Article

Prevalence of Spondylolysis in Symptomatic Adolescent Athletes: An Assessment of Sport Risk in Nonelite Athletes

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Abstract

Objective: To assess the risk of spondylolysis by sport in nonelite adolescent athletes with low back pain (LBP). Design: Retrospective case series. Setting: Hospital-based sports medicine clinic. Patients: The medical charts of 1025 adolescent athletes with LBP (age 15 ± 1.8 years) were examined; 308 (30%) were diagnosed with a spondylolysis. Assessment of risk: Risk of spondylolysis was assessed in 11 sports for males and 14 sports for females. Main outcome measure: Relative risk of diagnosis of spondylolysis injury. Results: The risk of spondylolysis differed by sex with baseball (54%), soccer (48%), and hockey (44%) having the highest prevalence in males and gymnastics (34%), marching band (31%), and softball (30%) for female athletes. Baseball was the only sport to demonstrate a significant increased risk of spondylolysis. Conclusions: The sports with the greatest risk of spondylolysis in adolescent athletes in this study were not consistent with published literature. Clinicians should be cautious generalizing high-risk sports to their practice, as geographic region and level of the athlete may significantly influence the incidence of spondylolysis in the population they are treating.

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... Современные исследователи, изучая спондилолиз, традиционно придерживаются двух основных теорий его происхождения и развития: врожденной [9,16,17] и приобретенной [18][19][20][21][22]. Основоположником теории о врожденном происхождении принято считать Ф.л. ...
... Интересную информациюоб этом приводят M. Selhorst с соавторами, проанализировавшие наличие спондилолиза у людей, профессионально занимающихся различными видами спорта. Оказалось, что из 11 видов спорта у мужчин и из 14 видов спорта у женщин наиболее опасными в плане формирования спондилолиза являются бейсбол и гимнастика соответственно [22]. ...
... нередко эта патология находится в «тени» более тяжелого заболевания, такого как спондилолистез, и при отсутствии его лучевых симптомов часто своевременно не диагностируется. В то же время поясничный болевой синдром, вызванный спондилолизом, заметно снижает качество жизни пациентов и нередко приводит к изменениям привычного режима двигательной активности, в том числе спортивной деятельности [10,22]. ...
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One of the main causes of lumbar spine pain is spondylolysis. The purpose of this review is to present the current state of the problem of diagnosis and treatment isolated and multilevel spondylolysis. Materials and Methods. The review includes 86 publications on the problem of spondylolysis for 2005–2019, obtained from electronic databases: PubMed, Cochrane Library, eLIBRARY, CYBERLENINKA. Results. There is still the only known classification of spondylolysis by P. Niggemann et al, which includes four severity of this pathology — from mild to very severe: A, BI, BII, BIII. The classification is based on the nature of changes in the area of bone defect of the vertebral arch when the patient performs functional tests. In some cases, the pathology can be regarded as a transition between different degrees of severity of type B. The treatment of spondylolysis can be both conservative and operational. The conservative therapy consists of physical activity restriction, physiotherapy, wearing a corset, massage, and pharmacotherapy. The purpose of surgical treatment is the removal of fibrous tissue from the zone of spondylolysis and the achievement in this area the bone fusion via a bone autoplasty and(or) osteosynthesis with different metal frameworks. Reasoned arguments about the need for a combination of conservative and surgical treatment of patients with spondylolysis are also reflected in the publications. Information on multilevel spondylolysis is represented by a small number of articles. only 15 authors described clinical cases of multilevel spondylolysis in a total of 21 patients. Spondylolysis is a high risk factor for the spondylolisthesis formation. Among the various categories of patients suffering from spondylolysis and lumbar spondylolysis spondylolisthesis, pregnant women are of particular interest. Hormonal restructuring and changes in the biomechanics of the spine in women during the gestational period often leads to the appearance or intensification pain syndrome in lumbar spine complicating the pregnancy, and hence a fetus development. Conclusion. Timely diagnosis of spondylolysis and the subsequent development of individual rehabilitation not only improves the quality of life of patients, but in some cases can prevent such a serious pathology as spondylolisthesis.
... 3 The most common identifiable cause of LBP in the adolescent athlete is an isthmic spondylolysis, a stress injury in the pars interarticularis. [4][5][6] Research on spondylolysis has focused on diagnosis, radiographic healing, the effects of bracing, and rest from activity. Although spondylolysis is a common injury among adolescent athletes, no detailed description of physical therapy care for this population exists. ...
... [7][8][9] The prevalence of spondylolysis in symptomatic adolescent athletes is reported to be two to five times higher than nonathletes, with a prevalence of 14-30% among adolescent athletes reporting LBP. 6,10,11 Spondylolysis is 1.6-4.5 times more prevalent in adolescent males than females reporting LBP. 6,11 Spondylolysis occurs in other populations but at a much lower rate; the prevalence reported in children is 2.5-4.5%, ...
... 6,10,11 Spondylolysis is 1.6-4.5 times more prevalent in adolescent males than females reporting LBP. 6,11 Spondylolysis occurs in other populations but at a much lower rate; the prevalence reported in children is 2.5-4.5%, increasing to 6% in the general adolescent and adult populations. ...
Article
Low back pain in adolescent athletes is quite common, and an isthmic spondylolysis is the most common identifiable cause. Spondylolysis, a bone stress injury of the pars interarticularis, typically presents as focal low back pain which worsens with activity, particularly with back extension movements. Research on spondylolysis has focused on diagnosis, radiographic healing, the effects of bracing, and rest from activity. Although physical therapy is frequently recommended for adolescent athletes with spondylolysis, there have been no randomized controlled trials investigating rehabilitation. Additionally, there are no detailed descriptions of physical therapy care for adolescent athletes with spondylolysis. The purpose of this clinical commentary is to provide a brief background regarding the pathology of isthmic spondylolysis and provide a detailed description of a proposed plan for physical therapy management of spondylolysis in adolescent athletes. Level of evidence: 5.
... Adolescent athletes and non-athletes show comparable frequencies of LBP, although athletes in some sports show greater risk [3,4]. The most prevalent recognized cause of LBP among adolescent athletes is lumbar spondylolysis [5,6], a fatigue fracture of the pars interarticularis resulting from repeated minor traumas due to loading [7]. Adolescent lumbar spondylolysis is categorized into early, progressive, or terminal stages [8]. ...
... Baseball is a popular sport among adolescents and is reported to show higher incidence of lumbar spondylolysis than other sports [3,6,15]. Previous studies investigating the clinical characteristics of ESS have included adolescent athletes participating in various sports [15e17]; such studies can be generalized, but studies focusing on one sport are more useful in providing specific suggestions. ...
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Background Many adolescent athletes experience low back pain; the most common cause is lumbar spondylolysis. Although early identification of lumbar spondylolysis in adolescent athletes is critical, few studies have focused on identifying the early stages of spondylolysis in baseball players. This study aimed to investigate the clinical characteristics of early-stage spondylolysis in male adolescent baseball players. Methods The participants comprised male junior and high school baseball players. Before magnetic resonance imaging, we recorded their demographic data, low back pain characteristics, and physical findings (lumbar flexion, extension, Kemp's test and the provocative tenderness of a spinous process). After the imaging evaluation, the association among low back pain characteristics, physical findings and the final diagnosis (early-stage spondylolysis or not) were investigated using univariate and multivariable analyses. Results A total of 171 players were included in this study. Univariate analyses indicated that the characteristics associated with early-stage spondylolysis were longer duration of low back pain (P = 0.0085), low back pain-related interference while running (P = 0.0022), low back pain starting with laterality (P = 0.0001), lumbar extension (P = 0.022), positive Kemp's test (P = 0.020), and the tenderness of a spinous process (P = 0.0003). After adjusting for confounding factors (age and position), we found that early-stage spondylolysis was significantly associated with low back pain duration ≥4 weeks (odds ratio 3.13, 95% confidence interval 1.42–6.92; P = 0.0048), low back pain-related interference while running (odds ratio 2.89, 95% confidence interval 1.30–6.46; P = 0.0094), low back pain starting with laterality (odds ratio 2.78, 95% confidence interval 1.24–6.27; P = 0.0133), and the tenderness of a spinous process (odds ratio 3.00, 95% confidence interval 1.36–6.57; P = 0.0062). Conclusions Male adolescent baseball players with early-stage spondylolysis might have low back pain duration of more than four weeks, low back pain-related interference while running, and a history of low back pain starting with laterality. The tenderness of a spinous process might be helpful in the diagnosis of early-stage spondylolysis in male adolescent baseball players.
... Keywords: Endoscopic, Direct repair, Lumbar spondylolysis, Pars defect, Minimally invasive surgery Background Lumbar spondylolysis, isthmic lysis, or discontinuity of the vertebral pars interarticularis, constitutes a comparatively common condition that causes low back pain (LBP) among young patients. The disease affects approximately 3-6% of the general population, and notably, 15% of athletes [1][2][3]. Nonsurgical managements, including physical therapy, activity modification, and bracing, remain the primary form of treatment of symptomatic lumbar spondylolysis and are successful in a considerable number of patients. Surgical intervention is usually indicated after 6 months of unsuccessful conservative management, with chronic pain, and non-union over 9-12 months. ...
... Lumbar spondylolysis is among the crucial causes of symptomatic low back pain and impacts an estimated 15-47% of young people [2]. According to Beutler et al. [15], 30 patients with pars defects were assessed on the cause and progression of the disease for over 45 years, and the results revealed that the risk of the progression of spondylolisthesis in patients with bilateral pars defect is similar to that of the general population. ...
Article
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Background: Multiple surgical procedures are applied in young patients with symptomatic lumbar spondylolysis when conservative treatments fail. Although the optimal surgical procedure option is controversial, the treatment paradigm has shifted from open surgery to minimally invasive spine surgery. To date, a limited number of studies on the feasibility of percutaneous endoscopic-assisted direct repair of pars defect have been carried out. Herein, for the first time, we retrospectively explore the outcomes of pars defect via percutaneous endoscopy. Methods: We retrospectively examined young patients with spondylolysis treated using the percutaneous endoscopic-assisted direct repair of pars defect supplemented with autograft as well as percutaneous pedicle screw fixation between September 2014 and December 2018. Six patients with a mean age of 18.8 years were enrolled in the study. We used preoperatively computed tomographic (CT) scans to evaluate the size of pars defect, and graded disc degeneration using Pfirrmann's classification through magnetic resonance images (MRI). We assessed the clinical outcomes using the Oswestry Disability Index (ODI), 36-Item Short-Form Health Survey (SF-36) as well as Visual Analogue Scale for back pain (VAS-B). Results: Our findings revealed that pain intensity and function outcomes, including VAS-B, ODI, and SF-36 (PCS and MCS) scores, were markedly improved after surgery and at the final follow-up visit. The change in the gap distance of the pars defect was remarkably significant after surgery and during the follow-up period. Only one of the 12 pars repaired was reported as a non-union at the final follow-up visit. Moreover, no surgery-related complications were reported in any of the cases. Conclusion: Percutaneous endoscopic-assisted direct repair of pars defect without general anesthesia, a minimally invasive treatment option, supplemented with autograft and percutaneous pedicle screw fixation, could be a satisfying treatment alternative for young patients with symptomatic lumbar spondylolysis.
... 2,3 However, outcomes of larger studies suggest that the prevalence of spondylolysis is likely closer to 14-30% among adolescent athletes reporting LBP. 3,4 Repetitive lumbar extension and rotation motions have been associated with increased risk of spondylolysis. 2,5 Sports involving these repetitive motions, such as baseball and gymnastics, have rates of spondylolysis as high as 47-58% among symptomatic athletes. ...
... 2,5 Sports involving these repetitive motions, such as baseball and gymnastics, have rates of spondylolysis as high as 47-58% among symptomatic athletes. 2,3 Given this high prevalence, spondylolysis should be given high priority as a diagnostic hypothesis in young athletes presenting with LBP. 6 The current model of care for adolescent athletes with LBP is a biomedical model which seeks to identify a specific pathoanatomical cause of LBP using advanced imaging. [6][7][8][9] Imaging is necessary to accurately distinguish spondylolysis from non-specific LBP, as there is no method to reliably identify a spondylolysis using physical examination and history. ...
Article
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Background and purpose: Half of adolescent athletes report low back pain (LBP) and there is a significant risk of vertebral injury in this population. The current model of care for adolescent athletes with LBP is to first confirm a medical diagnosis of spondylolysis which frequently requires advanced imaging. However, routine use of advanced imaging increases cost, delays treatment, and can expose the athlete to radiation. Purpose: The purpose of this pilot study was to assess the viability of a physical therapist guided functional progression program to manage low back pain (LBP) in adolescent athletes. Study design: Non-randomized, controlled clinical trial. Methods: Sixteen adolescents (15 ± 1.8 years, 50% female) with extension-based LBP were assigned to the biomedical model or physical therapy first model. The biomedical model sought to determine a spondylolysis diagnosis to guide treatment. In the physical therapy first model, patients began early therapeutic exercise and their ability to functionally progress determined the course of care. Dependent variables were change in Micheli Function Score, use of imagining, days out of sport, and ability to return to sport. Adverse events were monitored in order to assess safety. Descriptive statistics were completed to assess the viability of the alternative model. Results: Both models had similar improvements in pain and function. The physical therapy first model reduced use of advanced imaging by 88% compared to the biomedical model. Patients in the biomedical model who did not sustain a vertebral injury returned to sport sooner than the physical therapy first model (3.4 days versus 51 days), while those with a vertebral injury took longer in the current model (131 days versus 71 days). All of the patients in the physical therapy first model and 88% of patients in the current model made a full return to sport. Two adverse events occurred in the biomedical model, and none were noted in the physical therapy first model. Conclusion: This pilot study demonstrated that the physical therapist guided functional progression program may be a viable method for treating young athletes with LBP and further research is warranted. Level of evidence: 3b.
... Low back pain (LBP) is a critical problem in not only the adult population, but also youth and adolescents, especially among competitive athletes [1,2]. The risk of LBP in adulthood is higher if the individual has already experienced LBP events in adolescence. ...
... In addition, few prospective cohort studies have examined the relationship between limited flexibility of the lower extremities and the occurrence of LBP among adolescent athletes [11,12]. Baseball is one of the most popular sports and reportedly shows among the highest incidences of LBP compared with other sports [1,2,13]. However, links between limited flexibility of the lower extremities and occurrence of LBP in baseball players have only been investigated in cross-sectional studies and the results remain inconsistent [14,15]. ...
Article
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Background Limited flexibility of the lower extremities, such as hamstring tightness, has long been suggested as a physical risk factor for low back pain among adolescent athletes. However, few prospective cohort studies have examined the direction of causality for this relationship. This prospective cohort study investigated the relationship between limited flexibility of the lower extremities and the occurrence of low back pain among high school baseball players. Methods Participants comprised 335 high school baseball players from 43 high school baseball teams who had undergone baseline medical evaluations (a self-completed questionnaire and physical examination). Occurrence of low back pain during a 1-year follow up, and associations with measurements of flexibility of the lower extremities such as straight-leg-raising angle (hamstring tightness), Thomas test (iliopsoas tightness), heel-buttock-distance (quadriceps tightness), and passive range of motion of the hip were investigated. Results In total, 296 players (88.4%) participated in the 1-year follow-up survey, with 147 of the 296 players (49.7%) reporting the occurrence of low back pain during follow-up. The number of players with low back pain during follow-up peaked in November, then decreased and was lowest in June. After adjusting for factors associated with low back pain using logistic regression modeling, a significant association between hamstring tightness on the non-throwing arm side and low back pain (odds ratio 2.86, 95% confidence interval 1.17–6.94; P = 0.018) was found. Conclusions Hamstring tightness on the non-throwing arm side was identified as a potential risk factor for low back pain in high school baseball players. These results may provide guidance in the development of future prevention programs.
... LBP can represent a definitive issue for baseball players, affecting early career termination as a player [5]. In addition, LBP is a critical problem not only for adult players, but also for youth and adolescent players [1,2,6]. ...
... CS may be essential during these phases in which the core musculature needs to be appropriately activated to maintain lumbopelvic stability [25]. Reduced CS may result in excessive lumbar hyperextension, generating substantial force on the posterior elements of the lumbar spine and probably excessive mechanical stresses on the pars interarticularis, consequently risking the development of LBP due to lumbar spondylolysis, with a much higher incidence reported among young baseball players [2,3,24]. Furthermore, lumbar spondylolysis has been reported to be most prevalent in pitchers when examined by baseball position [26]. ...
Article
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Background Reduced core stability is a potential risk factor for low back pain in athletes. However, the association between core stability and low back pain in high school baseball players has not been thoroughly studied. The purpose of this study was to investigate the relationship between core stability and low back pain and its clinical characteristics in high school baseball players. Methods Participants comprised 812 high school baseball players who had undergone annual medical evaluations, comprising a self-completed questionnaire and a physical examination. We investigated the relationships between low back pain during the season and on the day of medical evaluations and core stability using a cross-sectional study design. Core stability was assessed using the Sahrmann core stability test. Results Reduced core stability was confirmed in 358 (44.1%) of all players, 98 (49.5%) pitchers, and 260 (42.3%) fielders. In total, 352 players (43.3%) reported incidents of seasonal low back pain during the previous year. Thirty-five pitchers (17.7%) and 153 fielders (24.9%) reported low back pain on the day of the medical evaluations. No significant associations were seen between low back pain throughout the season and reduced core stability. After adjusting for confounding factors (total amount of practice per week, hamstring tightness and quadriceps tightness) using logistic regression modeling, a significant association between presence of low back pain during lumbar extension movement and reduced core stability was found (odds ratio, 2.57; 95% confidence interval, 1.08–6.62; P = 0.033) in pitchers. Conclusions High school baseball pitchers with reduced core stability showed a higher probability of reporting low back pain during lumbar extension movement. Evaluation of core stability should be considered in high school baseball players, especially in pitchers.
... Sakai et al 34 reported that Japanese professional soccer and baseball players had >5 times the incidence of spondylolysis in comparison with the general population. Selhorst et al 37 reported that the risk of spondylolysis differed by sex and geographic region and that the activity level of athletes may significantly influence the incidence of spondylolysis. Therefore, the activity level of the athletes and the strength and frequency of their training would be more important than would the type of sports activity when clinicians evaluate adolescent athletes with LBP. ...
Article
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Background Spondylolysis and undiagnosed mechanical low back pain (UMLBP) are the main causes of low back pain (LBP) in adolescent athletes. No studies have evaluated the difference in clinical and radiographic factors between these 2 conditions. Furthermore, it remains unclear which adolescent athletes with LBP should undergo advanced imaging examination for spondylolysis. Purpose To compare the clinical and radiographic factors of adolescent athletes with spondylolysis and UMLBP who did not have neurological symptoms or findings before magnetic resonance imaging (MRI) evaluation and to determine the predictors of spondylolysis findings on MRI. Study Design Cohort study, Level of evidence, 3. Methods The study population included 122 adolescent athletes aged 11 to 18 years who had LBP without neurological symptoms or findings and who underwent MRI. Of these participants, 75 were ultimately diagnosed with spondylolysis, and 47 were diagnosed with UMLBP. Clinical factors and the following radiographic parameters were compared between the 2 groups: spina bifida occulta, lumbar lordosis (LL) angle, and the ratio of the interfacet distance of L1 to that of L5 (L1:L5 ratio, %). A logistic regression analysis was performed to evaluate independent predictors of spondylolysis on MRI scans. Results Significantly more athletes with spondylolysis were male (82.7% vs 48.9%; P < .001), had a greater LL angle (22.8° ± 8.1° vs 19.3° ± 8.5°; P = .02), and had a higher L1:L5 ratio (67.4% ± 6.3% vs 63.4% ± 6.6%; P = .001) versus athletes with UMLBP. A multivariate analysis revealed that male sex (odds ratio [OR], 4.66; P < .001) and an L1:L5 ratio of >65% (OR, 3.48; P = .003) were independent predictors of positive findings of spondylolysis on MRI scans. Conclusion The study findings indicated that sex and the L1:L5 ratio are important indicators for whether to perform MRI as an advanced imaging examination for adolescent athletes with LBP who have no neurological symptoms and findings.
... Spondylolysis occurs in individuals playing sports activities, and each sport requires specific movements and practice menu. It was reported that baseball and soccer were the greatest risk of spondylolysis in young male athletes [10]. Soccer demands several kinds of kicking, short sprints, collisions with other players, and occasionally throwing a ball with the hands. ...
Article
Full-text available
Background: Spondylolysis is the main cause of low back pain (LBP) in young athletes. There are few studies analyzing the difference of spondylolysis among young athletes with different sports activities. The purpose of this study was to compare the clinical factors and distribution of the lesions of spondylolysis on magnetic resonance imaging (MRI) scans in young soccer and baseball players with symptomatic spondylolysis. Methods: The medical records of 267 young athletes aged 7 to 18 years old who underwent MRI to evaluate the cause of LBP between 2017 and 2020 were retrospectively reviewed to identify patients with spondylolysis. Of the young athletes with symptomatic spondylolysis, clinical factors and MRI findings in soccer and baseball players were retrospectively evaluated. The clinical factors were age, sex, interval from onset of LBP to MRI, and side of the dominant leg in the sports field. MRI findings included number, lumbar level, and side of the lesions. Results: A total of 33 soccer players (mean age, 15.4 ± 1.4 years) and 49 baseball players (mean age, 15.4 ± 1.6 years) with symptomatic spondylolysis were enrolled. All patients were male. No significant differences were noted in age and the interval from onset of LBP to MRI between the groups. Soccer players had greater numbers of multiple (p < 0.001) and bilateral (p < 0.001) lesions than baseball players. The dominant side of the hand for pitching or batting was correlated with the contralateral-side lesions in baseball players (p = 0.001). Conclusions: The distribution of the lesions of spondylolysis differed in young soccer and baseball players. Pitching or batting with the dominant-side hand would be associated with contralateral-side lesions in baseball players. Sports-specific movements and the side of the dominant leg should be considered when treating young athletes with symptomatic spondylolysis.
... 74) is a relatively common condition (Ferembach, 1963). Similarly, spondylolysis (G.47) may result from trauma, especially in individuals with chronic overload (hyperextension) of the lumbar spine (in today's populations e.g. in gymnasts and basketball players) and occurs in hereditary disorders of connective tissues (Marfan syndrome, Ehlers-Danlos syndrome) and generalized inflammatory diseases (rheumatoid arthritis) (Hailer and Hailer, 2018;Horn et al., 2018;Selhorst et al., 2019). Alternatively, the co-occurrence of these developmental anomalies may also reflect kinship of the concerned individuals rather than their pathology (Barnes, 2012;Pietrusewsky and Douglas, 1992). ...
Article
Objectives To highlight conditions that may cause early-onset degenerative joint disease, and to assess the possible impact of such diseases upon everyday life. Material Four adults aged under 50 years from a medieval skeletal collection of Prague (Czechia). Methods Visual, osteometric, X-ray, and histological examinations, stable isotope analysis of bone collagen. Results All four individuals showed multiple symmetrical degenerative changes, affecting the majority of joints of the postcranial skeleton. Associated dysplastic deformities were observed in all individuals, including bilateral hip dysplasia (n = 1), flattening of the femoral condyles (n = 3), and substantial deformation of the elbows (n = 3). The diet of the affected individuals differed from the contemporary population sample. Conclusions We propose the diagnosis of a mild form of skeletal dysplasia in these four individuals, with multiple epiphyseal dysplasia or type-II collagenopathy linked to premature osteoarthritis as the most probable causes. Significance Combining the skeletal findings with information from the medical literature, this paper defines several characteristic traits which may assist with the diagnosis of skeletal dysplasia in the archaeological record. Limitations As no genetic analysis was performed to confirm the possible kinship of the individuals, it is not possible to definitively assess whether the individuals suffered from the same hereditary condition or from different forms of skeletal dysplasia. Suggestions for further research Further studies on premature osteoarthritis in archaeological skeletal series are needed to correct the underrepresentation of these mild forms of dysplasia in past populations.
... Low back pain is relatively common among adolescent athletes, particularly baseball players 1,2) . Lumbar stress fracture in the pars interarticularis (spondylolysis) is the most crucial differential diagnosis in this population 3) . ...
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Abdominal oblique muscle injury is characterized by acute pain and localized tenderness over the lateral trunk. This injury is particularly common among throwing athletes, and usually presents as anterolateral abdominal wall pain. Imaging evidence is scarce in regard to whether oblique muscle injury at its junction with the thoracolumbar fascia can instead present with low back pain. A high school baseball player with unilateral low back pain was referred to us with a different diagnosis. Careful palpation and magnetic resonance imaging guided our care, and the patient returned to high-level competition after 7 weeks of conservative treatment, with no report of recurrence in the subsequent 12 months. Oblique muscle injury at its junction with the thoracolumbar fascia should be added to the differential diagnosis for throwing athletes with unilateral low back pain following a torque movement.
... Spondylolysis occurs in individuals playing sports activities, and each sport requires speci c movements and practice menu. It was reported that baseball and soccer were the greatest risk of spondylolysis in young male athletes [10]. Soccer demands several kinds of kicking, short sprints, collisions with other players and occasionally throwing a ball with the hands. ...
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Background: Spondylolysis is a main cause of low back pain (LBP) in young athletes. There are few studies analyzing the difference of spondylolysis among young athletes with different sports activity. The purpose of this study was to compare the clinical factors and distribution of the lesions of spondylolysis on magnetic resonance imaging (MRI) scans in young soccer and baseball players with symptomatic spondylolysis. Methods: The medical records of 267 young athletes aged 7 to 18 years old who underwent MRI to evaluate the cause of LBP between 2017 to 2020 were retrospectively reviewed to identify patients with spondylolysis. Of the young athletes with symptomatic spondylolysis, clinical factors and MRI findings in soccer and baseball players were retrospectively evaluated. The clinical factors were age, sex, interval from onset of LBP to MRI, and side of the dominant leg in the sports field. MRI findings included number, lumbar level, and side of the lesions. Results: A total of 33 soccer players (mean age, 15.4 ± 1.4 years) and 49 baseball players (mean age, 15.4 ± 1.6 years) with symptomatic spondylolysis were enrolled. All patients were male. No significant differences were noted in age and the interval from onset of LBP to MRI between the groups. Soccer players had greater numbers of multiple (p < 0.001) and bilateral (p < 0.001) lesions than baseball players. The dominant side of the hand for pitching or batting was correlated with the contralateral-side lesions in baseball players (p = 0.001). Conclusions: The distribution of the lesions of spondylolysis differed in young soccer and baseball players. Pitching or batting with the dominant-side hand would be associated with contralateral-side lesions in baseball players. Sports-specific movements and the side of the dominant leg should be considered when treating young athletes with symptomatic spondylolysis.
... All positive diagnoses of spondylolysis had a history of athletic participation. A similar study also found spondylolysis rates as high as 30% among 1025 adolescent athletes presenting to a sports medicine clinic for low back pain [6]. us, there is a significantly higher incidence and prevalence of spondylolysis among young athletes than those in the general pediatric population. ...
Article
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Lumbar spondylolysis is a unilateral or bilateral defect of the pars interarticularis, an isthmus of bone connecting the superior and inferior facet surfaces in the lumbar spine at a given level. Spondylolysis is common in young athletes participating in sports, particularly those requiring repetitive hyperextension movements. The majority of young athletes are able to return to full sport participation following accurate diagnosis and conservative management, including a structured treatment program. Surgical intervention for isolated pars injuries is seldom necessary. A progressive physical therapy (PT) program is an important component of recovery after sustaining an acute pars fracture. However, there is a paucity of literature detailing PT programs specific to spondylolysis. Here, we provide an overview of the epidemiology, natural history, radiographic evaluation, and management of pars fractures in young athletes. In addition, a detailed description of a physiotherapy program for this population that was developed at a spine center within an academic medical center is provided.
... Isthmic spondylolysis, a bone stress injury of the pars interarticularis, is the most common identifiable cause of low back pain in adolescent athletes (Fredrickson et al., 1984;Micheli & Wood, 1995). Spondylolysis in symptomatic adolescent athletes is reported to be 2e5 times higher than nonathletes, with a prevalence of 14e30% among young athletes reporting LBP (Rossi & Dragoni, 2001;Schroeder et al., 2016;Selhorst et al., 2019). Although spondylolysis is a common injury among adolescent athletes, limited research exists to guide treatment for this population. ...
Article
Objective To assess the preliminary evidence for the efficacy and safety of an immediate functional progression program to treat adolescent athletes with an active spondylolysis. Design Prospective single-arm trial. Setting Hospital-based sports medicine and physical therapy clinic. Participants Twelve adolescent athletes (14.2 ± 2 years, 25% female) with an active spondylolysis. Main outcome measures Clinical outcomes included time out of sport, Micheli Functional Scale (Function and Pain) and adverse reactions. Clinical outcomes were assessed at baseline, 1 month, 3 months and 6 months. Magnetic resonance imaging was performed at baseline and 3 months to confirm diagnosis and assess healing of lesion. Results Eleven participants (92%) fully returned to sport in a median time of 2.5 months (75 days; interquartile range 55 days, 85 days). All participants demonstrated marked improvements in pain and function by the end of the program. One participant (8%) had an adverse reaction during care with a significant recurrence of LBP and had not returned to sport by 6 months. Magnetic resonance imaging demonstrated improvement of the spondylolytic lesion in all but one participant. Conclusion The immediate functional progression program appears a viable method for treating active spondylolysis and warrants future research.
... 1 In particular, athletes experience LBP more often than nonathletes. 15,16,29,34 Up to 9 in every 10 Olympic athletes experience LBP in their lifetime, and at any single point in time, up to 2 in every 3 athletes might be experiencing LBP. 38 Moreover, the incidence of LBP is 86% among professional beach volleyball players, 95.8% among Japanese volleyball players, and 76.9% among competitive swimmers, and the incidence of back pain is extremely high among athletes at high levels of competition. ...
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Background: Baseball is one of the most popular sports in Asia. It is known that baseball can easily lead to back pain. However, there has been no survey of low back pain (LBP) and lumbar disc degeneration in Japanese professional baseball players to date. Purpose: To investigate the cause of LBP and lumbar degeneration in professional Japanese baseball players. Study design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively reviewed the medical records of Japanese professional baseball players with LBP who visited our hospital. Data were collected from July 2018 to April 2021. We also investigated whether the results differed between players in their 20s and 30s or between pitchers and fielders. Data analysis was performed using the chi-square test. Results: We surveyed 32 professional baseball players. The most frequent causes of LBP among players in their 20s (n = 21) were lumbar disc herniation (LDH; 57%) and spondylolysis (24%). Of the players with spondylolysis, 50% had adult-onset spondylolysis. Players in their 30s (n = 11) most commonly had discogenic pain (55%) as well as LDH and facet joint arthritis (each 18%). The incidence of lumbar intervertebral disc degeneration was significantly higher in players in their 30s (91%) than those in their 20s (14%), as was the incidence of Schmorl nodes and Modic type 1 changes. There was no significant difference in the cause of LBP or the incidence of lumbar intervertebral disc degeneration between pitchers and fielders (P = .59). Conclusion: Among professional baseball players in their 20s, lumbar degeneration was less common, and they most frequently developed diseases less related to degeneration, such as LDH. However, among players in their 30s, lumbar degeneration was more advanced, and degenerative diseases such as discogenic pain occurred more frequently. Research on training methods could lead to the prevention of LBP. Our data may be applicable to other professional athletes and will contribute to diagnosis and treatment.
... Spondylolysis occurs in individuals playing sports activities, and each sport requires speci c movements and practice menu. It was reported that baseball and soccer were the greatest risk of spondylolysis in young male athletes [8]. Soccer demands several kinds of kicking, short sprints, collisions with other players and occasionally throwing a ball with the hands. ...
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Background: Spondylolysis is a main cause of low back pain (LBP) in young athletes. There are few studies analyzing the difference of spondylolysis among young athletes with different sports activity. The purpose of this study was to compare the clinical factors and distribution of the lesions of spondylolysis on magnetic resonance imaging (MRI) scans in young soccer and baseball players with symptomatic spondylolysis. Methods: The medical records of 178 young athletes aged 7 to 18 years old who underwent MRI to evaluate the cause of LBP between 2017 to 2019 were retrospectively reviewed to identify patients with spondylolysis. Of the young athletes with symptomatic spondylolysis, clinical factors and MRI findings in soccer and baseball players were retrospectively evaluated. The clinical factors were age, sex, interval from onset of LBP to MRI, and side of the dominant leg in the sports field. MRI findings included number, lumbar level, and side of the lesions. Results: A total of 21 soccer players (mean age, 15.2 ± 1.4 years) and 38 baseball players (mean age, 15.1 ± 1.7 years) with symptomatic spondylolysis were enrolled. All patients were male. No significant differences were noted in age and the interval from onset of LBP to MRI between the groups. Soccer players had greater numbers of multiple (p = 0.005) and bilateral (p = 0.004) lesions than baseball players. The dominant side of the hand for pitching or batting was correlated with the contralateral-side lesions in baseball players (p = 0.01). Conclusions: The distribution of the lesions of spondylolysis differed in young soccer and baseball players. Pitching or batting with the dominant-side hand would be associated with contralateral-side lesions in baseball players. Sports-specific movements and the side of the dominant leg should be considered when treating young athletes with symptomatic spondylolysis.
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Spine injuries are not only related to professional sports but also to recreational ones, and they can occur during competitions and training. The main mechanisms to these injuries in sports practice are the direct trauma of a specific anatomical structure or supraphysiological stress on the spine. Cervical, lumbar, and thoracolumbar spines are the anatomical sites where lesions can occur in sports practice; but the latter is the most affected and represents 10% of all injuries caused by sports. Most of them are produced by low-energy trauma which, in turn, results in complete rehabilitation without sequelae. However, spine injuries can also cause significant injuries that involve the spinal cord and nerve roots, and, therefore, there are potentially dangerous sequelae such as tetraplegia. High-energy trauma to the spine is more prevalent in sports such as football, ice hockey, wrestling, diving, skiing, rugby, and motorized sports which have a greater risk of developing serious injuries. Consequently, spine injuries in sports present a broad clinical spectrum ranging from non-specific low back pain to paraplegia. In this chapter, spinal injuries during sports practice are described; their biomechanical, epidemiologic, and anatomic aspects are studied as well as the athletes’ rehabilitation and return to play.
Article
Aims The primary aim of this study was to develop a diagnostic cluster of common clinical findings that would assist in ruling out an active spondylolysis in adolescent athletes with low back pain (LBP). Design Retrospective case-series. Setting Hospital-based sports medicine clinic. Patients One thousand and twenty-five adolescent athletes with LBP (age 15.0 ± 1.8 years, 56% female) were reviewed. Active spondylolytic injuries were identified in 22% (n = 228) of these patients. Main outcome measure presence or absence of active spondylolysis on advanced imaging. Results Through logistic regression analysis, pain with extension (p < 0.001), difference between active and resting pain ≥3/10 (p < 0.001), and male sex (p = 0.002) were identified as significantly associated with active spondylolysis. The clinical cluster had a sensitivity of 88% (95% CI 83%–93%) to help rule out active spondylolysis. The negative likelihood ratio was 0.34 (95% CI 0.23–0.51) and the negative predictive value was 90% (95% CI 86%–93%). Diagnostic accuracy of the cluster was acceptable (area under the curve = 0.72 (95% CI 0.69, 0.76; p < 0.001). Conclusion This study found a cluster of three patient characteristics that may assist in ruling out active spondylolysis in adolescent athletes with LBP.
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Low back pain in an adolescent athlete can be caused by a number of different conditions, but one of the most common is spondylolysis or stress fracture of the spine. History, physicals, and careful review of plain radiographs are essential when evaluating a child with these types of symptoms. Although common, spondylolysis is often difficult to detect on plain films, and so advanced imaging is often necessary to make the diagnosis. If rest and PT are not effective, refer to an orthopedic specialist with pediatric sports medicine interest and experience.
Article
Background Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players. Purpose To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population. Study Design Descriptive epidemiology study. Methods A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance. Results During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode. Conclusion Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.
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Low back pain has become a costly burden to society. It is currently the leading cause of disability worldwide. It is extremely common and affects all age groups throughout the world. Despite the steep rise in cost in the diagnosis and treatment of low back pain, outcomes have gotten worse, with more patients disabled than ever before. The physiatric approach to low back pain could reverse some of these worldwide trends. There are some serious causes of back pain in which a clear pathology can be identified, but for the vast majority of patients with low back pain, a specific cause cannot be found. Most people with new back pain recover quickly, but for a few, pain becomes persistent and costly. This chapter outlines the anatomy and biomechanics of the lumbar spine and our current understanding of the physiology of low back pain. Then, the clinical evaluation and treatment of various etiologies of low back pain and leg pain caused by lumbar spine disease are discussed. Information about how to recognize serious causes of low back pain so that they can be diagnosed early is covered. The evidence for various treatments of low back pain, and benefits and risks of treatment are thoroughly described so that physicians can protect patients from unproven or harmful approaches to management and deliver patient-centered care that focuses on self-management and healthy lifestyles. An overview of the treatment of low back pain in special populations, such as during pregnancy and back pain in children, is also covered.
Article
Isthmic spondylolysis is a common cause of back pain in young athletes. The condition presents to numerous medical providers who employ a variety of different practices in diagnosis and management. The purpose of this study was twofold: to review the literature of diagnosis and management of the young athlete with isthmic spondylolysis and to survey Pediatric Research in Sports Medicine (PRiSM) members during the 2021 PRiSM Annual Meeting on practice patterns of diagnosis and management of the young athlete with isthmic spondylolysis. The response rate was 27%. Per respondents: 24% obtain oblique radiographs; 90% use magnetic resonance imaging as the advanced imaging modality; 60% treat with bracing; 57% recommend rest prior to physical therapy (PT); 53% prescribe return to sport activity restrictions. Although there are similarities in the diagnosis of isthmic spondylolysis in young athletes, this survey confirmed variability in management, especially bracing, timing of PT and return to sport activity restrictions.
Article
Objective: To identify predictive risk factors of lumbar stress (LS) fracture developing from an asymptomatic stress reaction of the pedicle among adolescent male soccer players. Design: Prospective cohort study. Setting: Amateur Japanese adolescent male soccer team. Participants: Japanese adolescent male soccer players (n = 195) aged 12 to 13 years. Assessment of risk factors (independent variables): Height, body weight, body mass index, muscle tightness of both lower extremities (iliopsoas, hamstrings, and quadriceps), lumbar bone mineral content, developmental age, and lumbar lordosis angle were measured as baseline measurements. Main outcome measures (dependent variable): Players who were diagnosed with an asymptomatic stress reaction of the lumbar spine pedicle at baseline were followed; extension-based lumbar pain was defined 1 year after the baseline. The players were assigned to the LS fracture or control (CON) group at follow-up. Results: At baseline, 40 boys were diagnosed with an asymptomatic stress reaction of the lumbar spine pedicle. The difference in muscle tightness between the kicking leg and supporting leg was significantly different (P = 0.012) between the LS (n = 16) and CON (n = 22) groups. Increase in iliopsoas muscle tightness in the kicking leg was a predictive risk factor of developing extension-based lumbar pain after adjusting for developmental age and body mass index (odds ratio, 1.54; 95% confidence interval, 1.05-2.27). Conclusions: Development of extension-based lumbar pain from an asymptomatic stress reaction of the pedicle among adolescent male soccer players was associated with increased iliopsoas muscle tightness of the kicking leg relative to that of the supporting leg.
Article
Objectives Pars repair is less explored in adults due to associated disc degeneration with advancing age. The aim of our systematic review was to define optimal characteristics of adults with spondylolysis/grade-I spondylolisthesis suitable for pars repair and evaluate the feasibility, effectiveness, and safety of standard repair techniques in these adults. Methods This systematic review is reported in line with PRISMA-P and protocol is registered with PROSPERO(CRD42020189208). Electronic searches were conducted in PubMed, Embase, Scopus and Web of Science in June 2020 using systematic search strategy. Studies involving adults aged≥18-years with spondylolysis/grade-1 isthmic spondylolisthesis treated with standard pars repair techniques were considered eligible. A two-staged(titles/abstracts and full-text) screening was conducted independently by three authors followed by quality assessment using the Joanna Briggs Institute critical appraisal checklist for selection of final articles for narrative synthesis. Results A total of 5813-articles were retrieved using systematic search strategy. First screening followed by removal of duplicates resulted in 111-articles. Second (full-text) screening resulted in exclusion of 64-articles. A final 47-articles were considered for data extraction after quality assessment. A total of 590-adults were enrolled across 47-studies; 93% were ‘young adults’(18–35 years); 82% were males. Persistent low back pain was the common presenting complaint. Lysis defect was primarily bilateral(96.4%) and L5 was the most involved level(68.5%). Majority had no disc degeneration(83.5%) and had spondylolysis as the primary diagnosis(86%); only 14% had grade-I spondylolisthesis. Pars infiltration test was conducted in 22-studies and discography in 8-studies. Duration of prior conservative therapy was 3–72-months. Buck's repair was the commonest technique(27-studies, 372-adults). Successful repair was reported in 86% of patients treated with Buck's and ≥90% treated with Scott's, Morscher's and pedicle-screw-based techniques. Improvement in pain/functional outcomes, union rate and rate-of-return to sports/activity was high and comparable across all techniques. Intraoperative blood loss was low with minimally invasive versus traditional repair. The overall complication rate was 11.9%, with implant failure being the major complication. Conclusions Our systematic review establishes a definite place for lysis repair in carefully selected adults with spondylolysis/grade-I spondylolisthesis. We propose a treatment algorithm for optimizing patient selection and outcomes. We conclude that adults with age 18–45 years, no/mild disc or facet degenerative changes, positive diagnostic infiltration test, and normal pre-operative discography will have successful outcomes with pars repair, regardless of the technique.
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PurposeWe investigated the prevalence of Modic changes (MCs) and associated pathologies in pediatric patients.MethodsA total of 368 MRI obtained for 240 male and 128 female patients under the age of 18 years with complaints of low back/leg pain were retrospectively examined. All changes in signal intensity in the vertebral endplate and subchondral bone on MRI were defined as MCs. We investigated the relationship between MCs and underlying diseases, including lumbar spondylolysis/spondylolisthesis, and conditions of the growth plate in cases with MCs. The degree of disc degeneration in patients with MCs was evaluated using the Pfirrmann grading system.ResultsMCs were identified in six patients (1.6%). In five of the six patients, the signal intensity changes were localized to the anterosuperior endplate of the affected vertebra; the MCs were associated with anterior apophyseal ring fracture and an open growth plate in all these cases. Disc degeneration was classified as Pfirrmann grade I in three patients and grade II and III in one patient each. One patient had type I changes associated with grade IV disc degeneration and herniation and no sign of an open growth plate.Conclusion The prevalence of MCs in pediatrics patients was much lower than the rates reported in adults. Most MCs were associated with an anterior apophyseal ring fracture. If Modic type changes are seen in immature vertebrae of pediatric patients, growth plate lesions such as apophyseal ring fractures should be considered.Level of evidenceDiagnostic: individual l cross-sectional studies with consistently applied reference standard and blinding.
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Verschiedene Arbeiten der letzten Jahre dokumentieren die Häufigkeit und Bedeutung von Überlastungsbeschwerden des muskuloskelettalen Systems (MSK) bereits bei Nachwuchsathleten. Als verantwortlich hierfür gelten das sich noch im Wachstum befindliche und damit nicht voll ausgeprägte MSK und eine ansteigende Anzahl an Nachwuchsathleten, die zu einem früheren Zeitpunkt der Entwicklung hohe, zum Teil einseitige Trainingsumfänge und -intensitäten durchführen. Die Beschwerden sind vorrangig auf die Wirbelsäule und die unteren Extremitäten lokalisiert.
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Objective: The objective of the review was to describe the incidence and prevalence of injuries among female cricket players of all ages, participating in all levels of play. Introduction: Cricket, a bat-and-ball sport, is becoming popular among women of all ages and abilities worldwide. However, cricket participation carries a risk of injury. Injuries negatively affect sport participation, performance, and short- and long-term health and well-being. Injury prevention, therefore, is the key to safe, long-term cricket participation as a physical activity goal. Epidemiological data are needed to underpin evidence-based injury-prevention strategies. Inclusion criteria: Studies reporting incidence and prevalence of injuries in female cricket players of all ages, participating in all levels of play, were included in this review, including studies that report data by sex or by sport. Studies were excluded if they did not have enough data to calculate prevalence or incidence, did not distinguish female injury data from male injury data, focused on athletes participating in other sports, or focused on case studies. Methods: A systematic review and meta-analyses were conducted according to the JBI and PRISMA 2020 guidelines. MEDLINE, SPORTDiscus, Physiotherapy Evidence Database (PEDro), EBSCO MasterFILE Premier, EBSCO CINAHL Complete, ProQuest Health and Medical Complete, Scopus, and ScienceDirect were systematically searched from inception to August 2021. Additionally, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. EBSCO MegaFile Premier, OpenGrey (SIGLE), WorldCat, Grey Matters, Grey Literature, and Google Scholar were searched for gray literature. Full-text articles that met the inclusion criteria were critically appraised using tools from JBI, and were extracted and synthesized in narrative summary and tabular format. Three meta-analyses were conducted: injury incidence rates, injury prevalence proportions, and injury incidence proportions. Heterogeneity was assessed using the I2 statistic and the random-effects model. Results: Of the 7057 studies identified, 4256 were screened after duplicates were removed. A total of 23 studies met the inclusion criteria. Risk of bias was low for 21 studies. The injury incidence rate for elite cricket was 71.9 (SE 21.3, 95% CI 30.2–113.6) injuries per 1000 player hours, time-loss injury incidence rate was 13.3 (SE 4.4, 95% CI 4.6–22.0) injuries per 1000 player hours, and non-time-loss injury incidence rate was 58.5 (SE 16.9, 95% CI 25.6–91.7) injuries per 1000 player hours. The injury prevalence proportion for community to elite cricket was 65.2% (SE 9.3, 95% CI 45.7–82.3) and the injury prevalence proportion for community cricket was 60% (SE 4.5, 95% CI 51.1–68.6). The injury incidence proportion for community cricket was 5.6 (SE 4.4, 95% CI 0.1–18.3) injuries per 10,000 participants. Elite cricket players were more frequently injured than community cricket players. The most prevalent body regions injured were the shoulder and knee, and most were sustained by fast bowlers. Injuries to the hand, wrist, and fingers had the highest incidence and were most sustained by fielders. Conclusions: The study's findings can help stakeholders (including players, coaches, clinicians, and policymakers) make informed decisions about cricket participation by informing and implementing strategies to promote cricket as a vehicle for positive public health outcomes. This review also identified gaps in the available evidence base, and addressing these through future research would enhance women's cricket as a professional sport.
Article
Background Elite tennis athletes experience injuries throughout the entire body. Impairments in trunk stability, lower limb flexibility, and hip range of motion (ROM) are modifiable risk factors that can impact injuries and performance. Information on nonmodifiable risk factors such as age and gender is limited. The purpose of this investigation was to provide information on risk factors to direct clinical decision-making and injury prevention and rehab programming in this population. Hypothesis Prevalence and location of injuries will differ by age group and gender. Trunk stability, lower limb flexibility, and hip ROM will differ by age group and gender. Study Design Cross-sectional study. Level of Evidence Level 3. Methods A de-identified database (n = 237; females = 126) from the United States Tennis Association High Performance Profile (HPP) 2014-2015 was used for the analysis. Subjects were elite junior and professional tennis players (mean age 14.6 [range, 9-27] years). The HPP is a tennis-specific assessment and questionnaire that includes retrospective information on injury history. Subjects were categorized by injury, gender, and age. Injury locations were classified by region. Trunk stability measures included drop vertical jump (DVJ), single-leg squat, and prone and side planks. Lower limb measures included hamstring, quadriceps and hip flexor flexibility, and hip rotation ROM. Results A total of 46% of athletes reported an injury. Significant differences were found for injury prevalence and location by age group. Adolescent athletes (age 13-17 years) had more trunk injuries, while adult athletes (age ≥18 years) had more lower limb injuries. Adolescent athletes performed worse on DVJ, dominant side plank, and hamstring flexibility compared with young (age ≤12 years) and adult athletes. Significant gender differences in hip ROM included internal rotation on both the dominant and nondominant sides. Conclusion Impairments in trunk stability, lower limb flexibility, and hip rotation ROM may affect both health and performance outcomes in this population. Elite tennis athletes may benefit from additional off court programming to address trunk and lower limb impairments. Clinical Relevance Adolescent elite tennis athletes may be at higher risk of trunk injuries. Age, gender, injury history, and impairments should be considered with all assessments and programming.
Background Spondylolysis and spondylolisthesis are common pathologies among adolescent athletes. Repetitive sports-related stress in lumbar hyperextension and rotation, certain types of “high-risk” sports, sex and anatomical predispositions are being discussed as risk factors of the pathologies but haven’t been systematically reviewed yet. This study aims to detect and evaluate possible influencing factors for the presence of spondylolysis and spondylolisthesis in adolescent athletes. Materials and Methods A systematic literature review of databases “Medline” and “Web of science” from 2001 to 2021 was conducted to detect predisposing factors for spondylolysis and -listhesis. Eligible studies included adolescent athletes (11 to 19 years old) with spondylolysis or spondylolisthesis diagnosis. Studies were excluded if they were based on cadavers/ animals, or if they were review articles. Quality of studies was evaluated using PEDro scale or NIH tool. Results The initial search yielded n = 874 articles, of which n = 4 studies were eligible for inclusion for the review (n = 567 athletes (14.1 ± 2.3 to 16.8 ± 2.3 years)). Athletes with spondylolysis showed a greater sacral slope (SS = 42.4 ± 7.8°), lumbar lordosis angle (LA: 22.8 ± 8.1°), L1:L5 interfacet ratio (L1:L5: 67.4 ± 6.3%) and coronally oriented facet joint surfaces at the cranial segment to affected pedicle (orientation: 53.1 ± 7.5°) compared to control group without spondylolysis (SS = 37.4 ± 9.2°; LA = 19.3 ± 8.5°; L1:L5: 63.4 ± 6.6%; orientation: 46.2 ± 7.8°). Male athletes are 1.5 times more likely to have the pathology than females. Increased risks are indicated in athletes participating in throwing activities, gymnastics or soccer. Conclusions Anatomical-structural factors, sex, and type of performed sport seemingly influence the presence of spondylolysis and spondylolisthesis. Due to the lack of prospective long-term studies only correlations to potential risk factors are found, causation is not proven.
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This case-control study aimed to investigate differences in the sagittal spinal parameters between the symptomatic spondylolisthesis patients and the general population. Twenty-nine adolescent patients with symptomatic lumbar isthmic spondylolisthesis were included. For each patient, two age-matched, gender-matched and BMI-matched controls were enrolled. Comparison analyses detected higher values in the case group for the following parameters: CL (-22.06 ± 7.552° versus -20.36 ± 7.016°, P < 0.001), T1 Slope (19.84 ± 8.708° versus 13.99 ± 6.537°, P = 0.001), PT (21.54 ± 9.082° versus 8.87 ± 7.863°, P < 0.001), PI (64.45 ± 13.957° versus 43.60 ± 9.669°, P < 0.001), SS (42.90 ± 9.183° versus 34.73 ± 8.265°, P < 0.001), LL (-50.82 ± 21.596° versus -43.78 ± 10.356°, P = 0.042), SVA (16.99 ± 14.625 mm versus 0.32 ± 31.824 mm, P = 0.009), L5 Slope (33.95 ± 13.567° versus 19.03 ± 6.809°, P < 0.001), and L5I (8.90 ± 6.556° versus 1.29 ± 6.726°, P < 0.001). Conversely, TS-CL (6.56 ± 6.716° versus 11.04 ± 7.085°, P = 0.006), cSVA (11.31 ± 6.867 mm versus 17.92 ± 11.832 mm, P = 0.007), and TLK (-2.66 ± 10.101° versus 2.71 ± 7.708°, P = 0.007) were smaller in the case group. Slippage percentage was most correlated with PI (r = 0.530, P = 0.003), followed by PT (r = 0.465, P = 0.011) and L5I (r = 0.433, P = 0.019). Results of binary logistic regression showed that the main risk factor of isthmic spondylolisthesis was PI (OR = 1.145, 95%CI = 1.083-1.210, P < 0.001). Further subgroup analysis also showed that PI was the main risk factor of isthmic spondylolisthesis in the female adolescents (OR = 1.237, 95%CI = 1.086-1.493, P = 0.003) and in the male adolescents (OR = 1.523, 95%CI = 1.093-2.123, P = 0.013). PI was the main risk factor for adolescent symptomatic isthmic spondylolisthesis in the Chinese Han adolescents. The greater PI indicated the higher the progressive risk of spondylolisthesis. In these isthmic spondylolisthesis adolescents, the body always inclined forward and lumbar and cervical lordosis increased.
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Low back pain of various etiologies is a common clinical presentation in young athletes. In this article, we discuss the utility of SPECT/CT bone scintigraphy for the evaluation of low back pain in young athletes. The spectrum of lower spine lesions caused by sports injuries and identifiable on bone scan is presented along with strategies to avoid unnecessary irradiation of young patients. Also covered are pitfalls in diagnosis due to referred-pain phenomenon and normal skeletal variants specific to this age group.
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Data are lacking regarding the independent risk of injury related to intense single-sport training or growth rate in young athletes. To determine whether sports specialization, weekly training volumes, and growth rates are associated with increased risk for injury and serious overuse injury in young athletes. Case-control study; Level of evidence, 3. Injured athletes aged 7 to 18 years were recruited from 2 hospital-based sports medicine clinics and compared with healthy controls from affiliated primary care clinics undergoing sports physicals (2010-2013). Participants completed surveys reporting hours per week spent in organized sports, physical education class, and free play, as well as degree of sports specialization and Tanner stage. Heights and weights were measured. Injury details were obtained from athlete surveys and electronic medical records. Of 1214 athletes enrolled, 1190 (50.7% male) had data satisfactory for analysis. There were 822 injured participants (49.5% male; unique injuries, n = 846) and 368 uninjured participants (55% male). Injured athletes were older than uninjured athletes (14.1 ± 2.1 vs 12.9 ± 2.6 years; P < .001) and reported more total hours of physical activity (19.6 ± 9.2 vs 17.6 ± 8.9 h/wk; P < .001) and organized sports activity (11.2 ± 2.6 vs 9.1 ± 6.3 h/wk; P < .01). After accounting for age and hours in sports activity spent per week, sports-specialized training was an independent risk for injury (odds ratio [OR], 1.27; 95% CI, 1.07-1.52; P < .01) and serious overuse injury (OR, 1.36; 95% CI, 1.08-1.72; P < .01). Young athletes participating in more hours of sports per week than number of age in years (OR, 2.07; 95% CI, 1.40-3.05; P < .001) or whose ratio of organized sports to free play time was >2:1 hours/week had increased odds of having a serious overuse injury (OR, 1.87; 95% CI, 1.26-2.76; P < .01). Growth rates were similar between injured and uninjured athletes (4.8 cm/y for both groups; P = .96). Injured young athletes were older and spent more hours per week in organized sports. There is an independent risk of injury and serious overuse injury in young athletes who specialize in a single sport. Growth rate was not related to injury risk. The study data provide guidance for clinicians counseling young athletes and their parents regarding injury risks associated with sports specialization. © 2015 The Author(s).
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The aim of this paper was to systematically review the diagnostic ability of clinical tests to detect lumbar spondylolysis and spondylolisthesis. A systematic literature search of six databases, with no language restrictions, from 1950 to 2014 was concluded on February 1, 2014. Clinical tests were required to be compared against imaging reference standards and report, or allow computation, of common diagnostic values. The systematic search yielded a total of 5164 articles with 57 retained for full-text examination, from which 4 met the full inclusion criteria for the review. Study heterogeneity precluded a meta-analysis of included studies. Fifteen different clinical tests were evaluated for their ability to diagnose lumbar spondylolisthesis and one test for its ability to diagnose lumbar spondylolysis. The one-legged hyperextension test demonstrated low to moderate sensitivity (50-73) and low specificity (17-32) to diagnose lumbar spondylolysis, while the lumbar spinous process palpation test was the optimal diagnostic test for lumbar spondylolisthesis; returning high specificity (87-100) and mixed sensitivity (60-88) values. Lumbar spondylolysis and spondylolisthesis are identifiable causes of LBP in athletes. There appears to be utility to lumbar spinous process palpation for the diagnosis of lumbar spondylolisthesis, however the one-legged hyperextension test has virtually no value in diagnosing patients with spondylolysis. Keywords Systematic review; Diagnosis; Lumbar spine; Validity
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Background Low back pain (LBP) is common in children and adolescents, and it is becoming a public health concern. In recent years there has been a considerable increase in research studies that examine the prevalence of LBP in this population, but studies exhibit great variability in the prevalence rates reported. The purpose of this research was to examine, by means of a meta-analytic investigation, the prevalence rates of LBP in children and adolescents. Methods Studies were located from computerized databases (ISI Web of Knowledge, MedLine, PEDro, IME, LILACS, and CINAHL) and other sources. The search period extended to April 2011. To be included in the meta-analysis, studies had to report a prevalence rate (whether point, period or lifetime prevalence) of LBP in children and/or adolescents (≤ 18 years old). Two independent researchers coded the moderator variables of the studies, and extracted the prevalence rates. Separate meta-analyses were carried out for the different types of prevalence in order to avoid dependence problems. In each meta-analysis, a random-effects model was assumed to carry out the statistical analyses. Results A total of 59 articles fulfilled the selection criteria. The mean point prevalence obtained from 10 studies was 0.120 (95% CI: 0.09 and 0.159). The mean period prevalence at 12 months obtained from 13 studies was 0.336 (95% CI: 0.269 and 0.410), whereas the mean period prevalence at one week obtained from six studies was 0.177 (95% CI: 0.124 and 0.247). The mean lifetime prevalence obtained from 30 studies was 0.399 (95% CI: 0.342 and 0.459). Lifetime prevalence exhibited a positive, statistically significant relationship with the mean age of the participants in the samples and with the publication year of the studies. Conclusions The most recent studies showed higher prevalence rates than the oldest ones, and studies with a better methodology exhibited higher lifetime prevalence rates than studies that were methodologically poor. Future studies should report more information regarding the definition of LBP and there is a need to improve the methodological quality of studies.
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The aim of this review was to provide of the current knowledge in pathophysiology, diagnosis and management of spondylolysis based on the authors' experience and the pertinent medical literature. Spondylolysis represents a weakness or stress fracture in one of the bony bridges that connect the upper with the lower facet joints of the vertebra. It is the most common cause of low back pain in young athletes. One-half of all paediatric and adolescent back pain in athletic patients is related to various disturbances in the posterior elements including spondylolysis. The most common clinical presentation of spondylolysis is low back pain. This is aggravated by activity and is frequently accompanied by minimal or no physical findings. A pars stress fracture or early spondylolysis are common and a misdiagnosis is often made. Plain radiography with posteroanterior (P-A), lateral and oblique views have proved very useful in the initial diagnostics of low back pain, but imaging studies such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans are more sensitive in the establishment of the diagnosis. Several treatment options are available. Surgical treatment is indicated only for symptomatic cases when conservative methods fail. The fact that early and multiple imaging studies may have a role in the diagnosis of pars lesions and the selection of the optimal treatment approaches is also highlighted.
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Radiographs and bone scans of 40 young athletes with low back pain were reviewed retrospectively to correlate the imaging findings and assess the value of scintigraphy in the diagnosis of these patients. The radiographs were positive for spondylolysis with or without spondylolisthesis in 15 (38%), and scintigraphy showed focal disease in the posterior vertebral elements in 14 (35%). Five patients had positive radiographic studies but normal scans, indicating old injuries; four patients had positive scintigrams but normal radiographs, suggesting early or active injuries. The authors use radiography as the initial examination in the evaluation of patients with low back pain. Scintigraphy is most useful in early stages, when radiographs may be normal; and in cases in which the age and activity of a radiologic abnormality cannot otherwise be accurately determined before therapy.
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The diagnosis of spondylolysis is a major cause of concern for patients and their families, especially when the patients are young athletes with promising futures in their sports. In this study, 3152 case histories of high-level athletes were evaluated to determine which sports had a higher prevalence of spondylolysis. The overall percentage of spondylolysis among athletes in this study (8.02%) was not very much higher than that among the general population, which varies between 3% and 7%. However, when each sport was considered separately we found much higher values for some sports, with the highest percentages occurring in throwing sports (26.67%), artistic gymnastics (16.96%), and rowing (16.88%). The analysis of the biomechanical movements involved in the sports with greater prevalence of spondylolysis has led us to include the element of torsion against resistance as another possible causative factor for spondylolysis that should be added to the already known causative mechanisms, lumbar hyperextension and rotation. We have divided the sports into three risk groups according to the prevalence of spondylolysis shown and the characteristics of the sample, and we recommend systematic radiological examination of the lumbar spine in athletes considered to be at greater risk of developing spondylolysis.
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To determine whether the location of spondylolysis in the lumbar spine of athletes differs with biomechanical factors. Single photon emission computerised tomography and reverse gantry computerised tomography were used to investigate 42 cricketers and 28 soccer players with activity related low back pain. Sites of increased scintigraphic uptake in the posterior elements of the lumbar spine and complete or incomplete fracture in the pars interarticularis were compared for these two sports. Thirty seven (90.4%) cricketers and 23 (82.1%) soccer players studied had sites of increased uptake. In cricketers, these sites were on the left of the neural arch of 49 lumbar vertebrae and on the right of 33 vertebrae. In soccer players there was a significantly different proportion, with 17 sites on the left and 28 on the right (difference of 22.0%; 95% confidence interval (CI) 0.04 to 0.38). Lower lumbar levels showed increased scintigraphic uptake more frequently than did higher levels, although the trend was reversed at L3 and L4 in soccer. Forty spondylolyses were identified in the lumbar vertebrae of the cricketers and 35 spondylolyses in the soccer players. These comprised 26 complete and 14 incomplete fractures in the cricketers, and 25 complete and 10 incomplete fractures in the soccer players. Similar numbers of incomplete fractures were found either side of the neural arch in soccer players, but there were more incomplete fractures in the left pars (14) than in the right (2) in cricketers. The proportion of incomplete fractures either side of the neural arch was significantly different between cricket players and soccer players (difference of 37.5%; 95% CI 0.02 to 0.65). Most complete fractures were at L5 (66.7%) and more were found at L3 (15.7%) than L4 (6.9%). However, incomplete fractures were more evenly spread though the lower three lumbar levels with 41.7% at L5, 37.5% at L4, and 20.8% at L3. Fast bowling in cricket is associated with pars interarticularis bone stress response and with development of incomplete stress fractures that occur more frequently on the left than the right. Playing soccer is associated with a more symmetrical distribution of bone stress response, including stress fracturing. Within cricketers, unilateral spondylolyses tend to arise on the contralateral side to the bowling arm.
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The percentages of patients with acute low back pain (LBP) that go on to a chronic state varies between studies from 2% to 34%. In some of these cases low back pain leads to great costs. To evaluate the evidence for prognostic factors for return to work among workers sick listed with acute LBP. Systematic literature search with a quality assessment of studies, assessment of levels of evidence for all factors, and pooling of effect sizes. Inclusion of studies in the review was restricted to inception cohort studies of workers with LBP on sick leave for less than six weeks, with the outcome measured in absolute terms, relative terms, survival curve, or duration of sick leave. Of the studies, 18 publications (14 cohorts) fulfilled all inclusion criteria. One low quality study, four moderate quality studies, and nine high quality studies were identified; 79 prognostic factors were studied and grouped in eight categories for which the evidence was assessed. Specific LBP, higher disability levels, older age, female gender, more social dysfunction and more social isolation, heavier work, and receiving higher compensation were identified as predictors for a longer duration of sick leave. A history of LBP, job satisfaction, educational level, marital status, number of dependants, smoking, working more than 8 hour shifts, occupation, and size of industry or company do not influence duration of sick leave due to LBP. Many different constructs were measured to identify psychosocial predictors of long term sick leave, which made it impossible to determine the role of these factors.
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Prospective study with 8-year follow-up. To describe the evolution of low back pain from adolescence into adulthood. High prevalence rates of low back pain among children and adolescents have been demonstrated in several studies, and it has been theorized that low back pain in childhood may have important consequences for future low back pain. It is important to understand the nature of such a link if effective preventive programs are to be established. Almost 10,000 Danish twins born between 1972 and 1982 were surveyed by means of postal questionnaires in 1994 and again in 2002. The questionnaires dealt with various aspects of general health, including the prevalence of low back pain, classified according to number of days affected (0, 1-7, 8-30, >30). Low back pain in adolescence was found to be a significant risk factor for low back pain in adulthood with odds ratios as high as four. We also demonstrated a dose-response association: the more days with low back pain at baseline, the higher the risk of future low back pain. Twenty-six percent of those with low back pain for more than 30 days during the baseline year also had more than 30 days with low back pain during the follow-up year. This was true for only 9% of the rest of the sample. Our study clearly demonstrates correlations between low back pain in childhood/adolescence and low back pain in adulthood. This should lead to a change in focus from the adult to the young population in relation to research, prevention, and treatment.
Article
Study Design Retrospective Review with Phone Follow-Up. Background Acute spondylolytic injuries have a dramatic impact on the young athlete. Excellent short-term clinical outcomes have been observed, but not enough is known about long-term clinical outcomes. Objectives 1) to report long-term clinical outcomes for patients diagnosed with acute spondylolysis. 2) to assess the prognostic ability of retrospective variables on long-term outcomes. Methods A retrospective review of patients from 2010 through 2013 obtained demographic, baseline and short-term outcomes. Long-term follow-up data were collected on patients diagnosed with acute spondylolysis. Long-term follow-up assessed recurrence rate of low back pain, perceived outcome, pain, and functional ability. Patients were categorized as having a good or poor long-term outcome based on these measures. Logistic regression analysis was performed to assess the prognostic ability of the retrospective variables on long-term outcomes 3.4 years (range 1.5-5.6 years) after treatment. Results 121 (71%) patients completed the follow-up questionnaire (48 females, mean age of 14.5 years at baseline). At follow-up, 81 (66.9%) patients were able to maintain their same or higher level of sport. Recurrence of significant symptoms were reported by 55 (45.5%) patients, with 41 (33.9%) requiring medical treatment. The final logistic regression model revealed that female gender, adverse reaction during care, and multi-level injury were significant predictors of poor long-term outcome (R(2)= 0.22). Conclusion Although excellent short-term outcomes were noted, 42% of patients reported a poor outcome at long-term follow-up. Female gender, multi-level injury, and experiencing an adverse reaction during care were significant predictors of poor long-term outcome with acute spondylolysis. J Orthop Sports Phys Ther, Epub 8 Nov 2016. doi:10.2519/jospt.2016.7028.
Article
Study design: Systematic Review. Objective: To provide an evidence-based recommendation for when and how to employ imaging studies when diagnosing back pain thought to be caused by spondylolysis in pediatric patients. Summary of background data: Spondylolysis is a common structural cause of back pain in pediatric patients. The radiologic methods and algorithms used to diagnose spondylolysis are inconsistent among practitioners. Methods: A literature review was performed in PubMed and Cochrane databases using the search terms "spondylolysis" "pediatric" "adolescent" "juvenile" "young" "lumbar" "MRI" "bone scan" "CT" and "SPECT". After inclusion criteria were applied, 13 articles pertaining to diagnostic imaging of pediatric spondylolysis were analyzed. Results: Ten papers included sensitivity calculations for comparing imaging performance. The average sensitivity of MRI with CT as the standard of reference was 81.4%. When compared to SPECT, the average sensitivity of CT was 85% and the sensitivity of MRI was 80%. Thirteen studies made a recommendation as to how best to perform diagnostic imaging of patients with clinically suspected spondylolysis. When compared to 2-view plain films, bone scans had 7-9 times the effective radiation dose while 4-view plain films and CT were approximately double. Of the diagnostic methods examined, MRI was the most expensive followed by CT, bone scan, 4-view plain films, and 2-view plain films. Conclusions: Due to their efficacy, low cost, and low radiation exposure, we find 2-view plain films to be the best initial study. With unusual presentations or refractory courses, practitioners should pursue advanced imaging. MRI should be used in early diagnosis and CT in more persistent courses. However, the lack of rigorous studies makes it difficult to formulate concrete recommendations.
Article
Objectives: The purposes of this study were (1) to determine whether the duration of rest before referral to physical therapy (PT) affects the time to make a full return to activity for patients with an acute spondylolysis, (2) to assess the safety of an early referral to PT in patients with an acute spondylolysis. Study design: Retrospective chart review. Setting: Hospital-based sports medicine clinic. Patients: The medical charts of 196 adolescent athletes (mean age = 14.3 ± 1.8 years) with an acute spondylolytic injury met the inclusion criteria and were reviewed. Independent variable: Patients were subgrouped based on physician referral to PT. Patterns: An aggressive referral group (<10 weeks) and a conservative referral group (>10 weeks). Main outcome measures: Duration of rest before clearance to a full return to activity and the frequency of adverse reactions during the course of treatment. Safety was assessed by calculating the risk of experiencing an adverse reaction in each group. Results: Median days to a full return to activity for aggressive referral group (115.5 days, interquartile range 98-150 days) and conservative referral group (140.0 days, interquartile range 114.5-168 days) were significantly different (P = 0.002). Eleven patients had adverse reactions during the course of treatment. The risk of adverse reaction was not statistically significant between groups (P = 0.509). Conclusions: Patients with acute spondylolysis in the aggressive referral group were able to make a full return activity almost 25 days sooner. No differences in the risk of adverse reactions were noted between aggressive and conservative referral groups.
Article
Diagnosis is crucial in early-stage lumbar spondylolysis, as osseous healing can occur with conservative treatment. Single-photon emission computed tomography (SPECT) traditionally has been the most sensitive modality for diagnosing active (early) spondylolysis. More recently, high signal change (HSC) in the pedicle or pars interarticularis on fluid-specific (T2) magnetic resonance imaging (MRI) has been shown to be important in the diagnosis of early spondylolysis. We conducted a study to determine the clinical and radiographic characteristics associated with the diagnosis of early or active spondylolysis. Fifty-seven patients with a total of 108 pars defects and a mean age of 14.6 years were retrospectively identified. Defects with a positive SPECT or HSC on T2 MRI were classified as active. There were 49 active and 59 inactive defects. The active and inactive groups did not differ in age, body mass index, symptom duration, lumbar lordosis, pelvic incidence, slip percentage, or laterality. There was a difference in sex (35 vs 19 males; P < .0001) and presence of listhesis (16 vs 35; P = .006). Active or early juvenile spondylolysis appears to be associated with male patients and the absence of listhesis, which may be important in identifying patients with a higher potential to experience osseous healing with nonoperative treatment.
Article
Study design: Retrospective comparative cohort study. Objective: To elucidate the characteristics of low back pain (LBP) in adolescent patients with early-stage spondylolysis (ESS). Summary of background data: ESS is a common cause of acute LBP in adolescents. When treating patients with ESS, early diagnosis is important; however, early diagnosis is difficult without magnetic resonance imaging. Methods: Adolescent patients (n = 77) with acute LBP showing no pathological findings on plain radiography were included (<1 m after onset). Patients were divided into ESS and nonspecific LBP (NS-LBP) groups by conducting magnetic resonance imaging; patients showing no pathological findings that explain the cause of LBP were classified as NS-LBP. LBP was evaluated using a traditional visual analogue scale (VAS; 0-10 cm), Oswestry Disability Index, and a detailed VAS scoring system in which pain is independently evaluated in 3 different postural situations (in motion, standing, and sitting); the values were compared between the 2 groups. Results: Of 77 patients, 41 (mean age: 14.6 yr; 33 adolescent boys/8 adolescent girls) had ESS and 36 (mean age: 14.3 yr; 20 adolescent boys/16 adolescent girls) were considered to have NS-LBP. Respective traditional VAS and Oswestry Disability Index scores were 4.9, 16.1 in the ESS group, and 6.2, 26.3 in the NS-LBP group. Both scores were significantly higher in the NS-LBP group. The results of the detailed VAS revealed that the ESS group showed significantly greater pain intensity while in motion than while standing or sitting (4.2, 2.0, and 2.0, respectively), whereas the NS-LBP group showed similar pain intensities in all 3 postural situations (5.3, 4.0, and 4.9, respectively). Conclusion: This study revealed that LBP characteristics may provide important information for distinguishing ESS from other low back disorders. Because early diagnosis is essential for the treatment of ESS, MRI examination is recommended for patients showing severe pain in motion, but less pain when standing or sitting.
Article
Clinicians must have knowledge of the growth and development of the adolescent spine and the subsequent injury patterns and other spinal conditions common in the adolescent athlete. The management and treatment of spinal injuries in adolescent athletes require a coordinated effort between the clinician, patients, parents/guardians, coaches, therapists, and athletic trainers. Treatment should not only help alleviate the current symptoms but also address flexibility and muscle imbalances to prevent future injuries by recognizing and addressing risk factors. Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength. Copyright © 2014 Elsevier Inc. All rights reserved.
Article
Low back pain is an extremely common presenting complaint that occurs in upward of 80% of persons. Treatment of an acute episode of back pain includes relative rest, activity modification, nonsteroidal anti-inflammatories, and physical therapy. Patient education is also imperative, as these patients are at risk for further future episodes of back pain. Chronic back pain (>6 months' duration) develops in a small percentage of patients. Clinicians' ability to diagnose the exact pathologic source of these symptoms is severely limited, making a cure unlikely. Treatment of these patients should be supportive, the goal being to improve pain and function.
Article
Background: In early studies, magnetic resonance imaging (MRI) had low sensitivity and positive predictive value in the evaluation of the pars interarticularis pathology; however, more recent reports have suggested an expanded role for MRI. The purpose of the present study was to evaluate the effectiveness of MRI in the diagnosis of pars injuries and compare it to computed tomography (CT), which was used as the reference "gold standard" for the detection of fractures. Methods: The radiographic and clinic data of 93 adolescents and young adults with a presumptive diagnosis of spondylolysis based upon history and clinic examination were reviewed. Only 26 patients who had MRI and CT images obtained within 30 days of each other were included. All images were reviewed by a fellowship-trained musculoskeletal radiologist and fellowship-trained pediatric orthopaedist. Results: Overall, 39 individual pars lesions (stress reaction or fracture) were identified. MRI was effective in identifying 36 pars lesions. MRI identified 11 lesions in 9 patients with negative CT. Seven of these lesions were stress reactions (grade 1), whereas 4 were frank fractures. Three pars injuries were noted on CT while the MRI was negative. Conclusions: MRI is an effective method (92% sensitivity) for detecting pars injuries. It can detect stress reactions when a fracture is not visible on CT scan, allowing early treatment of these prelysis lesions. The 92% sensitivity of MRI is comparable with that of other diagnostic modalities such as bone scan, with the advantage of no radiation exposure. MRI should be strongly considered as the advanced imaging modality of choice in the evaluation of patients with suspected spondylolysis. Level of evidence: Level III-diagnostic study.
Article
This cohort study aimed to report the compliance of young athletes with nonoperative treatment and to clarify the role of sports modification on clinical outcome of symptomatic spondylolysis. This study included patients with a chief complaint of low back pain participating in regular sports activity, having spondylolysis, and being treated and followed up between 1990 and 2002 in the authors' hospital. One hundred thirty-two athletes were included in this study: 78 males and 54 females. The mean age of the patients was 13 yrs (range, 7-18 yrs). Only 56 patients (42.4%) were compliant to nonoperative treatment. Eighty-six patients (65%) stopped all sports activities for at least 3 mos, and 46 patients (35%) stopped exercising for a variable period of less than 3 mos. The grading of clinical outcome after nonoperative treatment was as follows: excellent in 48 patients (36.4%), good in 74 patients (56.1), fair in 6 patients (4.5%), and poor in 4 patients (3%). The patients who stopped sports for at least 3 mos were 16.39 times more likely to have an excellent result than those who did not stop sports. Bony healing on radiographs did not correlate with clinical outcome. Timely cessation of sports activity for 3 mos is considered an effective method of nonoperative treatment for young athletes with symptomatic lumbar spondylolysis.
Article
Purpose: Mechanical low back pain is common in the pediatric population; recent studies have shown that undiagnosed mechanical low back pain (UMLBP) is the most common cause of low back pain presenting in adolescents, accounting for up to 78% of cases. Spondylolysis/spondylolisthesis is the most common cause with diagnosed pathology observed in this age group. The goals of this study are to: determine the natural history of low back pain, evaluate the value of radiographic studies in establishing a diagnosis of spondylolysis, and determine the cost and radiation effective doses (EDs) associated with those studies with the associated risks radiation exposure. Methods: A retrospective review of patients records aged 10 to 19 years who presented to our institution with mechanical low back of undiagnosed etiology from January 1, 2000 to January 1, 2008 were identified. Patients with previous back surgery, high-energy trauma, congenital syndromes, or medical comorbidities were excluded. UMLBP was defined as back pain with etiology undetected by examination and imaging. We reviewed the following data: age at presentation, sex, the number of follow-up visits, the total length of follow-up, the type of imaging studies performed, and the results from imaging studies. Age-specific radiation EDs were calculated for 10 to 14.9 years, 15 to 18 years, and adults for plain films, fine cut 2-level L-spine computed tomography (CT) scans, and bone scans (BSs). Results: A total of 2846 patients (63% female) with average age of 14.3 years were identified. A total of 2159 (76%) patients had UMLBP, 61% of that had ≤2 follow-up visits. One hundred and ninety-four patients (7.8%) were diagnosed with spondylolysis; 119 (86%) by plain film, 56 (12.5%) by BSs, and 17 (1.5%) by CTs. Most patients (74%) with spondylolysis had a positive plain film study. There was no significant difference between 2-view (anterior-posterior, lateral) and 4-view (anterior-posterior, lateral, right oblique, left oblique) studies in sensitivity (78% vs. 72%, P=0.39). Advanced imaging was pursued in 90/354 (25%) patients with negative plain film studies. The sensitivity of BS for spondylolysis was 84% (73 of 88 BSs were positive). The sensitivity of CT for spondylolysis was 90% (44 of 49 CTs were positive. BSs exposed patients to much more radiation than CTs and plain film studies. Conclusions: Mechanical low back pain is common in adolescents and in most cases is undiagnosed; most require no imaging and ≤2 office visits. For spondylolysis, 2-view plain films are often diagnostic and oblique views did not add significant value. Advanced imaging increases diagnostic accuracy, but adds to the cost and considerable radiation exposure. Because diagnosis of spondylolysis rarely changes clinical management, physicians should use ionizing radiation studies sparingly in children.
Article
Symptomatic spondylolysis is a stress reaction caused by microtrauma during physical exercise, an imaging diagnostic subgroup of Adolescent Low Back Pain (ALBP), found in adolescent athletes. Early diagnosis increases the possibility of healing. Thus, it is important to divide ALBP into subgroups. The aim of this study was to evaluate clinical tests that can distinguish symptomatic spondylolysis from other forms of ALBP in order to facilitate early referral for diagnostic imaging. The investigation subjects were a prospective case series with a control group, 25 subjects with ALBP and 13 subjects that had no history of LBP. The 2 groups were examined using the same clinical protocol. MRI of the whole lumbar spine was performed in both the case and control groups and CT investigations of the L4 and L5 vertebrae were performed in the case group. Significant differences between the 2 groups were found in 8 of our clinical tests. No clinical test, alone or in combination, could distinguish between spondylolysis and other forms of ALBP. As 88% of the subjects in the case group had MRI findings and almost 50% had spondylolysis, MRI should be performed at an early age in young athletes with ALBP.
Article
Purpose: To assess radiographically the prevalence of spondylolysis and spondylolisthesis in symptomatic athletes from plain radiographs.Methods: A retrospective analysis was conducted on the plain radiographic lumbar spine series of 4243 male and female athletes with symptoms relating to the lumbar spine.Results: The study showed that 590 athletes (13.90%) had a radiological diagnosis of spondylolysis with concomitant spondylolisthesis in 280 of these (47.45%).Conclusions: High prevalence of spondylolysis in athletes with low back pain compared with the general population suggests that it would be good practise to include a radiological examination of the lumbar spine in symptomatic athletes engaged in sports who are considered to be at risk in the light of this and other studies although MRI could offer the most comprehensive evaluation of the lumbar spine, without the potential risks of gonad irradiation.
Article
Low back pain is an extremely common problem that most people experience at some point in their life. While substantial heterogeneity exists among low back pain epidemiological studies limiting the ability to compare and pool data, estimates of the 1 year incidence of a first-ever episode of low back pain range between 6.3% and 15.4%, while estimates of the 1 year incidence of any episode of low back pain range between 1.5% and 36%. In health facility- or clinic-based studies, episode remission at 1 year ranges from 54% to 90%; however, most studies do not indicate whether the episode was continuous between the baseline and follow-up time point(s). Most people who experience activity-limiting low back pain go on to have recurrent episodes. Estimates of recurrence at 1 year range from 24% to 80%. Given the variation in definitions of remission and recurrence, further population-based research is needed to assess the daily patterns of low back pain episodes over 1 year and longer. There is substantial information on low back pain prevalence and estimates of the point prevalence range from 1.0% to 58.1% (mean: 18.1%; median: 15.0%), and 1 year prevalence from 0.8% to 82.5% (mean: 38.1%; median: 37.4%). Due to the heterogeneity of the data, mean estimates need to be interpreted with caution. Many environmental and personal factors influence the onset and course of low back pain. Studies have found the incidence of low back pain is highest in the third decade, and overall prevalence increases with age until the 60-65 year age group and then gradually declines. Other commonly reported risk factors include low educational status, stress, anxiety, depression, job dissatisfaction, low levels of social support in the workplace and whole-body vibration. Low back pain has an enormous impact on individuals, families, communities, governments and businesses throughout the world. The Global Burden of Disease 2005 Study (GBD 2005) is currently making estimates of the global burden of low back pain in relation to impairment and activity limitation. Results will be available in 2011. Further research is needed to help us understand more about the broader outcomes and impacts from low back pain.
Article
The incidence of spondylolysis is at least 6% by the end of childhood, and painful lesions are not infrequent. The most common treatments for spondylolysis are nonoperative in nature and include bracing, activity restriction, and therapeutic exercises. These treatments have been used either alone or in concert. The aim of this meta-analysis was to identify and summarize the evidence from the literature on the effectiveness of nonoperative treatment for spondylolysis (including those with up to 25% spondylolisthesis) in children and young adults. A comprehensive literature search identified articles meeting the following inclusion criteria: (1) the target population was children and young adults with spondylolysis (including those with up to 25% spondylolisthesis); (2) the treatment intervention was nonoperative; (3) minimum follow-up was 1 year in studies using clinical parameters as the primary outcome; and (4) the studies included at least 10 subjects. Outcome data from eligible studies were pooled into 1 of 2 groups: clinical outcome or radiographic evidence of a union of the pars defects. Fifteen observational studies measuring the clinical outcome had a weighted and pooled success rate of 83.9% in 665 patients. A subgroup analysis comparing the clinical outcome of patients treated with a brace to patients treated without a brace was not significantly different (P=0.75). Ten studies evaluating radiographic healing of the defects had a pooled success rate of 28.0% (n=847). A subgroup analysis showed that unilateral defects healed at a pooled and weighted rate of 71% (n=92), significantly more than bilateral defects at 18.1% (n=446, P<0.0001). An additional subgroup analysis showed acute defects healed at a rate of 68.1% (n=236), significantly more than progressive lesions (28.3%, n=224, P<0.0001) and terminal lesions (n=217, P<0.0001), of which not one defect healed. A meta-analysis of observational studies suggests that 83.9% of patients treated nonoperatively will have a successful clinical outcome after at least 1 year. Bracing does not seem to influence this outcome. In contrast to the high rate of success with clinical parameters, most defects did not heal with nonoperative treatment suggesting that a successful clinical outcome does not depend on healing of the lesion. Lesions diagnosed at the acute stage were more likely to heal after nonoperative treatment as were unilateral defects when compared with bilateral defects. Meta-analysis of level IV studies. Therapeutic level IV.
Article
The aim of this study was to evaluate the effects of unspecific neck pain and low back pain at a given time (1990-91) with respect to physical and social functioning and role limitations due to emotional problems 12 years later. A rural male study population (2351 individuals) was established in 1989 and a first survey conducted in 1990-91. A follow-up survey was performed in 2002-03. A total of 1405 persons participated in both surveys. Functioning and role limitations in 2002-03 were evaluated using the SF-36 instrument. Several possible confounders were included in the analyses. Unspecific neck pain or low back pain in 1990-91 was shown in a multivariate longitudinal regression model to be significantly related to limited physical (odds ratio (OR)=2.08; 95% confidence interval (CI) 1.51-2.87) and social (OR=1.92; 95% CI 1.33-2.75) functioning 12 years later. The effects were only slightly modified by the confounders analysed. However, higher education independently and significantly predicted a low risk for functional limitations. Non-specific neck pain and low back pain at a given time impacted on the risk of limited physical and social functioning many years later. Current symptoms of depression and anxiety at the time for the second survey had a high impact on functional limitations.
Article
With the high incidence of low back pain in adults, especially in the work place, industrial and health care professionals must work together to reduce the physical, emotional, and monetary cost of back pain. Conservative management can be effective when it includes therapy and patient education. This article discusses back schools and work hardening programs, two methods used to return employees to productive levels.
Article
The complaint of low back pain in the adolescent must never be taken lightly. A high index of suspicion should be particularly entertained in a child participating in gymnastic training or competition. As noted in this article, steps can now be taken, particularly if a specific diagnosis is made early, to institute specific treatment with a high likelihood of success. Young gymnasts complaining of back pain must never be passed off as having sustained a back strain or "muscle spasms" and treated symptomatically. Persistent back pain beyond two weeks warrants, in our opinion, a complete evaluation, careful history and physical examination, a four-view radiographic assessment of the spine, and, if necessary, bone scans or other more advanced techniques to make a specific diagnosis of the cause of the pain.
Article
Planar bone scintigraphy (PBS) and single-photon emission computed tomography (SPECT) were compared in 19 adults with radiographic evidence of spondylolysis and/or spondylolisthesis. SPECT was more sensitive than PBS when used to identify symptomatic patients and sites of "painful" defects in the pars interarticularis. In addition, SPECT allowed more accurate localization than PBS. In 6 patients, spondylolysis or spondylolisthesis was unrelated to low back pain, and SPECT images of the posterior neural arch were normal. The authors conclude that when spondylolysis or spondylolisthesis is the cause of low back pain, pars defects are frequently heralded by increased scintigraphic activity which is best detected and localized by SPECT.
Article
We performed a prospective roentgenographic study to determine the incidence of spondylolysis, spondylolisthesis, or both, in 500 unselected first-grade children from 1955 through 1957. The families of the children with spondylolysis were followed in a similar manner. The incidence of spondylolysis at the age of six years was 4.4 per cent and increased to 6 per cent in adulthood. The degree of spondylolisthesis was as much as 28 per cent, and progression of the olisthesis was unusual. The data support the hypothesis that the spondylolytic defect is the result of a defect in the cartilaginous anlage of a vertebra. There is a hereditary pre-disposition to the defect and a strong association with spina bifida occulta. Progression of a slip was unlikely after adolescence and the slip was never symptomatic in the population that we studied.
Article
Fifty-six cases of spondylolysis were encountered in 1500 lumbar spine reports reviewed. The frequency of detecting isthmus defects on anteroposterior (AP), lateral, 45-degree right and left oblique, 30-degree up-angled AP, and collimated lateral views was determined. The collimated lateral view showed the largest number of pars defects, 84% of cases. The 30-degree up-angled AP view was more sensitive than the AP view, showing 55% versus 32% of cases. A previously unreported sign of spondylolysis, fragmentation of lamina demonstrated on the AP or AP up-angled view, was found in 14.2% of cases of spondylolysis.
To determine whether there are significant differences in the causes of back pain in young athletes compared with the general adult population and to review the diagnosis and assessment of young athletic adolescent patients who present with this complaint. Retrospective randomized case comparison study with two cohorts segregated by age and type of activity. The adolescent sports medicine clinic of a children's hospital compared with the acute low back pain clinic of an orthopedic hospital. One hundred adolescent athletes (aged 12 to 18 years; mean age, 15.8 years) with a chief complaint of low back pain were compared with 100 adults (aged 21 to 77 years; mean age, 31.9 years) with acute low back pain. None. MAIN OUTCOME MEASURES/RESULTS: Sixty-two percent of the adolescents had derangements of their posterior elements associated with the onset of back pain. Forty-seven percent of the 100 adolescents were ultimately shown to have a spondylolysis stress fracture of the pars interarticularis. By contrast, 5% of adult subjects were found to have spondylolysis associated with low back pain. Similarly, discogenic back pain was the final diagnosis in 48 of the 100 subjects in the adult group, while 11 of the 100 in the adolescent group had back pain attributable to disc abnormalities. Muscle-tendon strain accounted for back pain in 27% of the adults, while only 6% of the adolescents were diagnosed as having muscle-tendon strain. These differences were significant. Spinal stenosis and osteoarthritis as causes of back pain were encountered in 10% of the adults, while these conditions were not encountered in the children. There is a significant differences in the major causes of low back pain in young athletes compared with causes of low back pain in the general adult population. Physicians diagnosing back pain in young athletes must have a specific understanding of these differences to avoid incorrect diagnosis and harmful delays in proper treatment.
Article
A 5-year longitudinal interview and questionnaire-based survey of back pain in adolescents. To determine the natural history of back pain during adolescence in boys and girls and to explore the influence of sports participation and lumbar flexibility. Previous data on low back pain and flexibility in adolescents have come largely from cross-sectional studies with differing definitions and age groups. A longitudinal study would offer a more detailed description of aspects of the natural history of back pain. A cohort of 216 11-year-old children was given a structured questionnaire about back pain. Follow-up evaluation was annual for 4 more years. Lumbar sagittal mobility was measured in first and last years. Life-table analysis was the chosen statistical method. Annual incidence rose from 11.8% at age 12+ to 21.5% at 15+ years. Lifetime prevalence rose from 11.6% at age 11+ to 50.4% at age 15+ years. Experience of back pain was frequently forgotten. Recurrent pain was common, usually manifesting as such rather than as progression from a single episode; few children required treatment. Back pain was more common in boys than girls, especially by age 15 years. There was a positive link between sports and back pain only for boys. Severity and flexibility were not related to sex, treatment, or sport. Back pain in adolescents is common; it increases with age and is recurrent, but in general does not deteriorate with time. Much of the symptomatology may be considered a normal life experience, probably unrelated to adult disabling trouble.
Article
This study is based on data gathered by means of a postal questionnaire from a cohort of 640 38-year-old subjects. At the age of 14 years these subjects had been interviewed by their school doctor to ascertain whether any of them had a history of low back pain (LBP), and X-rays of the thoracic and lumbar spine were taken. The questionnaire contained related groups of questions, with LBP as the main topic. We wanted to identify probable risk factors in developing LBP. The results show a cumulative life-time prevalence of LBP of 70%, a 1-year prevalence of 63% and a point prevalence of 19%, independent of gender. Women reported a higher incidence of LBP than men during the month and week before they filled out the questionnaire, they also reported a higher incidence of sciatica and greater use of the health care system and analgestics over the previous year. Heavy manual work was associated with LBP and sciatica, and smoking (more than 16 cigarettes per day) was more common among unemployed and sick-listed subjects, Severe LBP was associated with increased morbidity, reduced work capacity, deterioration in social life, mental and sexual problems, and increased smoking. A stepwise logistic regression analysis of "early" independent variables indicated that severe LBP is positively correlated with low social class for men and with menstruation and pregnancy for women.
Article
Prospective study with follow-up by a postal questionnaire to 6626 men nearly 40 years of age who had been examined for the first time at the age of 18. To study the predictability of frequent musculoskeletal problems, health, lifestyle, and work situation from the examination 20 years earlier. Those who enlisted for military duty during 6 months in 1979-1980 answered a questionnaire focusing on back pain, smoking, and physical work exposure. As these men enter the biologic age when back pain is most frequent, a follow-up was of interest. A new questionnaire was sent to those from the enlistment group who could be identified in the population register, and the answers were compared with those given at enlistment. The prevalence of low back pain increased from 38% to 74% during the 20-year period. Neck or shoulder problems were nearly as common as back problems. The number of those with a body mass index more than 25 had increased from 9% to 50%, and smoking had decreased from 29% to 14%. The odds ratio for frequent back/neck/shoulder problems at follow-up evaluation was 8.7 (95% CI: 3.78-20.10) if the person had experienced back pain that greatly affected everyday life at enlistment, 3.0 (95% CI: 2.33-3.93) if he had been off work or school because of that pain, and 2.2 (95% CI 1.57-3.24) if he had been doing heavy work already at the time of enlistment. Early back pain causing absence from work, reduced activity levels because of the pain, and heavy work loads showed a significantly increased risk for frequent pain problems at follow-up examination.
Article
To evaluate whether MRI correlates with CT and SPECT imaging for the diagnosis of juvenile spondylolysis, and to determine whether MRI can be used as an exclusive image modality. Juveniles and young adults with a history of extension low back pain were evaluated by MRI, CT and SPECT imaging. All images were reviewed blindly. Correlative analyses included CT vs MRI for morphological grading and SPECT vs MRI for functional grading. Finally, an overall grading system compared MRI vs CT and SPECT combined. Statistical analysis was performed using the kappa statistic. Seventy-two patients (mean age 16 years) were recruited. Forty pars defects were identified in 22 patients (31%), of which 25 were chronic non-union, five acute complete defects and ten acute incomplete fractures. Kappa scores demonstrated a high level of agreement for all comparative analyses. MRI vs SPECT (kappa: 0.794), MRI vs CT (kappa: 0.829) and MRI vs CT/SPECT (kappa: 0.786). The main causes of discrepancy were between MRI and SPECT for the diagnosis of stress reaction in the absence of overt fracture, and distinguishing incomplete fractures from intact pars or complete defects. MRI can be used as an effective and reliable first-line image modality for diagnosis of juvenile spondylolysis. However, localised CT is recommended as a supplementary examination in selected cases as a baseline for assessment of healing and for evaluation of indeterminate cases.
Article
Spondylolysis and spondylolisthesis commonly are diagnosed in children and adolescents. The diagnostic workup and treatment plan vary widely among physicians. Although the orthopaedic literature is extensive on the topic, it is our opinion that a lack of clarity exists with regards to etiology, terminology, subtypes of spondylolysis and spondylolisthesis, and treatment. Important basic principles regarding spondylolysis and spondylolisthesis, with emphasis on clinical evaluation and nonsurgical treatment, serve as the basis for a new classification. We propose a new classification for pediatric spondylolysis and spondylolisthesis that is comprehensive, simple, and easily applied. This scheme is based on clinical presentation and spinal morphology and is more appropriate for the child and adolescent than the existing classification schemes of Wiltse-Newman and Marchetti-Bartolozzi. Algorithms for evaluation and treatment of spondylolysis and spondylolisthesis in children and adolescents, based on this new classification, are presented.
Article
Spondylolysis and spondylolisthesis are often diagnosed in children presenting with low back pain. Spondylolysis refers to a defect of the vertebral pars interarticularis. Spondylolisthesis is the forward translation of one vertebral segment over the one beneath it. Isthmic spondylolysis, isthmic spondylolisthesis, and stress reactions involving the pars interarticularis are the most common forms seen in children. Typical presentation is characterized by a history of activity-related low back pain and the presence of painful spinal mobility and hamstring tightness without radiculopathy. Plain radiography, computed tomography, and single-photon emission computed tomography are useful for establishing the diagnosis. Symptomatic stress reactions of the pars interarticularis or adjacent vertebral structures are best treated with immobilization of the spine and activity restriction. Spondylolysis often responds to brief periods of activity restriction, immobilization, and physiotherapy. Low-grade spondylolisthesis (< or =50% translation) is treated similarly. The less common dysplastic spondylolisthesis with intact posterior elements requires greater caution. Symptomatic high-grade spondylolisthesis (>50% translation) responds much less reliably to nonsurgical treatment. The growing child may need to be followed clinically and radiographically through skeletal maturity. When pain persists despite nonsurgical interventions, when progressive vertebral displacement increases, or in the presence of progressive neurologic deficits, surgical intervention is appropriate.
Article
A prospective case-series study. To evaluate the results of nonoperative and operative treatment of symptomatic unilateral lumbar pars stress injuries or spondylolysis. Most patients become asymptomatic following nonoperative treatment for unilateral lumbar pars stress injuries or spondylolysis. Surgery, however, is indicated when symptoms persist beyond a reasonable time affecting the quality of life in young patients, particularly the athletic population. We treated 42 patients (31 male, 11 female) with unilateral lumbar pars stress injuries or spondylolysis. Thirty-two patients were actively involved in sports at various levels. Patients with a positive stress reaction on single photon emission computerized tomography imaging underwent a strict protocol of activity restriction, bracing, and physical therapy for 6 months. At the end of 6 months, patients who remained symptomatic underwent a computed tomography (CT) scan to confirm the persistence of a spondylolysis. Eight patients subsequently underwent a direct repair of the defect using the modified Buck's Technique. Baseline Oswestry Disability Index (ODI) and Short-Form-36 (SF-36) scores were compared with 2-year ODI and SF-36 scores for all patients. Eight of nine fast bowlers in cricket were right-handed. The spondylolytic defect appeared on the left side of their lumbar spine. In the nonoperated group, the mean pretreatment ODI was 36 (SD = 10.5), improving to 6.2 (SD = 8.2) at 2 years. In SF-36 scores, the mean score for physical component of health (PCS) improved from 30.7 (SD = 3.2) to 53.5 (SD = 6.5) (P < 0.001), and the mean score for the mental component of health (MCS) improved from 39 (SD = 4.1) and 56.5 (SD = 3.9) (P < 0.001) at 2 years. Twenty of 32 patients resumed their sporting career within 6 months of onset of treatment, and a further 4 of 32 patients returned to sports within 1 year. The 8 patients who remained symptomatic at 6 months underwent a unilateral modified Buck's repair. The most common level of repair was L5 (n = 5). One patient with spina bifida and a right-sided L5 pars defect remained symptomatic following direct repair. The mean preoperative ODI was 39.4 (SD = 3.6), improving to 6.4 (SD = 5.2) at the latest follow-up. The mean score of PCS (SF-36) improved from 29.6 (SD = 4.4) to 49.2 (SD = 6.2) (P < 0.001), and the mean score of MCS (SF-36) improved from 38.7 (SD = 1.9) to 54.5 (SD = 6.4) (P < 0.001). The increased incidence of the unilateral lumbar pars stress injuries or frank defect on the contralateral side in a throwing sports, e.g., cricket (fast bowling), may be related to the hand dominance of the individual. Nonoperative treatment for patients with a unilateral lumbar pars stress injuries or spondylolysis resulted in a high rate of success, with 81% (34/42) of patients avoiding surgery. If symptoms persist beyond a reasonable period, i.e., 6 months, and reverse gantry CT scan confirms a nonhealing defect of the pars interarticularis, one may consider a unilateral direct repair of the defect with good functional outcome. Direct repair in patients with spina bifida at the same lumbar level as the unilateral defect may be complicated by nonunion.
Article
This systematic review of prospective cohort studies investigated the evidence for prognostic factors for poor recovery in recent-onset nonspecific low back pain (NSLBP). Medline, Cinahl, Embase, PsychINFO, and AMED databases were searched and citation tracking was performed. Fifty studies met the inclusion criteria. Bivariate and multivariable prognostic factor/outcome associations were extracted. Two reviewers independently performed data extraction and method quality assessment. Where data were available, odds ratios for bivariate associations were calculated and meta-analysis was performed on comparable prognostic factor/outcome associations. Despite the number of studies that have investigated these prognostic factors, uncertainty remains regarding which factors are associated with particular outcomes, the strength of those associations and the extent of confounding between prognostic factors. This uncertainty is the result of the disparate methods that have been used in these investigations, incomplete and contradictory findings, and an inverse relationship between study quality and the reported strength of these associations. The clinical implication is that the formation of clinically useful predictive models remains dependent on further high-quality research. The research implications are that subsequent studies can use the findings of this review to inform prognostic factor selection, and that prognostic studies would ideally be designed to enhance the capacity for findings to be pooled with those of other studies.
Article
Low back pain is a common problem among young athletes. These individuals are at risk for significant structural injuries or nonmechanical problems that can be associated with their symptoms. Any athlete who has severe, persisting, or activity-limiting symptoms must be evaluated thoroughly. Clinicians must have a working knowledge of the developmental issues, injury patterns, and particular conditions that may affect a given athlete and be able to work with patients in addition to families, coaches, trainers, and others involved in the care and training of the injured athlete.
Characteristics associated with active defects in juvenile spondylolysis
  • J L Gum
  • C H Crawford
  • Iii
  • P C Collis
Gum JL, Crawford CH III, Collis PC, et al. Characteristics associated with active defects in juvenile spondylolysis. Am J Orthop (Belle Mead NJ). 2015;44:E379-E383.
Acute and chronic low back pain
  • Patrick