Management of Lumbar Conditions in the Elite Athlete

Wellington K. Hsu, MD; Tyler James Jenkins, MD

Disclosures

J Am Acad Orthop Surg. 2017;25(7):489-498. 

In This Article

Spondylolysis

Spondylolysis is a defect within the pars interarticularis and is believed to be acquired from repetitive microtrauma. Shear forces are resisted by the IV disk and posterior bony elements. Cyclical shear loading of the posterior elements in the pediatric spine can lead to pars fatigue, eventual fracture, and the development of spondylolysis. The incidence of symptomatic spondylolysis in young athletes with LBP ranges from 15% to 47%, which is considerably higher than that of the general population (6% to 8%).[32] The incidence of spondylolysis is higher in wrestling, weightlifting, and diving athletes than in athletes in other sports.[33] The prevalence of spondylolysis has been reported to be as high as 38% and 44% in professional soccer and baseball players, respectively.[34] Spondylolisthesis, the ventral migration of the spinal column over its caudal segment, can occur in the setting of bilateral spondylolysis.

Clinical Presentation

Patients with symptomatic spondylolysis typically present with mechanical midline LBP or focal unilateral symptoms over the facet joint. In a study that compared 100 adolescent athletes and 100 adult athletes with LBP, 47% of adolescents were found to have spondylolysis compared with only 5% of adults.[18] In the presence of spondylolisthesis, neurologic symptoms, such as radiculopathy, and bilateral hip pain may be present. Severe isthmic spondylolisthesis at L5-S1 can lead to foraminal stenosis, which presents as an L5 radiculopathy.

An upright lateral lumbar radiograph can be used to diagnose spondylolysis and spondylolisthesis. Oblique lumbar radiographs may show a radiolucency through the pars interarticularis, often referred to as the Scottie dog sign. Imaging also can be used to assess for spondylolisthesis and can be classified according to the Meyerding grading system (Table 2 and Figure 3). CT is more sensitive than plain radiography for identifying spondylolysis but carries the risk of additional radiation exposure.[35] Technetium tc-99m single-photon emission CT often is used to identify acute lesions in athletes for whom the clinician has a high suspicion for spondylolysis in the setting of negative results on plain radiography, but this imaging modality can expose patients to high levels of radiation. Although MRI historically has not been recommended for detecting pars defects, more recent evidence suggests that specific sequences can enable successful detection in up to 98% of patients with pars defects.[35] It is the senior author's (W.K.H.) opinion that thin-sliced MRI is the advanced imaging study of choice for diagnosing spondylolysis because it greatly reduces radiation exposure to the adolescent population[36,37] and provides subtle clues not provided by CT (Table 3). For example, on a T2-weighted MRI of the spine, high signal changes in the pedicle adjacent to the pars are an early indicator of spondylolysis, and high signal change–positive pars defects have a higher rate of bony union than do high signal change–negative pars defects.[38] CT should be obtained in patients with acute pars defects diagnosed on MRI. This CT scan allows a comparison when assessing for bony union if follow-up CT scans are indicated.[35]

Figure 3.

Standing lateral radiograph of the lumbar spine showing the Meyerding classification of spondylolisthesis. (Reproduced with permission from Campbell RS, Grainger AJ, Hide IG, Papastefanou S, Greenough CG: Juvenile spondylolysis: A comparative analysis of CT, SPECT, and MRI. Skeletal Radiol 2005;34[2]:63–73.)

Management

Nonsurgical. Initially, acute symptomatic pars defects can be managed nonsurgically with activity modification, bracing, rest, and physical therapy. Lumbar extension specifically should be avoided because of the shear forces it generates, which may increase the risk of spondylolisthesis. Anti-inflammatory drugs can be used as needed for pain relief. Activity modification, including sport cessation, should take place for the first 3 to 6 months. Adolescent soccer players with spondylolysis who stopped playing sports for 3 months had considerably less pain and better outcomes than did players who continued to play their sport.[39] All 32 adolescents in the rest cohort returned to play, whereas only 18 of 24 adolescents in the control cohort returned to play (75%).

For acute spondylolysis, the potential for healing is high, with a reported healing rate of >90%.[40] Conversely, this method has not been shown to be effective for management of chronic defects. Historically, bracing has been recommended to limit lumbar extension during the activity modification phase of treatment; however, no substantial differences in 1-year outcomes were found between treatment with and treatment without bracing in a meta-analysis published in 2009.[40] Bracing can also be used to facilitate appropriate activity modification in adolescent athletes with minimal risk to the patient. Pars injections can be considered for diagnostic and therapeutic purposes in patients with persistent, painful chronic pars defects. In one study, the long-term results of nonsurgical treatment in young athletes with spondylolysis were favorable, with 90% having a good to excellent outcome 11 years after diagnosis.[41]

Surgical. Surgical treatment of spondylolysis can be considered after the failure of a 6-month course of nonsurgical management and in the setting of persistent neurologic symptoms or progressive spondylolisthesis. A variety of surgical techniques are available to manage this condition; these techniques can be classified as direct pars repair or decompression with or without fusion.

Direct repair of a pars defect can be performed in young patients with minimal spondylolisthesis, no neurologic symptoms, and minimal degenerative changes.[42] This procedure preserves motion in the affected segment and therefore may reduce the risk of adjacent segment disease. In this technique, it is crucial to débride the pars defect to aid in bony healing because the failure of bony union has been shown to result in worse outcomes.[42] Various constructs can be used for repair, including lag screw fixation, cerclage wiring, or screw fixation with a sublaminar hook (Figure 4). In one study, the rate of return to play in athletes treated with a direct pars repair was 80% to 100%.[43] In patients with Meyerding grade 1 to 2 isthmic spondylolisthesis, treatment typically involves an L5-S1 fusion, which has resulted in excellent clinical outcomes approaching 90% fusion in adolescents.[44] Decompression is indicated for surgical management of neurologic symptoms, which most often occur at the exiting L5 nerve root (Figures 5 and 6).

Figure 4.

Illustrations demonstrating three pars repair techniques, including buck direct screw fixation (A), in which a neutralization screw is placed directly across the pars deficit, the Scott cerclage wiring technique (B), and pedicle screw fixation combined with a sublaminar hook (C). (Reproduced from Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD: Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management. J Am Acad Orthop Surg 2006;14[8]:488–498.)

Figure 5.

A, Preoperative sagittal T2-weighted MRI of the lumbar spine showing grade III spondylolisthesis without neurologic deficits in a 22-year-old female Olympic equestrian. Postoperative lateral (B) and AP (C) radiographs of the lumbar spine obtained after a single-level anterior lumbar interbody fusion with percutaneous posterior fixation. D through F, Sagittal CT images of the lumbar spine demonstrating successful solid fusion achieved by 4 months postoperatively. The patient successfully returned to competitive horseback riding after completing a structured rehabilitation program. (Reproduced with permission from Burgmeier RJ, Hsu WK: Spine surgery in athletes with low back pain: Considerations for management and treatment. Asian J Sports Med 2014;5[4]:e24284.)

Figure 6.

Algorithm depicting the surgical treatment of athletes with symptomatic spondylolysis.

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