Pars Interarticularis Injury Workup

  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD   more...
 
Updated: Apr 19, 2011
 

Laboratory Studies

Laboratory studies are not indicated for diagnosing lumbosacral spondylolysis.

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Imaging Studies

Plain radiography

Traditionally, plain radiographs have been the hallmark of diagnostic imaging in cases of spondylolysis. The lateral oblique view, in which the pars interarticularis is best visualized, is described as having the appearance of a "Scotty dog." In isthmic spondylolytic lesions, the Scotty dog is described as having the appearance of a "collar" or a "broken neck," which is thought to be a pathognomonic finding.[5] In unilateral pars lesions, the contralateral region may demonstrate sclerosis secondary to the increased stresses in that area.[34]

In studies comparing the different views of plain radiographs, including anteroposterior (AP), lateral, and lateral oblique, 19% of pars interarticularis lesions were identified only on the lateral oblique view. Pierce reported the sensitivity of the AP view to be 32%, of the lateral view to be 75%, and of the lateral oblique view to be 77%.[35] The most sensitive view in one study was found to be the lateral spot view of the lumbosacral junction, which revealed 84% of pars interarticularis lesions.

Limitations of plain radiographs lie in the fact that to be optimally visualized, the lesion should ideally be aligned tangentially to the beam. Spondylolytic lesions are often not aligned within the plane of the standard 45º lateral oblique views. Although most authors support the belief that multiple views of the lumbosacral spine are necessary for optimal visualization of the pars interarticularis on plain radiography, the need for routine oblique radiographs has been questioned with concerns regarding increased radiographic exposure.[36] Additionally, spondylolytic lesions seen on radiographs are often believed to represent an old injury that may not be symptomatic.

Flexion and extension lateral radiographs may be obtained if spondylolisthesis or spine instability is suspected.

Single-photon emission tomography scan (SPECT)

Radionuclide imaging studies, including planar bone scanning and, more specifically, SPECT bone scanning, have been found to be more sensitive than plain radiography in detecting pars lesions. Several authors comparing planar bone scan versus plain radiographs concluded that planar bone scans could potentially detect pars lesions earlier in the clinical course than could plain radiographs. Furthermore, it appears that bone scanning may be more sensitive in differentiating pain-producing pars lesions from incidentally found lesions.

In a study by Lowe et al, a group of patients found to have spondylolysis on plain films were further imaged with a bone scan.[37] A positive bone scan in each case correlated with the presence of LBP, whereas those with negative bone scans were all without pain. Similar results have been obtained in other studies, and it appears that bone scans may have a role in identifying those cases in which the spondylolytic lesion is the pain generator rather than just an incidental finding.

SPECT scanning has been found to be more sensitive than either plain radiography or planar bone scintigraphy in detecting spondylolysis and has, for the most part, replaced planar bone scanning as the radionuclide imaging study of first choice in suspected pars interarticularis lesions.

Studies carried out that compared plain radiography, planar bone scanning, and SPECT scanning by Bodner et al and Bellah et al, respectively, both found the SPECT scan to be more sensitive compared with the other 2 imaging studies.[38, 39] Furthermore, as with planar bone scans, SPECT scans may be helpful in detecting symptomatic pars lesions from asymptomatic lesions as they can identify metabolically active bone change.

A particularly interesting study comparing the clinical outcome following surgery for pars interarticularis defects with SPECT scanning found that patients who became pain free after surgery have positive preoperative SPECT scans, whereas those in whom pain persisted after surgery had negative preoperative scans. This finding implies that those with negative scans may have been experiencing their symptomatology from a source other than the pars lesion.

A Japanese study was performed to clarify the role of SPECT scans. In this study, plain radiographs and SPECT scans were obtained in young patients (mean age 15.6 y) who had LBP and were clinically suspected of having spondylolysis. This study concluded that the SPECT scan is primarily indicated in patients with no apparent abnormality seen on plain radiograph and/or CT scan and who are still suspected of having spondylolysis from their history and physical examination. A positive study was thought to represent a stress reaction in the pars interarticularis, which may be amenable to rest and immobilization. A negative study at this point strongly suggests that spondylolysis is not the likely source of pain and may warrant further imaging to evaluate for a different pathology that may be causing symptomatology.[40]

Herring and Standaert offer the opinion that considering the relatively high radiation exposure one is subjected to in undergoing multiple views on plain film, along with the increased sensitivity of SPECT scanning, the latter may be the most appropriate choice for the initial screening study.[41] The authors feel with the advantages of SPECT scanning, multiple plain radiographic views as an initial screening tool may not play a role in detecting spondylolytic lesions.[41] In cases in which plain radiographs do reveal pars lesions, SPECT scanning can be helpful in documenting the acuity of injury.

Interpretation of plain radiographs coupled with SPECT scan results

Below, table 1 outlines the interpretation of plain radiographs coupled with SPECT scan results.

Table 1 also offers treatment strategies based on these results, as followed by a British institution.[42] These treatment strategies were outlined in a study conducted jointly by the investigators' orthopedic and radiology departments, who investigated the role of SPECT scanning in the management of patients with back pain and spondylolysis.[42]

Although radionuclide imaging may have increased sensitivity in detecting pars defects compared with plain radiographs, they are not necessarily highly specific for this detection and have been found to yield positive results from pathologies other than spondylolysis, including a infection and tumor such as osteoid osteoma and osteoblastoma.

Table 1. Outline of the Treatment Strategy Based on Results of Plain Radiographs and SPECT Scanning in the Evaluation of Defects of the Pars Interarticularis in Patients Clinically Suspected of Having Symptomatic Pars Interarticularis Lesions (Open Table in a new window)

Plain RadiographSPECT ScanInterpretationManagement
NegativeNegativePathology other than pars defect should be suspectedFurther investigation of cause of back pain should be performed (eg, MRI)
NegativePositiveEarly pars interarticularis fractureConservative management in form of rest, +/– bracing
PositiveHealingSpondylolysisConservative management in the form of rest and bracing
PositiveNegativePseudoarthrosis or old unhealed fractureConsider surgical intervention for stabilization to prevent spondylolisthesis and to relieve pain. Consider further investigation to rule out alternative pathology.

CT scanning

As with the above mentioned radionuclide studies, CT scanning has been found to be more sensitive than plain radiography in visualizing spondylolytic lesions.[43, 44]

In a study comparing plain radiography, CT scanning, and bone scintigraphy (either bone scan or SPECT), CT scanning was found to be more sensitive than plain radiographs, as well as more specific than radionuclide imaging. Both standard axial views and reverse gantry CT imaging were used for this study, and the authors noted that some pars interarticularis defects were seen more clearly with one versus the other, although a direct comparison of views was not made.

CT scanning has the added benefit of providing more detail about the nature of the pars interarticularis defect than bone scanning or SPECT scanning does. CT scanning has the advantage of visualizing other spinal pathologies, most notably intervertebral disc pathology, which is not seen on the other radionuclide imaging studies. The relationship between CT scanning and SPECT scanning has not been fully established, and it is presently unclear as to which is the more sensitive study. The role of CT scanning may be as an adjunctive study investigating the stage of healing in a pars fracture.

MRI

MRI has not been studied as well as plain radiography, radionuclide scanning, and CT scanning. Initial studies revealed that MRI provides great difficulty in identifying a normal intact pars interarticularis, resulting in a low positive predictive value.

MRI may be useful in detecting spondylolysis earlier in the clinical course than plain radiography or CT scanning does; this makes MRI comparable to radionuclide scanning, whereas removing the disadvantages of radiation exposure. However, MRI typically has been associated with an excessively high rate of false-positive diagnoses.[45] Improvements in the technical aspects of MRI have increased its usefulness in imaging pars interarticularis lesions. T1 imaging with sagittal 3-mm slices has been shown to be most useful.

MRI offers some advantages; this modality is the criterion standard of imaging in most other lumbosacral spine pathologies. The lack of ionizing radiation makes MRI especially attractive for use on adolescent athletes. An study comparing MRI findings found prevalent abnormalities of the lumbar spine in adolescents who were high-performance rowers; these abnormalities included disc disease and pars interarticularis stress reaction.[46]

The overall role of MRI has yet to be determined, as it is not clearly defined in the literature at this point. MRI is not a first-line imaging study in clinically suggested spondylolysis, but rather it is an adjunct study in evaluating for alternative pathologies (see Differentials).

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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; Endo Honoraria Speaking and teaching; Forest Labs 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.

Specialty Editor Board

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, University of Miami, Leonard A Miller School of Medicine

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 Medical Association, and Association of Academic Physiatrists

Disclosure: Pfizer Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine 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.

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Table 1. Outline of the Treatment Strategy Based on Results of Plain Radiographs and SPECT Scanning in the Evaluation of Defects of the Pars Interarticularis in Patients Clinically Suspected of Having Symptomatic Pars Interarticularis Lesions
Plain RadiographSPECT ScanInterpretationManagement
NegativeNegativePathology other than pars defect should be suspectedFurther investigation of cause of back pain should be performed (eg, MRI)
NegativePositiveEarly pars interarticularis fractureConservative management in form of rest, +/– bracing
PositiveHealingSpondylolysisConservative management in the form of rest and bracing
PositiveNegativePseudoarthrosis or old unhealed fractureConsider surgical intervention for stabilization to prevent spondylolisthesis and to relieve pain. Consider further investigation to rule out alternative pathology.
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