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Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis

Pierre A d'Hemecourt, MD
Lyle J Micheli, MD
Section Editor
Karl B Fields, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


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 diagnosis and non-operative management of spondylolysis and spondylolisthesis are reviewed here. Other causes of low back pain in children are discussed separately. (See "Back pain in children and adolescents: Overview of causes" and "Evaluation of the child with back pain".)


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 [3]. Multilevel involvement occurs approximately 4 percent of the time [4], and bilateral involvement occurs in approximately 80 percent of cases [5]. 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:


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Literature review current through: Sep 2016. | This topic last updated: Apr 16, 2015.
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