Between 1979 and 1989, we treated 22 patients with symptomatic lumbar spondylolysis which had not responded to conservative treatment by a modified Scott wiring technique to give direct repair of the lytic defects with stabilisation. The patients' mean age at the time of operation was 15 years; the mean follow-up period was four years. All 19 patients under 25 years old had satisfactory results. Two of the three patients over 25 years old had poor results. The age of the patient at surgery seems to be an important determinant of outcome. Radiologically confirmed fusion is of secondary importance. The presence of a grade I spondylolisthesis did not prejudice the result. We recommend the Scott wiring technique to stabilise the direct repair of a lumbar spondylolysis

The December 2023 Spine Roundup. 360. looks at: Does size matter in adolescent pedicle screws?; Effect of lumbar fusion and pelvic fixation rigidity on hip joint stress: a finite element analysis; Utility of ultrasonography in the diagnosis of lumbar spondylolysis in adolescent patients; Rett syndrome-associated scoliosis a national picture

It has been noted that bony union of a pars defect can be achieved in children if they wear a trunk brace. Our aim was to evaluate how the stage of the defect on CT and the presence or absence of high signal change in the adjacent pedicle on T2-weighted MRI were related to bony healing. We treated 23 children conservatively for at least three months. There were 19 boys and four girls with a mean age of 13.5 years (7 to 17). They were asked to refrain from sporting activity and to wear a Damen soft thoracolumbosacral type brace. There were 41 pars defects in 23 patients. These were classified as an early, progressive or terminal stage on CT. The early-stage lesions had a hairline crack in the pars interarticularis, which became a gap in the progressive stage. A terminal-stage defect was equivalent to a pseudarthrosis. On the T2-weighted MR scan the presence or absence of high signal change in the adjacent pedicle was assessed and on this basis the defects were divided into high signal change-positive or -negative. Healing of the defect was assessed by CT.

In all, 13 (87%) of the 15 early defects healed. Of 19 progressive defects, only six (32%) healed. None of the seven terminal defects healed. Of the 26 high signal change-positive defects 20 (77%) healed after conservative treatment whereas none of the high signal change-negative defects did so. We concluded that an early-stage defect on CT and high signal change in the adjacent pedicle on a T2-weighted MR scan are useful predictors of bony healing of a pars defect in children after conservative treatment.

We investigated 185 adolescents under the age of 19 years with spondylolysis. All but five were active in sport. The pars defect was classified into early, progressive and terminal stages. Of the 346 pars defects in 185 patients, 39.6% were early, 29.5% progressive and 30.9% in the terminal stages. Conservative management produced healing in 73.0% of the early, 38.5% of the progressive and none of the terminal defects. These results suggest that spondylolysis is caused by repetitive microtrauma during growth and can be successfully treated conservatively if treatment is started in the early stage. There was elongation of the pars interarticularis as the pars defect progressed, and this is likely to be a consequence of the defect rather than a contributing cause.

Radiography and CT and MRI scans of the lumbar spine were performed in young patients complaining of pain during extension of the lumbar spine but without neurological signs in the lower limbs. T1-weighted MR images in the coronal plane showed a hypo-intense area in the pars interarticularis before the detection of spondylolysis at that site by plain radiography or CT. We suggest that this may be useful in the early diagnosis of spondylolysis.

We studied the aetiology of vertebral slip in a long-term follow-up of 22 adult patients with isthmic spondylolysis or spondylolisthesis of L5. Of the 18 with spondylolysis without slip, 13 showed no slip after ten years, but five developed displacement of over 5%. All four patients with spondylolisthesis showed progression of the slip. We found that the vertical thickness of the transverse process of L5 was significantly greater (p < 0.01) in the 13 patients with no slip than in the other two groups. The relationship of vertebral slip to the shape of the transverse processes of L5 may be explained by differences in the bulk or physiological strength of the posterior bands of the iliolumbar ligament.

We report a prospective case-series study to evaluate the results of non-operative and operative treatment of symptomatic unilateral lumbar spondylolysis. Non-operative treatment results in healing in most patients with symptomatic unilateral spondylolysis. Surgery however is indicated when symptoms persist beyond a reasonable time affecting the quality of life in young patients particularly the athletic population. We treated 41 patients [31 male, 10 female] with suspected unilateral lumbar spondylolysis. Thirty-one patients were actively involved in sports at various levels. Patients with a positive stress reaction on SPECT imaging underwent a strict protocol of activity restriction, bracing and physical therapy for 6 months. At the end of six months, patients who remained symptomatic underwent a Computed Tomography [CT] scan to confirm the persistence of a spondylolysis. Seven patients subsequently underwent a direct repair of the defect using the modified Buck's Technique. Baseline Oswestry disability index [ODI] and Short-Form-36 [SF-36] scores were compared to two year ODI and SF-36 scores for all patients. In the non-operated group, the mean pre-treatment ODI was 36 [SD=10.5], improving to 6.2 [SD=8.2] at two years. In SF-36 scores, the physical component of health [PCS] improved from 30.7 [SD=3.2] to 53.5 [SD =6.5] [p<0.001], and the mean score for the mental component of health [MCS] improved from 39 [SD=4.1] to56.5 [SD=3.9] [p<0.001] at two years. 20/31 patients resumed their sporting career within 6 months of onset of treatment, a further 4/31 patients returned to sports within one year. The seven patients who remained symptomatic at six months underwent a unilateral modified Buck's Repair. The most common level of repair was L5 (n=4). The mean pre-operative ODI was 39.4 (SD=3.6) improving to 4.4 (SD=4) at the latest follow-up. The mean score of PCS [SF-36] improved from 29.6 [SD=4.4] to 51.2 [SD=5.2] (SD=5.2) (p<0.001) and the mean score of MCS (SF-36) improved from 38.7 (SD=1.9) to 55.5 (SD=5.4) (p<0.001). A specific protocol of conservative treatment for patients with a unilateral lumbar spondylolysis resulted in a high rate of success with 83% of patients avoiding surgery. If symptoms persist beyond a reasonable period (i.e. 6 months) and reverse gantry CT scan confirms a non-healing defect of the pars interarticularis one may consider a unilateral direct repair of the defect with good outcome ultimately

Lumbar spondylolysis is a stress fracture of the pars interarticularis. We have evaluated the site of origin of the fracture clinically and biomechanically. Ten adolescents with incomplete stress fractures of the pars (four bilateral) were included in our study. There were seven boys and three girls aged between 11 and 17 years. The site of the fracture was confirmed by axial and sagittal reconstructed CT. The maximum principal tensile stresses and their locations in the L5 pars during lumbar movement were calculated using a three-dimensional finite-element model of the L3-S1 segment. In all ten patients the fracture line was seen only at the caudal-ventral aspect of the pars and did not spread completely to the craniodorsal aspect. According to the finite-element analysis, the higher stresses were found at the caudal-ventral aspect in all loading modes. In extension, the stress was twofold higher in the ventral than in the dorsal aspect. Our radiological and biomechanical results were in agreement with our clinical observations

Reports of spondylolysis in vertebrae other than those of the lower lumbar spine are rare. We report 32 patients with upper lumbar spondylolysis who have been studied clinically, radiologically and scintigraphically. Twenty patients had bilateral lesions, and seven of those with unilateral lesions had structural changes or anomalies in the opposite posterior arch. Positive scans were found to be associated with a short clinical history, and indicated stress-related lesions. Our findings suggest that mechanical factors may play a role in the aetiology of spondylolysis in the upper lumbar spine similar to that which they play in the lower lumbar spine, and that local structural anomalies may contribute to abnormal loading of these vertebrae

Lumbar spondylolysis can heal with conservative treatment, but few attempts have been made to identify factors which may affect union of the defects in the pars. We have evaluated, retrospectively, the effects of prognostic variables on bony union of pars defects in 134 young patients less than 18 years of age with 239 defects of the pars who had been treated conservatively. All patients were evaluated by CT scans when first seen and more than six months later at follow-up. The results showed that the spinal level and the stage of the defects were the predominant factors. The site of the defects in the pars, the presence or development of spondylolisthesis, the condition of the contralateral pars, the degree of lumbar lordosis and the degree of lumbar inclination all significantly affected union

There is conflicting information regarding the recommendations of bracing, physical therapy and cessation of sports for young athletes with symptomatic spondylolysis. The purpose of this study was to identify factors affecting the prognosis and to find the optimal method of non-operative treatment. The patients in our study were athletes who visited our children's hospital for low back pain with lumbar spondylolysis and were treated non-operatively from 1990 to 2002. Clinical and radiological outcomes were reviewed retrospectively. The effects of bracing, physical therapy, cessation of sports, duration of symptoms before the first hospital visit, lateralisation of spondylolysis, age, gender, onset of low back pain after lumbar trauma during sports, bone scan uptake, vertebral level of the lesion, associated scoliosis or spina bifida and radiological bony healing were analysed using univariate and multivariate analysis with logistic regression. The mean age of patients was 13 years (range 7 to 18 years). The mean follow-up was 4.2 years (range 1.2 to 12 years). Of 132 patients, 48 patients had excellent results with no pain during sports, 76 good, 6 fair, and 4 poor. Cessation of sports, early non-operative intervention, and a unilateral spondylolysis appeared to be factors associated with excellent outcomes. However, bracing, physical therapy, age, gender, level of lesion, history of trauma, increased uptake on bone scan, or associated scoliosis or spina bifida were not factors. Bony healing was not related to the clinical outcome. The non-operative treatment of spondylolysis in children can yield excellent clinical outcomes, and the absence of bony healing has no influence on clinical outcome. Factors in this study found to correlate with an excellent outcome include unilateral spondylolysis, acute spondylolysis, and treatment with cessation of sports for 12 weeks

Introduction. Lumbar spondylolysis is a fatigue fracture of the pars interarticularis and correlates with Spina Bifida Oculta (SBO) in 67%. Hpothesis. Load is normally transferred across the arch in axial rotation. Bifid arch results in increased strain across the isthmus of the loaded inferior articular process. Aim of investigation. Finite element (FE) analysis of altered load transfer in combined axial rotation and anteroposterior shear in SBO potentially predisposing to fatigue fracture of the pars interarticularis. Methods. FE models of natural and SBO (L5-S1) including ligaments were axially load to 1kN and an axial rotation of 3° applied. Bilateral stresses and strains on intact and SBO lateral inferior lines of the L5 isthmus were assessed and compared. Results. Under 1000N axial load: Maximum von Mises stress observed on left and right lateral inferior lines of L5 isthmus were 0.13 and 0.24 MPa, with maximum equivalent strain values of 1.56 and 2.91 (strain, for natural spine and SBO, respectively. Combined with 3° axial rotation (rotation of spinal processes toward right lateral side): Left lateral L5 isthmus stresses increased to 0.49 and 0.77 MPa for natural spine and SBO, respectively. Right lateral L5 isthmus values increased to 0.67 and 0.95 MPa for natural spine and SBO, respectively. The percentage increase in SBO strains compared to the natural spine on the L5 isthmus were +57.9 and +40.2%. Conclusion. Significant load transfer occurs through the vertebral arch in axial rotation. In SBO this load transfer is lost and mechanical demand on the isthmus is significantly increased. Strain increases across the L5 isthmus in axial rotation by +40.2% to +57.9% compared to normal and may predispose to fatigue fracture

We studied prospectively 22 young athletes who had undergone surgical treatment for lumbar spondylolysis. There were 15 men and seven women with a mean age of 20.2 years (15 to 34). Of these, 13 were professional footballers, four professional cricketers, three hockey players, one a tennis player and one a golfer. Preoperative assessment included plain radiography, single positron-emission CT, planar bone scanning and reverse-gantry CT. In all patients the Oswestry disability index (ODI) and in 19 the Short-Form 36 (SF-36) scores were determined preoperatively, and both were measured again after two years in all patients. Three patients had a Scott’s fusion and 19 a Buck’s fusion. The mean duration of back pain before surgery was 9.4 months (6 to 36). The mean size of the defect as determined by CT was 3.5 mm (1 to 8) and the mean preoperative and postoperative ODIs were 39.5 (. sd. 8.7) and 10.7 (. sd. 12.9), respectively. The mean scores for the physical component of the SF-36 improved from 27.1 (. sd. 5.1) to 47.8 (. sd. 7.7). The mean scores for the mental health component of the SF-36 improved from 39.0 (. sd. 3.9) to 55.4 (. sd. 6.3) with p < 0.001. After rehabilitation for a mean of seven months (4 to 10) 18 patients (82%) returned to their previous sporting activity

Introduction: Spondylolysis in skeletally immature individuals is common but only a small proportion of cases develop pain and spondylolisthesis. The pattern of instability and pathologic consequences of surgically created spondylolytic defects have not previously been described. An animal model of lumbar spondylolysis was created using skeletally immature sheep with the aim of observing the intervertebral mobility and pathologic consequences of creating a spondylolytic segment. Methods: Bilateral spondylolytic defects were created in the fifth lumbar vertebrae of fourteen sheep aged approximately 16 weeks using a posterior surgical approach. Using tantalum markers that were placed in the lumbar spine segments in the vicinity of the lesion, three dimensional translations and rotations in flexion and extension were recorded under general anaesthetic using Radiostereometric Analysis (RSA) at the time of surgery. A novel method of ovine spine manipulation was developed. Briefly, with the animal in a lateral decubitus position spinal extension was achieved by fixing the shoulders and hips in full extension. Similarly, the limbs were brought into apposition to achieve spinal flexion. A control group of seven sheep had tantalum markers only in the same lumbar spine segments. The animals were re-tested under general anaesthetic at six weeks and six months following surgery. After six months the animals were sacrificed and their spines examined using CT and microscopic analysis. Results: Bilateral spondylolytic defects did not result in significant transverse (x-axis) translation. RSA showed significant differences between the spondylolytic group (mean 1.22°, range 0.30–3.74) and controls (mean 0.28°, range 0.03–0.77)) for rotation in the axial plane (y-axis, p< 0.0025) immediately after surgery. The spines radiologically stabilised over six months. Discussion: Surgically induced bilateral spondylolytic defects in this immature ovine model result in increased rotation in the axial plane but do not create transverse translation (spondylolisthesis)

The incidence of symptomatic pars defect varies between 15% and 47% in the young athletic population. We have analysed the outcome of direct repair spondylolysis on young professional athletes. We have prospectively studied 22 young athletes with lumbar spondylolysis in whom conservative treatment has failed. Fifteen male and 7 female patients with a mean age of 20.2 years (range 15–34 years) were surgically treated for radiographically confirmed spondylolysis between 1994 and 1999. Eleven patients were professional footballers and four were professional cricketers. Pre-operative assessment included plain X rays, SPECT imaging with planar bone scan and reverse gantry CT scans. All patients had the Oswestry disability index (ODI) and 19 patients had Short Form 36 (SF-36) scores recorded pre-operatively and two years post operatively. Nineteen patients underwent Buck’s fusion and 3 underwent Scott’s fusion. At two-year follow-up nineteen patients had ODI and SF36 scores recorded. Return to the sporting activity at the previous level was regarded as a successful outcome. The average duration of back pain prior to surgery was 8.9 months (range 1-36 months). The mean lysis defect determined by CT was 3.5 mm (range 1–8 mm). The mean pre-operative ODI was 39.5 (SD=8.7) and the mean post-operative ODI was 10.7 (SD=12.9). The mean scores of the physical health component of SF-36 improved from 27.1 (SD=5.1) to 47.8 (SD=7.7). The mean scores of the mental health component of SF-36 improved from 39.0 (SD=3.9) to 55.4 (SD=6.3) [P < 0.001]. The surgical repair of bilateral spondylolysis with modified Buck’s fusion in professional sportsmen and women results in a significant improvement in Oswestry Disability scores (p< 0.001) and in all domains of SF36 health questionnaire (p< 0.001). Ninety five percent of patients in this group return to active sport within seven months of surgery

To determine how long after injury a single photon emission computed tomography (SPECT) scan may remain positive in cases of symptomatic posterior element lumbar stress injuries. SPECT scans can identify posterior element lumbar stress injuries earlier than other imaging modalities. As these lesions evolve and the spondylolysis becomes chronic, the SPECT scan tends to revert to normal even though healing of the defect has not occurred. The aim of this study was to determine how long after initial injury a SPECT scan might remain positive. One hundred and sixty-five patients (85 male, 80 female) between the ages of 8 and 38 years with suspicion of lumbar spondylolysis or posterior element lumbar stress injuries were investigated. All patients underwent plain radiographs, planar bone scintigraphy and SPECT imaging. The duration of symptoms at clinical assessment was recorded. The age, sex, symptom reproduction on flexion or extension, level of sporting activity, and the Oswestry Disability Index both pre- and post-treatment were also recorded. SPECT positive images (hot scans) were depicted as cases and SPECT negative images as controls. Univariate and multivariate analysis was performed. Eighty-five patients (63 male, 22 female) had positive SPECT scans (cases); eighty had negative scans (controls). The mean age at onset of symptoms was 20.2 years for cases and 17.4 years for controls. Bilateral increased uptake on SPECT scan was more common than unilateral. The commonest site for increased uptake was the posterior elements of the fifth lumbar vertebra. Low back pain in extension was more common in SPECT positive cases. The mean time from injury / onset of symptoms to a positive SPECT scan was 7.1 months (range 5.2–9.2 months) and to a negative SPECT scan was 22.5 months (range 16.8–28.4 months). Intense scintigraphic activity in the posterior elements of the lumbar spine was associated with a more recent injury and was concordant with the patient’s history and physical examination. Chronic, un-united spondylolysis was often scintigraphically occult. There was a window of approximately six months from the onset of symptoms to investigation after which the sensitivity of SPECT imaging diminished

Objective: To assess the clinical outcome and return to sport following surgical treatment of spondylolysis in young sporting individuals. Design: A prospective outcome analysis of consecutive surgically treated cases of lumbar spondylolysis in young sporting individuals. Subjects: Twenty-two young sports persons (15M: 7F) with a mean age of 20.2 years (range 15–34 years) were surgically treated for radiographically confirmed spondylolysis between 1994 and 1999. Eleven patients were professional footballers and four were professional cricketers. Pre operative assessment included plain X-rays, SPECT imaging with planar bone scan and reverse gantry CT scans. All subjects had pre-operative Oswestry Disability Index (ODI) and SF36 scores recorded. Eighteen patients underwent Buck’s fusion and four patients underwent Scott’s fusion. A graduated exercise regime was commenced at 12 weeks. At two year follow-up nineteen patients had ODI and SF36 scores recorded. Outcome Measures: The clinical outcome in individual patients supported by statistical analysis of the pre operative and post-operative data was performed using SPSS (ver 10). Return to the sporting activity at the previous level was regarded as a successful outcome. Results: Eleven patients had bilateral spondylolysis at L5. Twenty patients had positive uptake on SPECT imaging and the remaining two were diagnosed to have lysis on CT scans alone. The average duration of back pain before the patients underwent surgery were 8.4 months (range 3–36 months). The mean lysis defect determined by CT was 3.5 mm (range 1–8 mm). The mean pre-operative and post-operative ODIs were 40.5 and 12.4 respectively (SEpreop = 2.06 and SEpostop = 3.05). The mean scores of physical health component of SF36 improved from 27.1 to 47.8 (SEmean = 1.1 and 1.7 respectively). The mean scores of mental health component of SF36 improved from 39.1 to 55.3 (SEmean = 0.9 and 1.4 respectively) [P < 0.001]. Eighteen patients returned to their previous active sporting career following an average of seven months of rehabilitation (range 4–10 months). Conclusions: The surgical repair of bilateral spondylolysis with Buck’s fusion in professional sportsmen and women results in a significant improvement in Oswestry Disability scores (P< . 001) and in all domains of SF36 health questionnaire (P< . 001). 90% return to active sport seven months following surgery

Aims

Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies.

Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.