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 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".)
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:
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- 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