Lumbosacral Spondylolysis 

  • Author: Achilles Litao, MD; Chief Editor: Craig C Young, MD   more...
 
Updated: Dec 14, 2011
 

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 the images below.

Radiograph of L4 defect in the pars interarticularRadiograph 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.

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 fracture[1, 2]
  • Increased lumbar lordosis
  • Impingement of the articular process on the pars articularis
  • Weakness of supporting structures[3]
  • Growth[2, 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 the image below).

Lateral radiograph of the lumbar spine shows spondLateral 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.

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Epidemiology

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]

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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] See the images below.

Long TR (T2-weighted) fat suppressed sagittal magnLong 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 resonanceSagittal 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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Sport-Specific Biomechanics

Lumbosacral spondylolysis (lumbar spondylolysis) occurs in 3-7% of the general population[14] 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]

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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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, 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, Director of Primary Care Sports Medicine Fellowship, 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.

References

  1. Arriaza BT. Spondylolysis in prehistoric human remains from Guam and its possible etiology. Am J Phys Anthropol. Nov 1997;104(3):393-7. [Medline].

  2. Morita T, Ikata T, Katoh S, Miyake R. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg Br. Jul 1995;77(4):620-5. [Medline].

  3. Aihara T, Takahashi K, Yamagata M, Moriya H, Tamaki T. Biomechanical functions of the iliolumbar ligament in L5 spondylolysis. J Orthop Sci. 2000;5(3):238-42. [Medline].

  4. Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine. Dec 15 1999;24(24):2640-8. [Medline].

  5. DeLisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1998:1646.

  6. Smith JA, Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am. Jul 1999;30(3):487-99, ix. [Medline].

  7. Dubousset J. Treatment of spondylolysis and spondylolisthesis in children and adolescents. Clin Orthop Relat Res. Apr 1997;337:77-85. [Medline].

  8. Albanese M, Pizzutillo PD. Family study of spondylolysis and spondylolisthesis. J Pediatr Orthop. 1982;2(5):496-9. [Medline].

  9. Stinson JT. Spondylolysis and spondylolisthesis in the athlete. Clin Sports Med. Jul 1993;12(3):517-28. [Medline].

  10. Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am. Jul 2000;84(4):983-1007, viii. [Medline].

  11. Weiker GG. Evaluation and treatment of common spine and trunk problems. Clin Sports Med. Jul 1989;8(3):399-417. [Medline].

  12. Ariyoshi M, Nagata K, Sonoda K, et al. Spondylolysis at three sites in the same lumbar vertebra. Int J Sports Med. Jan 1999;20(1):56-7. [Medline].

  13. Commandre FA, Taillan B, Gagnerie F, et al. Spondylolysis and spondylolisthesis in young athletes: 28 cases. J Sports Med Phys Fitness. Mar 1988;28(1):104-7. [Medline].

  14. Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med. Jan-Feb 2000;28(1):57-62. [Medline].

  15. Congeni J, McCulloch J, Swanson K. Lumbar spondylolysis. A study of natural progression in athletes. Am J Sports Med. Mar-Apr 1997;25(2):248-53. [Medline].

  16. Rossi F, Dragoni S. Lumbar spondylolysis: occurrence in competitive athletes. Updated achievements in a series of 390 cases. J Sports Med Phys Fitness. Dec 1990;30(4):450-2. [Medline].

  17. Ralston S, Weir M. Suspecting lumbar spondylolysis in adolescent low back pain. Clin Pediatr (Phila). May 1998;37(5):287-93. [Medline].

  18. Omey ML, Micheli LJ, Gerbino PG 2nd. Idiopathic scoliosis and spondylolysis in the female athlete. Tips for treatment. Clin Orthop Relat Res. Mar 2000;372:74-84. [Medline].

  19. Sward L. The thoracolumbar spine in young elite athletes. Current concepts on the effects of physical training. Sports Med. May 1992;13(5):357-64. [Medline].

  20. Mannor DA, Lindenfeld TN. Spinal process apophysitis mimics spondylolysis. Case reports. Am J Sports Med. Mar-Apr 2000;28(2):257-60. [Medline].

  21. Harvey CJ, Richenberg JL, Saifuddin A, Wolman RL. The radiological investigation of lumbar spondylolysis. Clin Radiol. Oct 1998;53(10):723-8. [Medline].

  22. Lowe J, Schachner E, Hirschberg E, Shapiro Y, Libson E. Significance of bone scintigraphy in symptomatic spondylolysis. Spine. Sep 1984;9(6):653-5. [Medline].

  23. Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology. Aug 1991;180(2):509-12. [Medline]. [Full Text].

  24. Collier BD, Johnson RP, Carrera GF, et al. Painful spondylolysis or spondylolisthesis studied by radiography and single-photon emission computed tomography. Radiology. Jan 1985;154(1):207-11. [Medline]. [Full Text].

  25. Elster AD, Jensen KM. Computed tomography of spondylolisthesis: patterns of associated pathology. J Comput Assist Tomogr. Sep-Oct 1985;9(5):867-74. [Medline].

  26. Kalichman L, Li L, Hunter DJ, Been E. Association between computed tomography-evaluated lumbar lordosis and features of spinal degeneration, evaluated in supine position. Spine J. Apr 2011;11(4):308-15. [Medline].

  27. Ulmer JL, Mathews VP, Elster AD, et al. MR imaging of lumbar spondylolysis: the importance of ancillary observations. AJR Am J Roentgenol. Jul 1997;169(1):233-9. [Medline]. [Full Text].

  28. Sairyo K, Sakai T, Yasui N. Conservative treatment of lumbar spondylolysis in childhood and adolescence: the radiological signs which predict healing. J Bone Joint Surg Br. Feb 2009;91(2):206-9. [Medline].

  29. Zehnder SW, Ward CV, Crow AJ, Alander D, Latimer B. Radiographic assessment of lumbar facet distance spacing and pediatric spondylolysis. Spine. Feb 1 2009;34(3):285-90. [Medline].

  30. Dutton JA, Hughes SP, Peters AM. SPECT in the management of patients with back pain and spondylolysis. Clin Nucl Med. Feb 2000;25(2):93-6. [Medline].

  31. [Best Evidence] Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. Oct 8 2008;CD003008. [Medline].

  32. [Best Evidence] Yuan J, Purepong N, Kerr DP, et al. Effectiveness of acupuncture for low back pain: a systematic review. Spine. Nov 1 2008;33(23):E887-900. [Medline].

  33. [Best Evidence] Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. May 11 2009;169(9):858-66. [Medline].

  34. [Best Evidence] Sertpoyraz F, Eyigor S, Karapolat H, Capaci K, Kirazli Y. Comparison of isokinetic exercise versus standard exercise training in patients with chronic low back pain: a randomized controlled study. Clin Rehabil. Mar 2009;23(3):238-47. [Medline].

  35. O'Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. Dec 15 1997;22(24):2959-67. [Medline].

  36. Moeller JL, Rifat SF. Spondylolysis in active adolescents: expediting return to play. Phys Sportsmed. Dec 2001;29(12):27-32.

  37. Buck JE. Direct repair of the defect in spondylolisthesis. Preliminary report. J Bone Joint Surg Br. Aug 1970;52(3):432-7. [Medline]. [Full Text].

  38. Morscher E, Gerber B, Fasel J. Surgical treatment of spondylolisthesis by bone grafting and direct stabilization of spondylolysis by means of a hook screw. Arch Orthop Trauma Surg. 1984;103(3):175-8. [Medline].

  39. Scott JHS. The Edinburgh repair of isthmic (Group II) spondylolysis [abstract]. J Bone Joint Surg Br. June 1987;69:491.

  40. Kakiuchi M. Repair of the defect in spondylolysis. Durable fixation with pedicle screws and laminar hooks. J Bone Joint Surg Am. Jun 1997;79(6):818-25. [Medline].

  41. Wu SS, Lee CH, Chen PQ. Operative repair of symptomatic spondylolysis following a positive response to diagnostic pars injection. J Spinal Disord. Feb 1999;12(1):10-6. [Medline].

  42. Chen JF, Lee ST. A physiological method for the repair of young adult simple isthmic lumbar spondylolysis. Chang Gung Med J. Feb 2000;23(2):92-8. [Medline].

  43. Sales de Gauzy J, Vadier F, Cahuzac JP. Repair of lumbar spondylolysis using Morscher material: 14 children followed for 1-5 years. Acta Orthop Scand. Jun 2000;71(3):292-6. [Medline]. [Full Text].

  44. Fellander-Tsai L, Micheli LJ. Treatment of spondylolysis with external electrical stimulation and bracing in adolescent athletes: a report of two cases. Clin J Sport Med. Jul 1998;8(3):232-4. [Medline].

  45. Micheli LJ, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med. Jan 1995;149(1):15-8. [Medline].

  46. [Best Evidence] Calmels P, Queneau P, Hamonet C, et al. Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study. Spine. Feb 1 2009;34(3):215-20. [Medline].

  47. Caterini R, Mancini F, Bisicchia S, Maglione P, Farsetti P. The correlation between exaggerated fluid in lumbar facet joints and degenerative spondylolisthesis: prospective study of 52 patients. J Orthop Traumatol. Jun 2011;12(2):87-91. [Medline]. [Full Text].

  48. El-Rich M, Villemure I, Labelle H, Aubin CE. Mechanical loading effects on isthmic spondylolytic lumbar segment: finite element modelling using a personalised geometry. Comput Methods Biomech Biomed Engin. Feb 2009;12(1):13-23. [Medline].

  49. [Best Evidence] Helmhout PH, Harts CC, Viechtbauer W, Staal JB, de Bie RA. Isolated lumbar extensor strengthening versus regular physical therapy in an army working population with nonacute low back pain: a randomized controlled trial. Arch Phys Med Rehabil. Sep 2008;89(9):1675-85. [Medline].

  50. Kalichman L, Kim DH, Li L, et al. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine. Jan 15 2009;34(2):199-205. [Medline].

  51. Physicians' Desk Reference. 54th ed. Montvale, NJ: Medical Economics Co; 2000.

  52. [Best Evidence] Suh KT, Park WW, Kim SJ, et al. Posterior lumbar interbody fusion for adult isthmic spondylolisthesis: a comparison of fusion with one or two cages. J Bone Joint Surg Br. Oct 2008;90(10):1352-6. [Medline].

  53. Wilms G, Maldague B, Parizel P, et al. Hypoplasia of L5 and wedging and pseudospondylolisthesis in patients with spondylolysis: study with MR imaging. AJNR Am J Neuroradiol. Apr 2009;30(4):674-80. [Medline].

 
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Radiograph of L4 defect in the pars interarticularis.
Computed tomography scan demonstrating defects in the left and right pars interarticularis.
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 resonance image shows decreased signal in the pars interarticularis on the left at L5 (same patient in Images 3-4).
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.
Sagittally reconstructed computed tomography scan of the lumbar spine shows a defect of the pars interarticularis on the left at L5.
Lumbar oblique radiograph showing the "Scotty dog." A pars defect is seen at L5.
 
 
 
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