Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis
- Pierre A d'Hemecourt, MD
Pierre A d'Hemecourt, MD
- Lecturer in Sports Medicine
- Harvard Medical School
- Lyle J Micheli, MD
Lyle J Micheli, MD
- Director, Division of Sports Medicine
- Boston Children’s Hospital
- Clinical Professor of Orthopaedic Surgery
- Harvard Medical School
- Secretary General
- International Federation of Sports Medicine
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Among child and adolescent athletes, spondylolysis typically represents a fracture of the posterior arch in the lower lumbar spine due to overuse and is a relatively common cause of low back pain. Spondylolisthesis involves anterior displacement of a vertebral body due to bilateral defects of the posterior arch and is less common than spondylolysis.
The clinical presentation, approach to imaging, and diagnosis of spondylolysis and spondylolisthesis in children and adolescents are reviewed here. The treatment of spondylolysis and spondylolisthesis, as well as other causes of low back pain in children, are discussed separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Management" and "Back pain in children and adolescents: Causes" and "Evaluation of the child with back pain".)
DEFINITIONS, PATHOGENESIS, AND LOCATION
Spondylolysis is a unilateral or bilateral defect (fracture or separation) in the vertebral pars interarticularis, usually in the lower lumbar vertebrae (figure 1 and figure 2). In young athletes, spondylolysis usually represents a fatigue fracture in the posterior arch of the spine, specifically the bony area of the pars interarticularis (pars) between the zygapophyseal (facet) joints. Although usually an overuse injury, spondylolysis may present following an acute overload. Several observations suggest spondylolysis is primarily a fatigue fracture. First, it has never been reported in a fetus or non-ambulatory person [1,2]. Second, it occurs most frequently in athletes whose sport involves repetitive increased spinal loads. (See 'Epidemiology and risk factors' below.)
Spondylolysis occurs at the fifth lumbar vertebra (L5) approximately 85 to 95 percent of the time, with an L4 locus in 5 to 15 percent of cases. Most injuries occur at L5 because the pars interarticularis at this level is subject to a direct pincer-like effect from the inferior articular process of L4 above and the superior articular process of S1 below. Rarely, the injury develops at levels above L4, but it has been reported as high as L1 . Multilevel involvement occurs approximately 4 percent of the time , and bilateral involvement occurs in approximately 80 percent of cases . When bilateral defects develop, the vertebral body may slip anteriorly relative to the subadjacent vertebra and this is termed spondylolisthesis (figure 3).
The Wiltse Classification is typically used to categorize spondylolisthesis. This system is based on the etiology of vertebral slippage:
- ROWE GG, ROCHE MB. The etiology of separate neural arch. J Bone Joint Surg Am 1953; 35-A:102.
- Rosenberg NJ, Bargar WL, Friedman B. The incidence of spondylolysis and spondylolisthesis in nonambulatory patients. Spine (Phila Pa 1976) 1981; 6:35.
- Standaert CJ, Herring SA. Spondylolysis: a critical review. Br J Sports Med 2000; 34:415.
- Morita T, Ikata T, Katoh S, Miyake R. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg Br 1995; 77:620.
- Labelle H, Roussouly P, Berthonnaud E, et al. The importance of spino-pelvic balance in L5-s1 developmental spondylolisthesis: a review of pertinent radiologic measurements. Spine (Phila Pa 1976) 2005; 30:S27.
- McPhee IB, O'Brien JP, McCall IW, Park WM. Progression of lumbosacral spondylolisthesis. Australas Radiol 1981; 25:91.
- Hu SS, Bradford DS. Spondylolysis and spondylolisthesis. In: The Pediatric Spine: Principles and Practice, 2nd ed, Weinstein SL (Ed), Lippincott Williams & Wilkins, Philadelphia 2001. p.433.
- Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine (Phila Pa 1976) 2007; 32:2630.
- Taimela S, Kujala UM, Salminen JJ, Viljanen T. The prevalence of low back pain among children and adolescents. A nationwide, cohort-based questionnaire survey in Finland. Spine (Phila Pa 1976) 1997; 22:1132.
- Kujala UM, Taimela S, Erkintalo M, et al. Low-back pain in adolescent athletes. Med Sci Sports Exerc 1996; 28:165.
- Tall RL, DeVault W. Spinal injury in sport: epidemiologic considerations. Clin Sports Med 1993; 12:441.
- Micheli LJ, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 1995; 149:15.
- Beutler WJ, Fredrickson BE, Murtland A, et al. The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine (Phila Pa 1976) 2003; 28:1027.
- Sakai T, Sairyo K, Suzue N, et al. Incidence and etiology of lumbar spondylolysis: review of the literature. J Orthop Sci 2010; 15:281.
- McTimoney CA, Micheli LJ. Current evaluation and management of spondylolysis and spondylolisthesis. Curr Sports Med Rep 2003; 2:41.
- Rossi F, Dragoni S. Lumbar spondylolysis: occurrence in competitive athletes. Updated achievements in a series of 390 cases. J Sports Med Phys Fitness 1990; 30:450.
- Seitsalo S, Osterman K, Poussa M. Scoliosis associated with lumbar spondylolisthesis. A clinical survey of 190 young patients. Spine (Phila Pa 1976) 1988; 13:899.
- Wojtys EM, Ashton-Miller JA, Huston LJ, Moga PJ. The association between athletic training time and the sagittal curvature of the immature spine. Am J Sports Med 2000; 28:490.
- Krabbe S, Christiansen C, Rødbro P, Transbøl I. Effect of puberty on rates of bone growth and mineralisation: with observations in male delayed puberty. Arch Dis Child 1979; 54:950.
- Wynne-Davies R, Scott JH. Inheritance and spondylolisthesis: a radiographic family survey. J Bone Joint Surg Br 1979; 61-B:301.
- Fredrickson BE, Baker D, McHolick WJ, et al. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am 1984; 66:699.
- ROCHE MB, ROWE GG. The incidence of separate neural arch and coincident bone variations; a survey of 4,200 skeletons. Anat Rec 1951; 109:233.
- Merbs CF. Patterns of activity-induced pathology in a Canadian Inuit population. Archaeol Surv Canada 1983; 119:120.
- Merbs CF. Incomplete spondylolysis and healing. A study of ancient Canadian Eskimo skeletons. Spine (Phila Pa 1976) 1995; 20:2328.
- Ko SB, Lee SW. Prevalence of spondylolysis and its relationship with low back pain in selected population. Clin Orthop Surg 2011; 3:34.
- d'Hemecourt PA, Gerbino PG 2nd, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 2000; 19:663.
- Sakai T, Sairyo K, Takao S, et al. Incidence of lumbar spondylolysis in the general population in Japan based on multidetector computed tomography scans from two thousand subjects. Spine (Phila Pa 1976) 2009; 34:2346.
- Nadler SF, Malanga GA, Bartoli LA, et al. Hip muscle imbalance and low back pain in athletes: influence of core strengthening. Med Sci Sports Exerc 2002; 34:9.
- Sjölie AN, Ljunggren AE. The significance of high lumbar mobility and low lumbar strength for current and future low back pain in adolescents. Spine (Phila Pa 1976) 2001; 26:2629.
- Kujala UM, Taimela S, Oksanen A, Salminen JJ. Lumbar mobility and low back pain during adolescence. A longitudinal three-year follow-up study in athletes and controls. Am J Sports Med 1997; 25:363.
- Ogilvie JW, Sherman J. Spondylolysis in Scheuermann's disease. Spine (Phila Pa 1976) 1987; 12:251.
- Greene TL, Hensinger RN, Hunter LY. Back pain and vertebral changes simulating Scheuermann's disease. J Pediatr Orthop 1985; 5:1.
- Sairyo K, Goel VK, Vadapalli S, et al. Biomechanical comparison of lumbar spine with or without spina bifida occulta. A finite element analysis. Spinal Cord 2006; 44:440.
- Farfan HF, Osteria V, Lamy C. The mechanical etiology of spondylolysis and spondylolisthesis. Clin Orthop Relat Res 1976; :40.
- Sairyo K, Katoh S, Komatsubara S, et al. Spondylolysis fracture angle in children and adolescents on CT indicates the fracture producing force vector: a biomechanical rationale. Internet J Spine Surg 2005; 1.
- Terai T, Sairyo K, Goel VK, et al. Tensile stress at the ventral aspect of the pars interarticularis causes the initial defect of the pediatric lumbar spondylolysis. 38th annual meeting of the Japanese Society for Spine Surgery and Related Research. J Bone Joint Surg Br 2009; 20:390.
- Terai T, Sairyo K, Goel VK, et al. Spondylolysis originates in the ventral aspect of the pars interarticularis: a clinical and biomechanical study. J Bone Joint Surg Br 2010; 92:1123.
- Porter RW, Park W. Unilateral spondylolysis. J Bone Joint Surg Br 1982; 64:344.
- Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. J Bone Joint Surg Am 2008; 90:656.
- Gunzburg R, Fraser RD. Stress fracture of the lumbar pedicle. Case reports of "pediculolysis" and review of the literature. Spine (Phila Pa 1976) 1991; 16:185.
- Kobayashi A, Kobayashi T, Kato K, et al. Diagnosis of radiographically occult lumbar spondylolysis in young athletes by magnetic resonance imaging. Am J Sports Med 2013; 41:169.
- Weiker GG. Evaluation and treatment of common spine and trunk problems. Clin Sports Med 1989; 8:399.
- Masci L, Pike J, Malara F, et al. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. Br J Sports Med 2006; 40:940.
- Hirano A, Takebayashi T, Yoshimoto M, et al. Characteristics of clinical and imaging findings in adolescent lumbar spondylolysis associated with sports activities. J Spine 2012; 1:5.
- Janda V. Muscles and motor control in low back pain: Assessment and management. In: Physical Therapy of the Low Back, Twomey LT (Ed), Churchill Livingstone, New York City 1987. p.253.
- Tofte JN, CarlLee TL, Holte AJ, et al. Imaging Pediatric Spondylolysis: A Systematic Review. Spine (Phila Pa 1976) 2017; 42:777.
- Libson E, Bloom RA, Dinari G. Symptomatic and asymptomatic spondylolysis and spondylolisthesis in young adults. Int Orthop 1982; 6:259.
- Saifuddin A, White J, Tucker S, Taylor BA. Orientation of lumbar pars defects: implications for radiological detection and surgical management. J Bone Joint Surg Br 1998; 80:208.
- Miller R, Beck NA, Sampson NR, et al. Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain. J Pediatr Orthop 2013; 33:282.
- Beck NA, Miller R, Baldwin K, et al. Do oblique views add value in the diagnosis of spondylolysis in adolescents? J Bone Joint Surg Am 2013; 95:e65.
- Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology 1991; 180:509.
- van den Oever M, Merrick MV, Scott JH. Bone scintigraphy in symptomatic spondylolysis. J Bone Joint Surg Br 1987; 69:453.
- Drubach LA, Connolly LP, D'Hemecourt PA, Treves ST. Assessment of the clinical significance of asymptomatic lower extremity uptake abnormality in young athletes. J Nucl Med 2001; 42:209.
- Hollenberg GM, Beattie PF, Meyers SP, et al. Stress reactions of the lumbar pars interarticularis: the development of a new MRI classification system. Spine (Phila Pa 1976) 2002; 27:181.
- Cohen E, Stuecker RD. Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects. J Pediatr Orthop B 2005; 14:63.
- Sairyo K, Sakai T, Yasui N. Conservative treatment of lumbar spondylolysis in childhood and adolescence: the radiological signs which predict healing. J Bone Joint Surg Br 2009; 91:206.
- Maurer M, Soder RB, Baldisserotto M. Spine abnormalities depicted by magnetic resonance imaging in adolescent rowers. Am J Sports Med 2011; 39:392.
- Congeni J, McCulloch J, Swanson K. Lumbar spondylolysis. A study of natural progression in athletes. Am J Sports Med 1997; 25:248.
- Sairyo K, Sakai T, Yasui N, Dezawa A. Conservative treatment for pediatric lumbar spondylolysis to achieve bone healing using a hard brace: what type and how long?: Clinical article. J Neurosurg Spine 2012; 16:610.
- DEFINITIONS, PATHOGENESIS, AND LOCATION
- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL ANATOMY
- CLINICAL PRESENTATION AND EXAMINATION
- Common presentations
- Physical examination
- DIAGNOSTIC IMAGING
- Approach to imaging for spondylolysis
- Plain radiographs
- SPECT bone scan
- Magnetic resonance imaging
- Computed tomography
- Younger adolescents
- Older adolescents/young adults
- INDICATIONS FOR SURGICAL REFERRAL
- Emergent referral
- Non-urgent consultation
- DIFFERENTIAL DIAGNOSIS
- Lumbar disc
- Scheuermann’s (juvenile) kyphosis of lumbar spine
- Sacroiliac instability
- Lordotic low-back pain
- Vertebral segmentation abnormalities
- Discitis and osteomyelitis
- Osteoid osteoma
- Other tumors
- SUMMARY AND RECOMMENDATIONS