Spondylolysis and spondylolisthesis in child and adolescent athletes: Management
- James M Daniels, MD, MPH, RMSK
James M Daniels, MD, MPH, RMSK
- Professor of Family & Community Medicine and Orthopedic Surgery
- Vice Chair and Director of Scholarly Activity
- Department of Family & Community Medicine
- Southern Illinois University School of 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
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. In the large majority of cases, treatment consisting primarily of rest and symptom management allows children and adolescents to recover from these conditions without complications.
The management of spondylolysis and spondylolisthesis in child and adolescent athletes is reviewed here. The clinical presentation and diagnosis of these conditions, and the assessment of unspecified back pain in children, are discussed separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis" and "Evaluation of the child with back pain" and "Back pain in children and adolescents: Overview of causes".)
INITIAL MANAGEMENT WHEN SPONDYLOLYSIS IS SUSPECTED
Ruling out dangerous causes of back pain — Patients, particularly younger children, with a potentially dangerous cause of low back pain must be worked up appropriately; their care is reviewed in detail separately. (See "Evaluation of the child with back pain".)
Symptoms and signs associated with dangerous causes of back pain include:
●Age less than four years
- 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.
- Bouras T, Korovessis P. Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review. Eur J Orthop Surg Traumatol 2015; 25 Suppl 1:167.
- Lee GW, Lee SM, Ahn MW, et al. Comparison of surgical treatment with direct repair versus conservative treatment in young patients with spondylolysis: a prospective, comparative, clinical trial. Spine J 2015; 15:1545.
- Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop 2009; 29:146.
- Kurd MF, Patel D, Norton R, et al. Nonoperative treatment of symptomatic spondylolysis. J Spinal Disord Tech 2007; 20:560.
- Garet M, Reiman MP, Mathers J, Sylvain J. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review. Sports Health 2013; 5:225.
- Belfi LM, Ortiz AO, Katz DS. Computed tomography evaluation of spondylolysis and spondylolisthesis in asymptomatic patients. Spine (Phila Pa 1976) 2006; 31:E907.
- Djulbegovic B, Guyatt GH. Evidence-based practice is not synonymous with delivery of uniform health care. JAMA 2014; 312:1293.
- Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA 2014; 312:1295.
- Syrmou E, Tsitsopoulos PP, Marinopoulos D, et al. Spondylolysis: a review and reappraisal. Hippokratia 2010; 14:17.
- Iwamoto J, Sato Y, Takeda T, Matsumoto H. Return to sports activity by athletes after treatment of spondylolysis. World J Orthop 2010; 1:26.
- Debnath UK, Freeman BJ, Grevitt MP, et al. Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis. Spine (Phila Pa 1976) 2007; 32:995.
- Helenius I, Lamberg T, Osterman K, et al. Scoliosis research society outcome instrument in evaluation of long-term surgical results in spondylolysis and low-grade isthmic spondylolisthesis in young patients. Spine (Phila Pa 1976) 2005; 30:336.
- Debnath UK, Freeman BJ, Gregory P, et al. Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes. J Bone Joint Surg Br 2003; 85:244.
- Standaert CJ, Herring SA, Halpern B, King O. Spondylolysis. Phys Med Rehabil Clin N Am 2000; 11:785.
- Fredrickson BE, Baker D, McHolick WJ, et al. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am 1984; 66:699.
- Alfieri A, Gazzeri R, Prell J, Röllinghoff M. The current management of lumbar spondylolisthesis. J Neurosurg Sci 2013; 57:103.
- Lim MR, Yoon SC, Green DW. Symptomatic spondylolysis: diagnosis and treatment. Curr Opin Pediatr 2004; 16:37.
- Steiner ME, Micheli LJ. Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace. Spine (Phila Pa 1976) 1985; 10:937.
- Iwamoto J, Takeda T, Wakano K. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports 2004; 14:346.
- Blanda J, Bethem D, Moats W, Lew M. Defects of pars interarticularis in athletes: a protocol for nonoperative treatment. J Spinal Disord 1993; 6:406.
- O'Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine (Phila Pa 1976) 1997; 22:2959.
- Miller RA, Hardcastle P, Renwick SE. Lower spinal mobility and external immobilization in the normal and pathologic condition. Orthop Rev 1992; 21:753.
- Tuong NH, Dansereau J, Maurais G, Herrera R. Three-dimensional evaluation of lumbar orthosis effects on spinal behavior. J Rehabil Res Dev 1998; 35:34.
- McClellan JW 3rd, Vernon BA, White MA, et al. Should 25-hydroxyvitamin D and bone density using DXA be tested in adolescents with lumbar stress fractures of the pars interarticularis? J Spinal Disord Tech 2012; 25:426.
- Cranney A, Weiler HA, O'Donnell S, Puil L. Summary of evidence-based review on vitamin D efficacy and safety in relation to bone health. Am J Clin Nutr 2008; 88:513S.
- Cranney A, Horsley T, O'Donnell S, et al. Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess (Full Rep) 2007; :1.
- Watkins RG. The spine in sports. In: Spinal Exercise Program, 1st ed, CRC Press, St. Louis 1995. p.283.
- Nau E, Hanney WJ, Kolber MJ. Spinal Conditioning for Athletes With Lumbar Spondylolysis and Spondylolisthesis. Strength and Conditioning Journal 2008; 30:43. (http://scottsevinsky.com/pt/reference/spine/lumbar/scj_spinal_conditioning.pdf)
- McNeely ML, Torrance G, Magee DJ. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Man Ther 2003; 8:80.
- Bookhout MR. Evaluation and conservative management of spondylolisthesis. J Back Musculoskelet Rehabil 1993; 3:24.
- McGregor AH, Cattermole HR, Hughes SP. Global spinal motion in subjects with lumbar spondylolysis and spondylolisthesis: does the grade or type of slip affect global spinal motion? Spine (Phila Pa 1976) 2001; 26:282.
- Rosenberg NJ, Bargar WL, Friedman B. The incidence of spondylolysis and spondylolisthesis in nonambulatory patients. Spine (Phila Pa 1976) 1981; 6:35.
- Nazarian S. Spondylolysis and spondylolytic spondylolisthesis. A review of current concepts on pathogenesis, natural history, clinical symptoms, imaging, and therapeutic management. Eur Spine J 1992; 1:62.
- Herman MJ, Pizzutillo PD, Cavalier R. Spondylolysis and spondylolisthesis in the child and adolescent athlete. Orthop Clin North Am 2003; 34:461.
- Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. J Bone Joint Surg Am 2008; 90:656.
- Donaldson LD. Spondylolysis in elite junior-level ice hockey players. Sports Health 2014; 6:356.
- Lundine KM, Lewis SJ, Al-Aubaidi Z, et al. Patient outcomes in the operative and nonoperative management of high-grade spondylolisthesis in children. J Pediatr Orthop 2014; 34:483.
- Joelson A, Hedlund R, Frennered K. Normal Health-Related Quality of Life and Ability to Work Twenty-nine Years After in Situ Arthrodesis for High-Grade Isthmic Spondylolisthesis. J Bone Joint Surg Am 2014; 96:e100.
- Molinari RW, Sloboda JF, Arrington EC. Low-grade isthmic spondylolisthesis treated with instrumented posterior lumbar interbody fusion in U.S. servicemen. J Spinal Disord Tech 2005; 18 Suppl:S24.
- Schlenzka D. [Spondylolisthesis in childhood and adolescence]. Orthopade 1997; 26:760.
- Davis R, Auerbach JD, Bae H, Errico TJ. Can low-grade spondylolisthesis be effectively treated by either coflex interlaminar stabilization or laminectomy and posterior spinal fusion? Two-year clinical and radiographic results from the randomized, prospective, multicenter US investigational device exemption trial: clinical article. J Neurosurg Spine 2013; 19:174.
- Schlenzka D, Seitsalo S, Poussa M, Osterman K. Operative treatment of symptomatic lumbar spondylolysis and mild isthmic spondylolisthesis in young patients: direct repair of the defect or segmental spinal fusion? Eur Spine J 1993; 2:104.
- Ye YP, Xu H, Chen D. Comparison between posterior lumbar interbody fusion and posterolateral fusion with transpedicular screw fixation for isthmic spondylolithesis: a meta-analysis. Arch Orthop Trauma Surg 2013; 133:1649.
- Westacott DJ, Cooke SJ. Functional outcome following direct repair or intervertebral fusion for adolescent spondylolysis: a systematic review. J Pediatr Orthop B 2012; 21:596.
- Lad SP, Babu R, Baker AA, et al. Complications, reoperation rates, and health-care cost following surgical treatment of lumbar spondylolisthesis. J Bone Joint Surg Am 2013; 95:e162.
- Choi KC, Kim JS, Shim HK, et al. Changes in the adjacent segment 10 years after anterior lumbar interbody fusion for low-grade isthmic spondylolisthesis. Clin Orthop Relat Res 2014; 472:1845.
- Remes V, Lamberg T, Tervahartiala P, et al. Long-term outcome after posterolateral, anterior, and circumferential fusion for high-grade isthmic spondylolisthesis in children and adolescents: magnetic resonance imaging findings after average of 17-year follow-up. Spine (Phila Pa 1976) 2006; 31:2491.
- Yoshimura N, Muraki S, Oka H, et al. Serum levels of 25-hydroxyvitamin D and the occurrence of musculoskeletal diseases: a 3-year follow-up to the road study. Osteoporos Int 2015; 26:151.
- Jayanthi N, Pinkham C, Dugas L, et al. Sports specialization in young athletes: evidence-based recommendations. Sports Health 2013; 5:251.
- Malina RM. Early sport specialization: roots, effectiveness, risks. Curr Sports Med Rep 2010; 9:364.
- INITIAL MANAGEMENT WHEN SPONDYLOLYSIS IS SUSPECTED
- Ruling out dangerous causes of back pain
- Initial evaluation and observation
- INDICATIONS FOR SPINE SURGERY REFERRAL
- MANAGEMENT OF PATIENTS WITH SPONDYLOLYSIS ESTABLISHED CLINICALLY OR RADIOGRAPHICALLY
- Overview and principles of management
- First follow-up visit for patients with persistent pain
- Treatment by radiograph findings and patient willingness to rest
- Symptom control and basic treatment
- Return to play
- Patients with hypermobility
- Adjunctive treatments
- - Vitamin D
- - Physical therapy
- - Clinic visits and reassessments
- - Surveillance imaging
- PATIENTS WITH PERSISTENT PAIN DESPITE 90-DAYS REST
- PROGNOSIS AND COMPLICATIONS
- SUMMARY AND RECOMMENDATIONS