Spondylolysis is a congenital or acquired defect in the area of the vertebral arch. Usually the lumbar region (L4-L5) suffers. The disease is often asymptomatic, may be accompanied by stiffness and pain in the lumbar region. The pain is usually prolonged, but not intense, less often there is a pronounced pain syndrome that restricts physical activity. Radiography, scintigraphy and computed tomography are used to confirm the diagnosis. Treatment is more often conservative, in some cases surgical interventions are required. The prognosis is favorable.
ICD 10
M43.0 Spondylolysis
Meaning
Spondylolysis is a defect in the area of the vertebral arch. It is a widespread pathology, according to statistical studies, it is detected in about 4-7% of the population. People younger than 20 years of age are affected by spondylolysis with the same frequency regardless of gender, in older age men suffer twice as often as women. There is evidence confirming the presence of a hereditary predisposition. In 99% of cases it is localized in the lumbar region, while in 85% of cases the V lumbar vertebra is affected, and in 10% of cases the IV lumbar vertebra is affected. Simultaneous defeat of L4 and L5 is also possible.
Spondylolysis is equally often detected both in athletes and in people who lead a low-activity lifestyle. Exceptions are some sports, including rowing, American football, wrestling, weightlifting, gymnastics and diving, where the prevalence of spondylolysis is higher than the average in the population. Spondylolysis can not only cause back pain, but also cause spondylolisthesis – sliding of the upper vertebra anteriorly, while in some cases there is infringement of nerve roots with the development of sciatica.
Causes
Taking into account the etiology in orthopedics and traumatology , there are three types of spondylolysis:
- Congenital spondylolysis – occurs when there is a violation of the fusion of two ossification nuclei forming a defective arc.
- Acquired spondylolysis is formed under the influence of excessive physical exertion in combination with a violation of bone nutrition.
- Mixed spondylolysis – occurs with excessive physical exertion in combination with previous dysplasia of the vertebral arch.
Pathogenesis
The mechanism of formation of acquired and mixed spondylolysis consists in the accumulation of force effects exceeding the elasticity of the bone tissue of the vertebral arch. The immediate cause of spondylolysis is usually multiple intensive extensions of the spine (sometimes in combination with lifting weights). Due to excessive load, a Loser zone is formed in the area of the arch (a zone of pathological bone restructuring), and then a fatigue fracture occurs in this area.
Classification
Taking into account the location of the defect , there are:
- A typical spondylolysis defect is formed in the area of the interarticular gap.
- Atypical spondylolysis is a defect formed between the base of the arch and the articular gap.
- Retrosomatic spondylolysis – the defect is located in the area of the arch root (just behind the vertebral body).
Symptoms
In some cases, the pathology proceeds asymptomatically and becomes an accidental finding during spine x-ray for other reasons. Persistent, but not intense pain in the lumbar region is also possible. Less often, patients complain of severe pain syndrome, which significantly restricts physical activity. A characteristic symptom of spondylolysis is a decrease in pain when bending forward and an increase in the extension of the lumbar region. Sometimes patients report that they feel pain or discomfort in the supine position. Very rarely, there is an irradiation of pain in the buttock or the posterior surface of the thigh.
Diagnostics
The diagnosis of spondylolysis is made by a vertebrologist or orthopedist on the basis of examination data and X-ray examination. External signs of spondylolysis are usually quite scarce. Some limitation of active extension in the lumbar region is revealed. With careful passive extension, the patient, as a rule, notes an increase in pain. Sometimes pain is determined by palpation in the affected area.
A provocative test helps to confirm the diagnosis of spondylolysis – the patient is asked to stand on one leg and bend back, with spondylolysis during this movement, the pain on the side of the lesion increases. Neurological symptoms are usually absent. To make a final diagnosis, use:
- Radiography of the spine in lateral, straight and two oblique projections (left and right). This study reveals a defect in the vertebral arch in 85% of cases.
- CT of the spine. Allows you to consider the arc defect on horizontal sections. The disadvantage of computed tomography is the low accuracy in determining the clinical significance and prescription of the defect.
- Radioisotope research. More accurate and more sensitive methods are scintigraphy and single-photon emission tomography, during which the accumulation of an isotope in the defect area is detected. In some cases, the results are indicative.
Treatment
Conservative treatment
In the absolute majority of cases, conservative therapy is indicated for spondylolysis. The treatment strategy is chosen taking into account the radiography data, the prescription of the disease, the severity of the symptoms and the age of the patient. With an asymptomatic course of spondylolysis, treatment is not required, a person can continue to lead a normal lifestyle. With minor pain in the lower back, exercise therapy is prescribed to strengthen the muscular corset. With pronounced manifestations of spondylolysis, it is recommended to limit physical activity, in some cases, rigid or flexible anti-lordotic and lordotic corsets are used for a short time.
The duration of load restriction and active corseting in severe spondylolisthesis is usually 6-8 weeks. At night, the corset is allowed to be removed. Usually, these therapeutic methods are sufficient to provide fibrous fusion of a fatigue fracture. Subsequently, rehabilitation measures are prescribed with an emphasis on exercises that increase the flexibility of the spine. Full recovery, as a rule, occurs after another 6-8 weeks. It should be borne in mind that with unilateral arc defects, the probability of fusion is higher than with bilateral ones.
Surgical treatment
Surgical intervention in spondylolysis is required if there are no signs of fusion and complaints persist for six months after the start of treatment. The classical method is considered to be posterolateral fusion, but this method of surgical correction entails a significant limitation of the mobility of the segment, so recently, along with the “reference” technique, other variants of osteosynthesis have been used. In particular, pin, hook and screw fixation, osteosynthesis with translaminar interfragmental screws and fixation with wire hooks are used. All of these methods provide a good result in more than 90% of cases.
Operations are performed in the conditions of the vertebrological or neurosurgical department, as planned, after the examination. In the postoperative period, antibiotic therapy is carried out, analgesics, physiotherapy and physical therapy are prescribed. After the radiologically confirmed fusion of the fatigue fracture, active rehabilitation measures begin. Full recovery takes from 5 months to 1 year.
Literature
- Spondylolysis: a review and reappraisal. Syrmou E, Tsitsopoulos PP, Marinopoulos D, Tsonidis C, Anagnostopoulos I, Tsitsopoulos PD. Hippokratia. 2010 Jan;14(1):17-21. link
- Spondylolysis. Standaert CJ, Herring SA, Halpern B, King O. Phys Med Rehabil Clin N Am. 2000 Nov;11(4):785-803. link
- Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis. Debnath UK, Freeman BJ, Grevitt MP, Sithole J, Scammell BE, Webb JK. Spine (Phila Pa 1976). 2007 Apr 20;32(9):995-1000. link
- Management of lumbar spondylolysis in the adolescent athlete: a review of over 200 cases. Choi JH, Ochoa JK, Lubinus A, Timon S, Lee YP, Bhatia NN. Spine J. 2022 Oct;22(10):1628-1633. link