Spondylolysis and Spondylolisthesis
That’s a mouthful, it’s almost as bad as Supercalifragilisticexpialidocious (Mary Poppins). Who would have thought that there was such a thing? Most people who have back pain, call it back pain right? However, this is not just back pain.
What is it?
In a child with low back pain, the most common cause will be a Spondylolysis, which is a defect or fracture of the pars interarticularis of the vertebral arch (pictures below). Repetitive forces overtime cause minute damage to the bone and when cells don’t have time to repair a fracture occurs. The Scotty Dog image seen on x-rays, it usually occurs in the lower segments of the spine L5 (85-95% of the time) and L4 (4-15% of the time). This fracture can occur on both sides of the spine, and can progress to what we call a Spondylolisthesis. This progression means that the vertebral body has moved further forwards or slips and is graded from 1- 5 stages based on how bad it is (5 being the worst).
The Scottie Dog
Symptoms
Many patients don’t have symptoms and this condition will generally go unnoticed. However, in the population who do have symptoms it tends to be in more severe cases and this requires intervention. Symptoms include:
low back pain
back pain with backwards bending
night pain
increased lumbar spine lordosis; in more severe cases we see an increased lumbosacral kyphosis
tight contracted hamstrings
If the condition has progressed to a slippage (Spondylolisthesis) this means that there will be compression of the spinal nerve roots, then we see symptoms of:
pain (radicular pain, shooting into the buttocks and leg/thigh)
numbness, tingling and weakening of muscles in the legs of the affected side (Radiculopathy)
sharp shooting pains into the legs especially with back hyperextension
and a loss in the lumbar spine lordosis (the lower back will look flattened)
Why does it happen?
A Spondylolysis occurs due to the repetitive stress on the pars interarticularis which fractures as a result. The pars is what keeps the vertebral body in line, without it, slippage can occur. We more commonly see this in children who engage in particular types of sports that take them into back bends especially hyperextension. Sports such as football, weight lifters, gymnastics, acrobatics, dancing and cricket bowlers. There is some evidence to show a genetic component to this condition, and it is seen in males more so with a 2:1 ratio. Why children? Well, children have different tissue to adults, the neural arch that makes up the bridge that is the Pars Interarticularis is not very strong as yet, which means it can fracture more easily. In addition, adolescents and children have more elastic intervertebral discs, which again puts more stress on the pars. We also see a higher rate of incidence with children who have Rheumatoid Arthritis and Scoliosis.
How is it diagnosed?
Plain imaging (x-rays) and even a CT scan have a high rate of sensitivity, which means that they do pick up abnormalities well, but have a low specificity, which means they aren’t as useful for a specific diagnosis. Generally, it is a clinical diagnosis based on a good patient history, thorough physical assessment, and sometimes further imaging.
Treatment
If there are symptoms, then treatment is necessary and the good news is there is a very high rate of success with conservative methods including physiotherapy, pain management, restriction of aggravating activities and a progressive exercise program. Generally, protocols advise a period of rest from back bending and high load bearing activities for 3 months minimum, to give tissue time to repair, and then more active therapy begins. Sometimes surgery is required, depending on the degree of the vertebral slippage, and how early it is diagnosed. After the ages of 20, progression of any slippage is minimal and this is in part due to the growth plates fusing.
We know that this post has a lot of information in it and is dense to read. If you have any questions regarding our post please reach out to us via social media or email and we are happy to discuss in more detail.
All the best
Sam and Andy