Spondylolysis

Adolescent patient presents with back pain for > 3 weeks. Pain located at the level of L4-L5 and is worse with lumbar spine hyperextension. Patient actively involved in gymnastics, football, soccer, weightlifting, volleyball, dance. Hyperlordosis and limited flexion/extension on exam. Pain reproduced with single-leg hyperextension.

  • Obtain lumbar spine x-ray with AP/lateral/bilateral oblique views

    • Evaluate for stress fracture of pars interarticularis

    • Diagnosis uncertain s/p plain film: Consider lumbosacral SPECT scan

  • Treatment

    • Recommend relative rest from offending activity, NSAIDs for pain

      • Patient may return to full activity in 6 months

      • Consider referral to physical therapy after ruling out spondylolisthesis (see below)

    • Refer to orthopedics if symptoms persist

Example of spondylolisthesis: Anterior dislocation of L5 due to stress fracture in the pars interarticularis. By BruceBlaus - Own work.

Example of spondylolisthesis: Anterior dislocation of L5 due to stress fracture in the pars interarticularis. By BruceBlaus - Own work.

Spondylolisthesis

12 y/o F gymnast presents with chronic and paroxysmal lumbar back pain. Chronic pain is a dull ache in the lumbar region. Paroxysmal pain is sharp, worse with extension (e.g. during back handspring), and radiates both laterally and into the buttocks. Paroxysmal pain sometimes accompanied by paresthesias in the back/buttocks and transient lower extremity weakness. Denies fever, chills, night pain, urinary retention, fecal incontinence. Kyphotic posture, hyperlordosis with anterior pelvic tilt, pain with deep L-spine palpation, hamstring/gluteal weakness, and positive Stark (single leg hyperextension) test on exam.

  • Imaging

    • Obtain plain anteroposterior (AP) and lateral radiograph of the lumbar spine and evaluate for fracture/vertebral displacement

    • Obtain MRI if plain films do not show pathology and

      • Pain persists after 2-3 weeks rest

      • Patient is an athlete and wishes to return to play

  • Imaging reveals spondylothisthesis: Refer to orthopedics for back brace x 6 weeks

Notes

  • Pathophysiology:

    • Stress fracture in pars interarticularis (spondylosis) leading to vertebrals displacement (spondylolisthesis)

    • Other sports related injuries may include serving/spiking ball in tennis/volleyball

  • Stark test

    • Patient stands on each leg and extends back

    • Considered positive if pain is elicited

  • Imaging

    • Consider repeating plain films if both x-ray and MRI are negative but pain persists for > 6 weeks

    • CT is not indicated