Summary Pediatric Spondylolysis & Spondylolisthesis represent a continuum of disease where there is a fracture of the pars interarticularis (spondylolysis) which may progress to anterior subluxation of one vertebral body anterior to the adjacent inferior vertebral body (spondylolisthesis). Diagnosis of spondylolysis alone can be challenging on imaging and the ideal study is controversial. Radiographs, CT scan, and MRI may all play a role. Spondylolisthesis is diagnosed on a lateral radiograph. Treatment may be nonoperative or surgical depending on the degree of back pain, malalignment of vertebral bodies, and neurological symptoms. Epidemiology Incidence common up to 6-7% of adolescent athletes implicated in up to 47% of low back pain complaints in this population Demographics higher incidence in Native Americans Anatomic location typically involves pars of L5 and anterolisthesis of L5 relative to S1 Risk factors prevalence of spondylolysis may be as high as 47% in certain athletes (gymnasts, weightlifters, football linemen) contact sports and those involving repetitive hyperextension (ex. linebacker) higher sacral table index, pelvic incidence, sacral slope, and lower sacral table angle Etiology Pathophysiology conditions represent a continuum of disease including pars stress reaction login to view 1 more bullet spondylolysis login to view 4 more bullets isthmic spondylolisthesis (spondylolytic spondylolithesis) login to view 8 more bullets spondyloptosis login to view 1 more bullet Genetics possible autosomal dominant inheritance pattern Classification Wiltse-Newman Classification Type I Dysplastic Secondary to congenital abnormalities of lumbosacral articulation including mal-oriented 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-BartolozziClassification Developmental Includes Wiltse I and II Acquired Traumatic, postsurgical, pathologic, degenerative Meyerding Classification Grade I < 25% Grade II 25-50% Grade III 50-75% Grade IV 75-100% Grade V Spondyloptosis Presentation History classic history is healthy active adolescent who presents with acute onset of low back pain with athletic activity Symptoms asymptomatic many cases of spondylolysis are asymptomatic low back pain no association between radiologic grade and clinical presentation symptoms include insidious onset of activity related low back pain leg symptoms buttock pain hamstring tightness (most common) and knee contracture radicular pain (L5 nerve root) listhetic crisis severe back pain aggravated by extension and relieved by rest neurologic deficit hamstring spasm bowel and bladder symptoms rare cauda equina syndrome (rare) Physical exam inspection high grade/dysplastic patients may develop "heart shaped buttocks" due to sacral prominence flattened lumbar lordosis palpation login to view 1 more bullet motion limitation of lumbar flexion and extension measure popliteal angle to evaluate for hamstring tightness neurovascular straight leg raise may be positive rectal exam if bowel and bladder symptoms present provocative tests pain with single-limb standing lumbar extension gait may walk with a crouched gait when symptoms severe Imaging Pars stress reaction & spondylolysis radiographs indications login to view 1 more bullet AP view login to view 1 more bullet lateral view login to view 1 more bullet oblique view login to view 2 more bullets CT inidcations login to view 1 more bullet findings login to view 1 more bullet single photon emission computer tomography (SPECT) indications login to view 2 more bullets techniques login to view 1 more bullet MRI indications login to view 3 more bullets sensitivity & specificity login to view 1 more bullet bone scan indications login to view 1 more bullet sensitivity & specificity login to view 1 more bullet Spondylolisthesis radiographs views login to view 2 more bullets measurements login to view 29 more bullets CT best study to diagnose and delineate anatomy of pars defect MRI indicated if neurologic symptoms present useful to diagnose associated central and foraminal stenosis Treatment Nonoperative observation alone (no activity limitations) indications login to view 2 more bullets return to in contact sports is controvesial login to view 2 more bullets outcomes login to view 1 more bullet physical therapy & activity restriction indications login to view 2 more bullets technique login to view 4 more bullets outcomes login to view 2 more bullets bracing for 6 to 12 weeks indications login to view 3 more bullets technique login to view 1 more bullet outcomes login to view 1 more bullet Operative pars interarticularis repair indications login to view 2 more bullets outcomes login to view 1 more bullet L5-S1 posterolateral fusion, +/- ALIF, +/- sacroiliac fusion indications login to view 6 more bullets return to sport login to view 2 more bullets outcomes login to view 1 more bullet L4-S1 posterolateral fusion, +/- reduction, +/- sacroiliac fusion, +/- ALIF indications login to view 2 more bullets outcomes login to view 2 more bullets Techniques Pars 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 contraindications login to view 1 more bullet L5-S1 posterolateral fusion +/- ALIF approach posterior midline approach to lumbar spine technique decompression only indicated if clinical symptoms of stenosis or radiculopathy in-situ fusion with bone grafting / with or without instrumentation postoperative usually postoperative immobilization in a TLSO L4-S1 posterolateral fusion, +/- reduction, +/- sacroiliac fusion, +/- ALIF approach posterior midline approach to lumbar spine technique reduction login to view 8 more bullets fusion/decompression login to view 3 more bullets Complications Neurologic deficits consider neuromonitoring during reduction, especially in a high-grade slip L5 n. root injury is the most common neuro cx Pseudoarthrosis Slip Progression Hardware failure Prognosis Most symptomatic patients can be successfully managed nonoperatively In patients who fail non-operative management, spinal fusion results in 90% success rates Return to sports is controversial