eMedicine Specialties > Sports Medicine > Spine

Lumbosacral Spondylolysis

Author: Achilles Litao, MD, Consulting Staff, Department of Pediatrics, MedCentral, Mansfield, Ohio
Coauthor(s): Achilles Litao, MD, Consulting Staff, Department of Pediatrics, MedCentral, Mansfield, Ohio; John Munyak, MD, Associate Program Director, Director of Sports Medicine Education, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Contributor Information and Disclosures

Updated: Jun 12, 2009

Introduction

Background

Lumbosacral spondylolysis (lumbar spondylolysis) is a unilateral or bilateral defect of the pars interarticularis that affects one or more of the lumbar vertebrae (see Images 1-2 or below).

Radiograph of L4 defect in the pars interarticula...

Radiograph of L4 defect in the pars interarticularis.

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Radiograph of L4 defect in the pars interarticula...

Radiograph of L4 defect in the pars interarticularis.


Computed tomography scan demonstrating defects in...

Computed tomography scan demonstrating defects in the left and right pars interarticularis.

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Computed tomography scan demonstrating defects in...

Computed tomography scan demonstrating defects in the left and right pars interarticularis.


The term spondylolysis is derived from the Greek words spondylos, meaning vertebra, and lysis, meaning break or defect. Numerous hypotheses have been proposed on the etiology of lumbosacral spondylolysis (lumbar spondylolysis), as follows:
  • Separate ossification centers
  • Fracture during postnatal life
  • Stress fracture1,2
  • Increased lumbar lordosis
  • Impingement of the articular process on the pars articularis
  • Weakness of supporting structures3
  • Growth2,4
  • Pathologic changes in the pars articularis
  • Dysplasia of the pars interarticularis

However, mechanical factors are widely believed to be the cause or at least the trigger of the development of lumbosacral spondylolysis (lumbar spondylolysis), especially when congenital abnormalities are present.5 Moreover, lumbosacral spondylolysis (lumbar spondylolysis) is argued to be related to the human erect posture and lumbar curve.1

Ambulation may have a role in the genesis of lumbosacral spondylolysis (lumbar spondylolysis) because no known cases exist in nonambulatory patients.6 As an acquired condition, no reports exist of its occurrence in stillborn fetuses or in the newborn.7 Heredity is also implicated.8

When the defect in the pars interarticularis is not associated with a forward displacement, the term spondylolysis applies.9 The term spondylolisthesis is derived from spondylos and listhesis, meaning movement or slipping, and refers to the slipping forward of one vertebra on the next caudal vertebra (see Image 5 or below).

Lateral radiograph of the lumbar spine shows spon...

Lateral radiograph of the lumbar spine shows spondylolysis at L5 with spondylolisthesis at L5 through S1. On this single view, it is not possible to determine if these pars defects are unilateral or bilateral. Oblique views may help resolve this issue.

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Lateral radiograph of the lumbar spine shows spon...

Lateral radiograph of the lumbar spine shows spondylolysis at L5 with spondylolisthesis at L5 through S1. On this single view, it is not possible to determine if these pars defects are unilateral or bilateral. Oblique views may help resolve this issue.


Lumbosacral spondylolysis (lumbar spondylolysis) is most common at L5, accounting for 85% of all cases,10  and may be observed as high as L2.11  Therefore, a slip is most common at the level of L5 slipping forward on S1. Lumbosacral spondylolysis (lumbar spondylolysis) is the cause of the most common type of spondylolisthesis.4 Moreover, Ariyoshi et al reported a case of lumbosacral spondylolysis (lumbar spondylolysis) that occurred at 3 sites in L5 that involved the bilateral pars interarticularis and the center of the right lamina.12

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Back Pain.

Frequency

United States

Lumbosacral spondylolysis (lumbar spondylolysis) is more commonly observed in males,10 but this difference may not be significant.13,14

In the United States, a reported difference exists between the sexes and races, with an incidence of lumbosacral spondylolysis (lumbar spondylolysis) of 6.4% in white men, 2.8% in black men, 2.3% in white women, and 1.1% in black women. A pars defect is twice as common in boys than in girls, although high-grade slippage is 4 times more common in girls than in boys. Alaskan Eskimos (26%) have the highest incidence, with the highest rate in Eskimos from north of the Yukon River.4

Functional Anatomy

Repetitive axial loading, especially in an extended lumbar spine is thought to be the most important contributing mechanism causing lumbosacral spondylolysis (lumbar spondylolysis), leading to fatigue fracture of the pars interarticularis. Shear stresses on the isthmic pars are greater when the lumbar spine is extended. When repetitive extension stresses occur, the pars interarticularis becomes impinged from the inferior facet of the cephalad vertebrae, which results in microfractures and attempts at repair.15

Long TR (T2-weighted) fat suppressed sagittal mag...

Long TR (T2-weighted) fat suppressed sagittal magnetic resonance image shows increased signal in the pars interarticularis on the left at L5 (same patient in Images 3-4). This is an acute stress reaction.

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Long TR (T2-weighted) fat suppressed sagittal mag...

Long TR (T2-weighted) fat suppressed sagittal magnetic resonance image shows increased signal in the pars interarticularis on the left at L5 (same patient in Images 3-4). This is an acute stress reaction.


Sagittal short TR (T1-weighted) magnetic resonanc...

Sagittal short TR (T1-weighted) magnetic resonance image shows decreased signal in the pars interarticularis on the left at L5 (same patient in Images 3-4).

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Sagittal short TR (T1-weighted) magnetic resonanc...

Sagittal short TR (T1-weighted) magnetic resonance image shows decreased signal in the pars interarticularis on the left at L5 (same patient in Images 3-4).


Sport-Specific Biomechanics

Lumbosacral spondylolysis (lumbar spondylolysis) occurs in 3-7% of the general population14 The athletic population is believed to be more prone to the development of this condition,15 because the incidence of lumbosacral spondylolysis (lumbar spondylolysis) in competitive athletes is higher than the percentage reported for the nonsports population.16
 
The overall percentage of lumbosacral spondylolysis (lumbar spondylolysis) among athletes in a study by Soler et al was about 8%, a figure not significantly higher than that among the general population.14 However, certain sporting events were found to contribute higher percentages when each sport was considered separately, with the highest percentages of lumbosacral spondylolysis (lumbar spondylolysis) occurring in throwing sports (26.67%), artistic gymnastics (16.96%), and rowing (16.88%).14 In an earlier series, a high percentage of lumbosacral spondylolysis (lumbar spondylolysis) was been observed in diving (43.13%), wrestling (29.82%), and weight lifting (22.68%).16

Other sports with high incidence rates of lumbosacral spondylolysis (lumbar spondylolysis) are ballet, dancing, football, volleyball, and fast bowlers in cricket. In ballet, the higher incidence rate is due in part to an inability to reach or maintain proper turn-out and thus overcompensation with lordosis.

In general, the presence of the repetitive actions of flexion, extension, rotation, and torsion, either alone or in combination, that are often associated with resistance are the biomechanical movements that show the highest prevalence of lumbosacral spondylolysis (lumbar spondylolysis).14

Clinical

History

  • Among the general population, most cases of lumbosacral spondylolysis (lumbar spondylolysis) are clinically inapparent, and the condition is symptomatic in only 10% of patients.14 Many athletes with lumbosacral spondylolysis (lumbar spondylolysis) are likewise asymptomatic.10
  • Lumbosacral spondylolysis (lumbar spondylolysis) typically occurs in young people,1 with a mean age at diagnosis in athletes of about 15-16 years.10
  • Patients with lumbosacral spondylolysis (lumbar spondylolysis) generally report low back pain aggravated by activity,17 particularly with hyperextension maneuvers such as in gymnastics. In general, patients present without a history of neurologic symptoms.11

Physical

  • The physical examination of patient with lumbosacral spondylolysis (lumbar spondylolysis) frequently yields minimal findings.
    • No tenderness to palpation is noted, but some discomfort can be elicited with deep percussion over the midline of the lumbar area.
    • Range of motion is full.
    • Because of the previously increased range of motion of dancers and gymnasts, they appear to have normal flexibility. Athletes suspected of having an injury must have their flexibility compared with that of their preinjury state.
    • Forward flexion does not increase symptoms.
    • Hyperextension mimicking the sporting movement generally elicits pain.11
    • Sciatica can occur but is rare.18
    • Physical findings that may also be present include antalgic or normal gait, tight lumbar musculature and hamstrings, hyperlordosis, and buttock or thigh pain.
  • If a unilateral defect is present, the 1-leg hyperextension test elicits pain on the involved side. This test is performed by the patient bearing weight on one leg, with both the hip and knee of the other extremity flexed while hyperextending the lumbar spine.11 The maneuver is performed on both sides, and asymmetric low back pain indicates unilateral disease. Bilateral disease may show symmetric or asymmetric pain with this maneuver.17
  • The neurovascular examination findings are normal.
  • The rest of the general low back pain examination must be performed, taking note of all dermatomes, myotomes, and reflexes.18

Causes

  • The repetitive actions of flexion, extension, rotation, and torsion, either alone or in combination, that are often associated with resistance are the biomechanical movements that show the highest prevalence of lumbosacral spondylolysis (lumbar spondylolysis).14
  • In general, athletes may have an increased chance of having symptomatic lumbosacral spondylolysis (lumbar spondylolysis). Whether the overall incidence is any different than the general population is unknown.

More on Lumbosacral Spondylolysis

Overview: Lumbosacral Spondylolysis
Differential Diagnoses & Workup: Lumbosacral Spondylolysis
Treatment & Medication: Lumbosacral Spondylolysis
Follow-up: Lumbosacral Spondylolysis
Multimedia: Lumbosacral Spondylolysis
References
Further Reading
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References

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Contributor Information and Disclosures

Author

Achilles Litao, MD, Consulting Staff, Department of Pediatrics, MedCentral, Mansfield, Ohio
Achilles Litao, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Achilles Litao, MD, Consulting Staff, Department of Pediatrics, MedCentral, Mansfield, Ohio
Achilles Litao, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Association
Disclosure: Nothing to disclose.

John Munyak, MD, Associate Program Director, Director of Sports Medicine Education, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Disclosure: Nothing to disclose.

Medical Editor

Andrew D Perron, MD, Residency Director, Department of Emergency Medicine, Maine Medical Center
Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Henry T Goitz, MD, Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa
Disclosure: Nothing to disclose.

 
 
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