Basics
Description
- Spondylolysis:
- Bony defect at the pars interarticularis (the isthmus of bone between the superior and inferior facets)
- Can be unilateral or bilateral
- Bilateral form has a much higher likelihood of slippage or spondylolisthesis than the unilateral form.
- Spondylolisthesis:
- The slipping forward of 1 vertebra upon another
- Spondylolysis can contribute to spondylolisthesis, which is noted in ó ł ╝5% of the population. It is 2 " ô4 times more common in males.
- Of those with spondylolysis, 50% will have some degree of spondylolisthesis develop during their lifetime, and 50% of those will be symptomatic:
- Literature does not associate athletic activity with increased slippage.
- Spondylolisthesis predisposes to nerve root impingement and frequently sciatica.
- Classification:
- Type 1 " ödysplastic: Congenital defect of the neural arch or intra-articular facets is often associated with spina bifida occulta
- Type 2 " öisthmic: Stress fracture from repetitive microtrauma through the neural arch
- Type 3 " ödegenerative: Long-standing segmental instability
- Type 4 " ötraumatic
- Type 5 " öpathologic: Generalized or focal bone disease
- Spondylolisthesis is divided into 4 grades based on degree of slippage (Meyerding grading system):
- Grade I: Up to 25% of the vertebral body width
- Grade II: 26 " ô50% of vertebral body width
- Grade III: 51 " ô75% of vertebral body width
- Grade IV: 76 " ô100% of vertebral body width
- The most common location for spondylolisthesis is L5 displaced on the sacrum (85 " ô95%), followed by L4 on L5.
- Spondylolysis is one of the most common causes of serious low back pain in children, although it is most often asymptomatic.
- Symptoms most often present during adolescent growth spurt from age 10 " ô15 yr.
- Seen commonly in athletic teens; particularly in sports involving back hyperextension (e.g., gymnastics, diving, football).
- Acute symptoms are related to trauma.
Etiology
Unknown; theories include congenital pars anomalies, alterations in bone density, and recurrent subclinical stress injury. é á
Diagnosis
Signs and Symptoms
History
- Onset often gradual, unless traumatic
- Often associated with feeling of stiffness or spasm in paravertebral muscles
- Pain in the back and proximal legs aggravated by standing and walking
- Sitting or forward bending relieves pain.
- Pain occurs after varying amounts of exercise, with standing, or with coughing:
- Aggravating factors can include repetitive hyperextending movements.
- Alleviating factors can include rest, although the course is variable and slow and usually requires sitting or stooping positions.
- Systemic/neurologic symptoms: Minimal, unless there is significant trauma or "slip. " Ł
Physical Exam
- Hyperlordotic posture:
- Trunk may appear shortened.
- Rib cage approaches iliac crests.
- Hamstring tightness:
- Knees flexed to allow patient to stand upright
- Only "typical " Ł finding is 1-legged hyperextension:
- Standing on 1 leg and leaning backward reproduces pain on ipsilateral side.
- Palpation may reveal step-off with a prominent spinous process of L5 in significant spondylolisthesis.
- Neurologic exam is usually normal:
- If abnormal, pain and sensorimotor loss is in a dermatomal distribution.
- Consider herniation or spondylolisthesis.
- Spondylolysis in a child <10 yr is rare; these patients should be watched for the following:
- Constant pain lasting several weeks
- Pain occurring spontaneously at night
- Pain that interferes repeatedly with school, play, or sports
- Pain associated with marked stiffness, limitation of motion, fever, or neurologic signs
- Pain at the lumbosacral junction
Diagnosis Tests & Interpretation
Lab
There are no required lab studies. é á
Imaging
- Lumbosacral spine radiographs:
- Lateral and oblique radiographs of spine most helpful.
- Spondylolysis will manifest as a radiolucent defect in the pars interarticularis, visible as a "collar " Ł or "broken neck " Ł on the oblique view "Scottie dog " Ł
- Secondary radiographic signs may include sclerosis of the contralateral pedicle and spina bifida occulta at the level of the spondylolysis.
- Majority (80 " ô95%) found at L5 " ôS1 level, 15% at L4 " ôL5.
- Spondylolisthesis will manifest as forward slipping of one vertebral body on another (seen on lateral view).
- Single photon emission computed tomography (SPECT) " öbetter specificity for linking back pain to spondylolysis.
- CT scan:
- Pathology more clearly demonstrated than on plain films
- Can identify other spinal pathology
- Plays an important role for orthopedics in management decisions through identification of new stress fractures and healing of old stress fractures.
- If a CT scan is obtained in the ED, sagittal reconstructions should be performed and the CT scanner should be at minimum a 16-slice scanner.
- Outpatient evaluation unless history of recent trauma.
- MRI " öexact role not yet clarified in literature:
- Useful for defining nerve root impingement and central canal and neuroforaminal narrowing.
- May be useful in the assessment of acuity of abnormality.
- Can identify alternate pathologic diagnoses.
- Lower threshold for ordering imaging studies.
- Progressive slipping more likely to occur than in adults.
Differential Diagnosis
- Tuberculosis (Pott disease)
- Discitis
- Bone or spinal cord tumor
- Pyelonephritis
- Retroperitoneal infection
- Injury to muscles or joints of back
- Congenital hip dislocation
- Rickets
- Ruptured intervertebral disc
- Vascular claudication
- Osteomyelitis
- Osteoid osteoma
- Aortic aneurysm
Treatment
Pre-Hospital
Spinal precautions are not needed unless there is a history of recent trauma. é á
Initial Stabilization/Therapy
Vigorous attempts at traction should not be pursued. é á
Ed Treatment/Procedures
- Pain control and muscle relaxants as clinically needed
- Supportive therapy if symptoms are mild
- Restrict activities if repetitive trauma is likely aggravating cause (e.g., sports) for 3 " ô6 wk, followed by reintroduction of activity when asymptomatic.
- Consider antilordotic braces (controversial) or physical therapy.
- Orthopedic consult or referral if symptoms are moderate to severe or unresponsive to supportive care
- Surgical intervention typically consists of spinal fusion in the flexed position:
- 50% of symptomatic patients with spondylolisthesis may require surgery.
- All symptomatic patients with grade III or IV spondylolisthesis should probably undergo surgery.
- Exercises are not of proven benefit.
- Activity restriction is not necessary if minimal or no symptoms.
- Literature suggests good outcome for young athletes with conservative treatment.
Medication
- Muscle relaxants:
- E.g. " ömethocarbamol: 1,000 " ô1,500 mg PO QID (peds: Safety and effectiveness for children <12 yr of age not established)
- Diazepam: 2 " ô10 mg PO TID " ôQID
- Cyclobenzaprine: 5 " ô10 mg PO TID (peds: Safe for ages >15 yr old)
- NSAIDs:
- E.g. " öibuprofen: 200 " ô800 mg PO TID " ôQID (peds: 5 " ô10 mg/kg PO q6h)
- Opioids (doses can vary on oral medications):
- Example " ömorphine sulfate: 0.1 mg/kg up to 2 " ô4 mg increments IV.
- Acetaminophen/hydrocodone: 5/500 mg 1 " ô2 tabs PO QID; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)
- Acetaminophen/oxycodone: 5/325 mg 1 " ô2 tabs PO QID; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)
- Acetaminophen/codeine: 300/30 mg 1 " ô2 tabs PO QID (peds: 0.5 " ô1 mg/kg codeine PO q4 " ô6h; max. 60 mg/dose codeine; 1 g/dose, 75 mg/kg/d up to 4 g/d >3 yr old); do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)
Follow-Up
Disposition
Admission Criteria
- Inability to walk
- Inability to cope at home due to pain or social situation
- New or progressive neurologic deficit
Discharge Criteria
- Orthopedic follow-up arranged
- Social support system in place
- Pain control
- Patient education
Close follow-up is mandatory. é á
Additional Reading
- Clifford é áR, Wheeless é áIII. Wheeless Textbook of Orthopaedics. Spondylolysis/Spondylolisthesis. Accessed on April 25, 2012.
- Congeni é áJ, McCulloch é áJ, Swanson é áK. Lumbar spondylolysis. A study of natural progression in athletes. Am J Sports Med. 1997;25(2):248 " ô253.
- Iwamoto é áJ, Takeda é áT, Wakano é áK. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports. 2004;14(6):346 " ô351.
- Tsirikos é áAI, Garrido é áEG. Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br. 2010;92(6):751 " ô759. doi:10.1302/0301-620X.92B6.23014.
Codes
ICD9
- 738.4 Acquired spondylolisthesis
- 756.11 Spondylolysis, lumbosacral region
- 756.12 Spondylolisthesis
ICD10
- M43.00 Spondylolysis, site unspecified
- M43.10 Spondylolisthesis, site unspecified
- M43.16 Spondylolisthesis, lumbar region
- Q76.2 Congenital spondylolisthesis
SNOMED
- 240221008 spondylolysis (disorder)
- 274152003 Spondylolisthesis (disorder)
- 307138004 Spondylolisthesis L5/S1 level (disorder)
- 80712009 Congenital spondylolysis of lumbosacral region (disorder)
- 13131000 Spondylolisthesis, grade 3 (disorder)
- 13236000 congenital spondylolisthesis (disorder)
- 203681002 acquired spondylolisthesis (disorder)
- 3472009 Spondylolisthesis, grade 4 (disorder)
- 44494000 Spondylolisthesis, grade 1 (disorder)
- 62620001 Spondylolisthesis, grade 2 (disorder)