Spondylolysis and Spondylolisthesis

Adolescent back pain has been reported to affect more than half of school age patients. Parents are often confused by the severity of the complaints, yet their teenager continues in sports or other activities. The child will complain for months and get minimal relief of symptoms with anti-inflammatory drugs. Then the family will seek an evaluation.

There may be many reasons other than overuse or growing pains for an adolescent to have lower (lumbar) back pain. These include:

Metabolic.

• Juvenile osteoporosis.

Inflammatory.

• Ankylosing Spondylitis.

• Sero-negative Arthritis.

Neoplasm.

• Osteoid osteoma.

Congenital.

• L5-S1 facet Hypoplasia.

Developmental.

• Lumbar Scheurmann's.

Trauma.

• Pars interarticularis.

The clinical exam provides information. This includes the location of the pain, if there is muscle spasm, lower spine range of motion, hamstring muscle tightness, muscle strength in the legs, reflexes and sensation in the legs.

X-ray studies may discount several of the potential diagnoses. X-rays may direct the physician to propose the diagnosis of a pars interarticularis stress injury or fracture.

The pars interarticularis is a portion of the lumbar spine. It joins together the upper and lower joints. The pars is normal in the vast majority of children.

When they are about 8 years old, certain patients begin to experience abnormal growth and development of this particular region in the bone. A genetic weakness to the bone has been established in certain ethnic groups. One such group is Alaskan Indians. It does appear that certain athletic activities or injuries (gymnastics, heavy weight lifting) may result in problems in susceptible individuals.

There are three stages of injury to the pars interarticularis:

• Stress reaction

• Fracture (spondylolysis)

• Slippage (spondylolisthesis)

Stress reaction or injury may occur when the bone experiences excessive wear and tear. This can happen from activities of daily living, sports or a fall. The symptoms may include lumbar pain, stiffness and hamstring muscle tightness. X-rays will not reveal any abnormality. A bone scan will show the inflammation in the pars. Treatment consists of relieving the pain and restoring spinal flexibility. After several months, most patients resume most activities.

If the pars "cracks" or fractures, the condition is called Spondylolysis. The X-ray confirms the bony abnormality. Treatment is customized. It is based on the severity of symptoms. Anti-inflammatory drugs, physical therapy, wearing a brace and changing activities will be considered.

If the fracture gap at the pars widens, then the condition is called Spondylolisthesis. Widening of the gap leads to the fifth lumbar vertebra shifting. It shifts forward on the part of the pelvic bone called the sacrum. The doctor measures standing lateral spine X-rays. This determines the amount of forward slippage.

Treatment Options

Treatment is prescribed. It decreases any acute spasm and restores flexibility of the spine.

Prognosis is affected by the amount of slippage. In general, most patients with less than 50 percent slippage tend to fare well through adolescence. With slippage of 50 percent or greater patients have more potential for additional slippage as they grow and age.

Treatment Options: Surgical

A small number of patients do not respond to conservative medical management. They are evaluated for a spinal fusion.

posted 7/1/2004

AAOS