%

(52/2064)

4

In-situ posterolateral fusion of L5-S1

1%

(26/2064)

5

Epidural steroid injection

0%

(8/2064)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ07.71) What additional diagnostic test is most sensitive to diagnose pediatric spondylolysis when AP and lateral radiographs are normal. Review Topic

QID: 732
1

Flexion-extension lateral radiographs

9%

(203/2264)

2

Oblique radiographs of the of the lumbosacral spine

13%

(296/2264)

3

Single photon emission computed tomography (SPECT)

71%

(1616/2264)

4

Indium-labeled bone scan

6%

(137/2264)

5

Ultrasound

0%

(6/2264)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
EVIDENCE & REFERENCES (36)
VIDEOS (2)
GROUPS (1)
Topic COMMENTS (32)
Private Note