Spondylolysis

Aka: Spondylolysis, Pars Interarticularis Fracture, Pars Interarticularis Defect, Pars Defect, Scotty Dog Sign

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II. Definitions

  1. Spondylolysis
    1. Vertebral defect at pars interarticularis (one or two defects)
    2. When two, bilateral Pars Defects occur, Spondylolisthesis (Vertebral slippage) occurs

III. Epidemiology

  1. Uncommon cause of back pain in general population, non-athletes
  2. Incidence in age <40 years old: 6%
    1. Spondylolisthesis is much less common, and typically at L5-S1
  3. Pars Interarticularis Defect is twice as common in men
    1. However women have higher risk of high grade Spondylolisthesis
  4. Common cause of back pain in athletes (esp. repeated spine extension)
    1. Gymnastics, ballet or dance
    2. Football (e.g. blocking, lineman)
    3. Volleyball (e.g. serving the ball)
    4. Soccer
    5. Weightlifting
    6. Diving
    7. Baseball Players

IV. Pathophysiology

  1. Repetitive back hyperextension
  2. Most commonly occurs at L4 or, especially L5
  3. Results in Fracture at pars interarticularis resulting in Pars Interarticularis Defect
    1. One Pars Defect: Spondylolysis
    2. Two Pars Defects: Spondylolisthesis

V. Symptoms

  1. History should include Cauda Equina Syndrome symptoms and other cord compression symptoms
  2. Back pain exacerbated by Lumbar Spine hyperextension
  3. Radiation into posterior legs

VI. Signs

  1. Perform complete Neurologic Exam of lower extremity
  2. Hyperlordotic curvature of the Lumbar Spine
  3. Decreased Lumbar Spine range of motion
  4. Hamstring tightness
  5. Quadriceps tightness
  6. Altered gait (crouched position)
  7. One Legged Hyperextension (Stork Standing Test)
    1. Examiner stands behind patient for support
    2. Patient balances on one leg and hyperextends back
    3. Positive if pain at affected lumbar Vertebrae

VII. Imaging: XRay

  1. Indicated for back pain lasting >3 weeks (esp. athletes)
  2. Views: AP, lateral and oblique views
  3. Findings: Scotty Dog Sign on oblique view
    1. Identify landmarks corresponding to Scotty Dog
      1. Head of Scotty Dog: Superior articular process
      2. Neck of Scotty Dog: Pars interarticularis
      3. Front leg of Scotty Dog: Inferior articular process
      4. Body and back leg of Dog: Transverse process
    2. Findings consistent with Spondylolysis
      1. Collar on Scotty Dog neck: Fracture through pars
  4. Pitfalls
    1. Pars Fracture often not seen in early Spondylolysis

VIII. Imaging: Advanced Imaging

  1. MRI L-Spine
    1. Preferred imaging for non-diagnostic XRay
    2. MRI sequenced for pedicle and pars region Bone Marrow edema
  2. Single photon emission computed tomography (SPECT)
    1. Most sensitive for Spondylolysis
    2. Consider for nondiagnostic XRay
  3. CT L-S Spine (thin cut, reverse gantry CT)
    1. Highly specific for Spondylolysis
    2. Consider for positive SPECT scan
    3. Differentiates acute versus chronic Spondylolysis

IX. Management

  1. Consider 6 weeks of conservative therapy if XRay negative, but suspect Spondylolysis
  2. NSAIDs
  3. Relative rest period with no sports activity
    1. Chronic Spondylolysis: Rest until no pain
    2. Acute Spondylolysis: Rest minimum of 3 months
  4. Adjunctive measures
    1. Low Thoracolumbar Orthosis bracing could be considered at 3 weeks of rest
      1. Taper the Orthosis to pain free status (regardless of imaging)
    2. Transcutaneous electrical nerve stimulation (TENS)
    3. Consider repeat imaging to survey acute injury for healing
  5. Rehabilitation program
    1. Quadriceps and Hamstring flexibility
    2. Spine stabilization (flexion, core Muscle)
    3. Low-impact aerobics
    4. Progress to sport-specific activity
    5. Gradual return to activity over a 5 month period
  6. Orthopedics or spine surgery referral indications
    1. Spondylolysis refractory to above management (<10% of cases)

X. Complications

  1. Spondylolisthesis

XI. References

  1. Connolly (1995) Fractures and Dislocations, p. 443-4
  2. Achar (2020) Am Fam Physician 102(1):19-28 [PubMed]
  3. Cassas (2006) Am Fam Physician 73:1014-22 [PubMed]
  4. Standaert (2002) Clin J Sports Med 12:119-22 [PubMed]

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Related Studies

Ontology: Spondylolysis (C0038018)

Definition (MSH) Deficient development or degeneration of a portion of the VERTEBRA, usually in the pars interarticularis (the bone bridge between the superior and inferior facet joints of the LUMBAR VERTEBRAE) leading to SPONDYLOLISTHESIS.
Concepts Disease or Syndrome (T047)
MSH D013169
ICD10 M43.0 , M43.00, M43.09
SnomedCT 203688008, 240221008
English Spondylolyses, Spondylolysis, Spondylolysis [Disease/Finding], Spondylolysis, site unspecified, spondylolyses, spondylolysis, spondylolysis (diagnosis), Spondylolysis (disorder)
Japanese 脊椎分離, ｾｷﾂｲﾌﾞﾝﾘ
Swedish Spondylolys
Czech spondylolýza, Spondylolýza
Finnish Spondylolyysi
Russian SPONDILOLIZ, SPONDILOZIS, СПОНДИЛОЗИС, СПОНДИЛОЛИЗ
Korean 척추분리증
Croatian Not Translated[Spondylolysis]
Polish Spondyloliza
Hungarian Spondylolysis
Norwegian Spondylolyse
Dutch Spondylolyse, spondylolyse, Spondylolysis
Spanish Espondilolisis, espondilólisis (trastorno), espondilólisis, Espondilólisis
French Spondylolyse
German Spondylolyse
Italian Spondilolisi
Portuguese Espondilólise
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Lumbar Spine Disorders

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