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Pars Interarticularis Injury

Author: Gerard A Malanga, MD, Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine
Coauthor(s): David L Tung, MD, MPH, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Nancy Kim, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Chris Perez, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Dec 17, 2009

Introduction

Background

Lumbar spondylolysis, a unilateral or bilateral stress fracture of the narrow bridge between the upper and lower pars interarticularis, is a common cause of low back pain (LBP) in adolescent athletes.1 The lifetime prevalence of LBP in those aged 11-17 years has been reported to be as high as 30.4% among adolescents participating in sports.2 Although a variety of disorders are likely responsible for these cases, lumbar spondylolysis must be considered in the differential diagnosis of LBP in this population.

Lumbar spondylolysis is a radiographic finding that is believed to develop, in most cases, during early childhood. Typically, it is not associated with any clinical symptomatology of significance, except in a particular subset of patients who are young and adolescent athletes participating in sports that involve repetitive spinal motion, especially lumbar flexion/extension, and to a lesser degree, rotation.

Athletes who are involved in gymnastics, diving, weight lifting, wrestling, rowing, figure skating, dancing, volleyball, soccer, tennis, and football have been found to have a higher incidence of spondylolysis.3 The pars interarticularis defect is believed by most authors to represent a fatigue fracture caused by repetitive loading and unloading of this region of the vertebrae from physical activity. The natural history of the fracture appears to be relatively benign, and in most cases, there is no significant progression of the pars defect.

Spondylolysis can persist in some cases to become spondylolisthesis.4 Spondylolisthesis occurs when one vertebra slips forward in relation to an adjacent vertebra, usually in the lowest lumbar vertebral segment (L5). As a result, the L5 vertebral body slips forward on the S1 vertebral body. This also commonly occurs at the L4 and L5 levels. Spondylolisthesis is almost never due to trauma; however, it is usually discovered after a trauma or prolonged episode of back pain in an athlete prompts radiographic studies.

Most patients with either spondylolysis or spondylolisthesis have excellent clinical outcomes with conservative measures, and surgical intervention rarely is rarely necessary.1,4,5 In selected cases, those patients unresponsive to nonoperative measures may benefit from surgical management. The approach to surgical management is dictated by the age of the patient and the degree of associated spondylolisthesis.6

This article focuses on isthmic spondylolysis as an independent entity from spondylolisthesis and its relationship to athletes, as this type of spondylolysis is a primary focus of concern in athletic adolescents.

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

Frequency

United States

The incidence of isthmic spondylolysis varies according to different surveys, but it has been estimated to be approximately 3-6% in the general adult population. The incidence has been found to vary amongst different ethnic groups, possibly identifying genetic factors as having a degree of influence. Roche and Lowe examined 4200 cadaveric spines and found an overall incidence of 4.2%, with an incidence of 6.4% for white males, 2.3% for white females, 2.8% for black males, and 1.1% for black females.7 Lifestyle differences among cultural groups undoubtedly account for at least part of the difference in incidence among ethnic groups, and these findings must be treated with a degree of caution.8

Most studies reveal that males are consistently affected 2-3 times as often as females, and whites are affected almost 3 times as often as blacks. Most studies also show no significant change in incidence in individuals aged 20-80 years. Based on these studies, spondylolytic lesions are generally believed to occur in the early school-age years.

A prospective study demonstrated a 4.4% incidence of spondylolysis in 500 first-grade children, which increased to an incidence of 6% in adulthood, with a follow-up interval of 45 years.9 The prevalence of spondylolytic lesions among adolescent athletes appears to be much higher than the prevalence among the general population. According to large-scale radiographic studies, the prevalence among adolescent athletes ranges from 8-15%; among adolescent athletes referred for evaluation of back pain, this figure has been reported to be as high as 47%.10

A large screening study in Japan obtained from children who presented with LBP and who were participating in sports found that 32% of the patients younger than 19 years had at least one or more pars interarticularis defects.11 Morita et al investigated 185 adolescents younger than 19 years with spondylolysis and found 180 to be currently active in sports.11

Within competitive sports, increasing age and training more than 15 hours per week correlates with a higher incidence of spondylolytic defects.12 The most common level of a spondylolytic lesion is at the L5 level, estimated at 85-95%, followed by the L4 level, estimated at 5-15%.

Further evidence supporting the role of genetics as a significant factor was found by Fredrickson et al, who discovered an increased incidence of spondylolysis in fathers, mothers, and male siblings of affected people in their study.13 In an earlier study, as many as 26% of the immediate relatives of those with a demonstrable spondylolysis were found to have a similar problem.14

A strong association exists between lumbar spondylolysis and the presence of spina bifida occulta, which has been found to occur in 5-10% of the general population.7,13,15 One theory is that spina bifida occulta may lead to instability of the lower lumbar segment, predisposing an individual to the development of pars interarticularis defects.16 Hyperlordosis of the lumbosacral spine, such as seen in Scheuermann kyphosis, has been associated with a higher incidence of spondylolysis.17

Spondylolysis is associated with spondylolisthesis in approximately 25% of cases; however, the progression of the spondylolisthesis to any significant degree is generally uncommon in those who participate in athletics and in those who do not participate in athletics. The tendency of progression of spondylolisthesis is correlated with the pubescent growth spurt; in a study involving a 20-year follow-up of 255 patients, the mean slip progression was 4 mm.18 Only 11% of adolescents and 5% of adults had slip progressions of greater than 10 mm in this radiologic review.

Functional Anatomy

Spondylolysis is derived from the Greek word spondylo, which means vertebrae, and lysis, which means fracture. Spondylolysis is defined as a defect in the pars interarticularis of the vertebral arch. Often, it is described in association with spondylolisthesis, which can be found concurrently with spondylolysis. Spondylolisthesis is defined as the anterior or posterior displacement of a vertebral body on the one below it. These conditions are generally described according to the following classification of Wiltse, Newman, and Macnab19 :

  • Type I (dysplastic): Congenital abnormalities of L5 or the upper sacrum allow anterior displacement of L5 on the sacrum, which can occur with the pars interarticularis remaining intact.
  • Type II (isthmic): A lesion in the pars interarticularis occurs. This type of spondylolysis is subclassified as a fatigue fracture (IIA), elongation (IIB), or acute fracture (IIC).
  • Type III (degenerative): This type of spondylolysis is associated with long-standing segmental instability and alterations in the articular processes with associated remodeling of the articular process.
  • Type IV (traumatic): Acute fractures of the vertebral arch occur in areas other than the pars.
  • Type V (pathologic): This type of spondylolysis is due to generalized or focal bone disease affecting the vertebral arch.

Clinical

History

The clinical presentation and reported findings of the historical examination of patients with spondylolysis may include the following:

  • Although most patients with spondylolysis are asymptomatic, those who do develop symptoms typically present during the preadolescent growth spurt.20
  • Patients predominantly complain of focal LBP brought on by certain performance activities. Pain may be sharp and lancinating in the acute period or may become chronic, dull, and aching over time. The pain is usually of mild to moderate intensity. Pain may be located unilaterally or bilaterally, usually along the belt line. On occasion, the pain may radiate into the buttock or proximal lower extremity.
  • The onset of symptoms may be either insidious or acute. Often, mild symptoms may be present for a time period, but then the symptoms may become exacerbated by a specific incident.
  • Movements, particularly those involving spinal extension and, to a lesser extent, rotation, are typically described as exacerbating events. Pain is often improved with rest. One study showed up to 98% of adolescent patients with spondylolysis have pain with extension and rotation movements of the spine.21

Physical

Common findings during the physical examination of a patient with spondylolysis may include the following:

  • Upon inspection of the lumbar spine: A patient with LBP resulting from spondylolysis often exhibits a reduced lordotic posture with excessive hamstring tightness.
  • The classically described Phalen-Dickson sign (ie, a knee-flexed, hip-flexed gait) may be demonstrated in patients with spondylolysis. Although this sign is more often seen in those with concomitant spondylolisthesis, it may be present regardless of the degree of vertebral slippage.22
  • A gait pattern described as the pelvic waddle has also been described in association with spondylolysis. The hallmark of this gait abnormality includes a stiff-legged gait with a short stride length due to hamstring tightness.
  • The clinician should also note the presence or absence of skin dimpling in the lumbosacral region that may signify the presence of spina bifida occulta, thereby raising the clinical suspicion of spondylolysis.
  • Palpation of the overlying paraspinal region often produces tenderness, and there may be spasm of the paraspinal musculature that causes splinting in acute cases.3 Take care to identify a possible "step-off" when palpating over the spinous process. This step-off is indicative of concomitant spondylolisthesis, particularly over the L5-S1 level.
  • In assessing lumbar range of motion (ROM), forward flexion is commonly diminished secondary to hamstring tightness. Flexion typically does not increase symptoms, and in many cases, it provides relief. However, extension and rotation commonly cause discomfort for the patient.
  • The preeminent physical examination maneuver thought to most reliably reproduce pain from spondylolysis is the one-legged, hyperextension maneuver, also known as the stork test.
    • The patient is asked to stand on one leg and is brought backward into lumbar extension. Pain due to spondylolysis is thought to be elicited in unilateral lesions by standing on the ipsilateral leg.
    • Although this maneuver is most often described in association with spondylolysis, it stresses other structures besides the pars interarticularis and can therefore be considered to be only suggestive of a pars interarticularis lesion within the context of the clinical picture.
  • The neurologic examination should include assessment of motor strength, sensation, and reflexes. The findings of the neurologic examination should be within normal limits. Typically, radicular findings are absent in patients with isolated spondylolysis.

Causes

Spondylolysis is considered by most to represent a fatigue fracture that results from repeated mechanical stress with microtrauma and eventual overload to the pars interarticularis rather than as a result of a single traumatic event.23 However, a traumatic event may result in the completion of a developing fracture.23 Studies have shown a remarkably low or absent rate of occurrence in newborns and very young children, as well as in those patients who have never been ambulatory.

Rosenberg et al studied 143 patients who had never walked, with an average age of 27 years, and found no cases of spondylolysis.24 This finding appears to support the theory that loading of the pars interarticularis during upright, weight-bearing activities plays a role in the pathogenesis of these lesions.

Another study investigating the mechanical loading of the spine tested cadaveric lumbar vertebrae that were cyclically loaded at the inferior articular processes to simulate shear force.23 The authors found 55 of 74 vertebrae to sustain pars fractures. They concluded that the pars interarticularis was particularly vulnerable to this type of repetitive loading. Further analysis of the vertebrae of those subjects without a fracture revealed a larger cross-sectional area of cortical bone in the pars compared with the control group.23 This led Wiltse et al to hypothesize that a genetic predisposition may be related to the cortical bone density of the pars. This study also suggested that the strength of the neural arch may increase up to the 4th or 5th decade of life.23

In an experimental model, Dietrich and Kurowski found that the greatest mechanical loads occur at L5 and S1 with flexion and extension movements.25 Furthermore, the greatest mechanical stress was found to occur at the region of the pars interarticularis. The investigators also noted that the loads and stresses across this region are related to the physical dimensions of the vertebrae, which may offer a partial explanation regarding the varying incidence among different races and the sexes. Repeated flexion and extension maneuvers, and to a lesser degree rotation, typically have been thought to be the movements that are responsible for generating the forces across the pars interarticularis that result in spondylolysis.25,26

In a retrospective analysis of 213 young athletes, Gregory et al found left-sided lower lumbar pain was more common than the right side, and a marked increase in scintigraphic uptake was noted on the left side of the neural arch more often than the right side.27 Unilateral spondylolysis was identified by reverse gantry computed tomography (CT) scanning on the left pars 36 times and on the right pars 16 times. These findings support the hypothesis that asymmetric repetitive movements associated with certain sports may be responsible for the development of unilateral spondylolysis.27

Green et al concluded from their cadaveric study on pars interarticularis stress, which investigated mechanical loading, that activities involving alternating flexion and extension movements cause large stress reversals in the pars interarticularis, thereby creating the highest risk for developing a pars defect.28 The authors found compressive or axial loading to have little effect in generating these stresses likely responsible for spondylolysis.28 Other anatomic studies have suggested that shear stresses on the isthmic pars are the greatest with lumbar spine extension.29

The specific cause of LBP associated with spondylolysis and spondylolytic spondylolisthesis has not been definitively established. Theories include nerve root compression by floating laminae, intervertebral disc pain, lumbar facet joint pain resulting from spinal instability, or a combination of these pathologies.30 . A fibrocartilage mass of scar tissue forms at the site of lumbar spondylolysis and eventually develops into a structure frequently indistinguishable from a normal ligament by adulthood.

Eisenstein et al identified nerve fibers in the fibrocartilage masses histologically,31 and Nordstrom et al detected the existence of the slow-conducting type C pain fibers and substance P in spondylolytic tissue obtained from patients who underwent resection.32 Mechanoreceptors were later identified in these masses as well.

Hasegawa et al concluded that these fibrocartilage masses appear to be one source of pain, as LBP was induced by injecting hypertonic saline and was blocked by injecting lidocaine into these masses in all patients in their study before resection of the lesion.33 The authors hypothesized that the fibrocartilage mass plays a protective role by sensing instability through the mechanoreceptor and then conveying this information through nociceptive fibers as pain, while at the same time, stabilizing this area of instability by acting as a ligamentlike structure across the defect.33

Given the high number of asymptomatic spondylolytic lesions, an important issue that is lacking in the literature and warrants further investigation is determining the factors that are responsible for producing pain in one patient but not another.

More on Pars Interarticularis Injury

Overview: Pars Interarticularis Injury
Differential Diagnoses & Workup: Pars Interarticularis Injury
Treatment & Medication: Pars Interarticularis Injury
Follow-up: Pars Interarticularis Injury
References
Further Reading
[ CLOSE WINDOW ]

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Keywords

pars interarticularis injury, spondylolysis, spondylolisthesis, pars defect, pars interarticularis, pars fracture, pars defects, pars injury, pars stress reaction, lumbar spondylolysis, lumbosacral spondylolysis, low back pain, back pain

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Contributor Information and Disclosures

Author

Gerard A Malanga, MD, Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Cephalon Honoraria Speaking and teaching

Coauthor(s)

David L Tung, MD, MPH, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Disclosure: Nothing to disclose.

Nancy Kim, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Nancy Kim, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Chris Perez, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Chris Perez, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Andrew L Sherman, MD, MS, Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, Leonard A Miller School of Medicine, University of Miami
Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Paraplegia Society, American Spinal Injury Association, and Association of Academic Physiatrists
Disclosure: pfizer Honoraria Speaking and teaching

Pharmacy Editor

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

Managing Editor

Henry T Goitz, MD, Fellowship Director, Sports Medicine, Department of Orthopedic Surgery, Henry Ford Hospital
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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