Lumbosacral Spondylolysis 

Updated: Sep 05, 2018
Author: Achilles Litao, MD; Chief Editor: Craig C Young, MD 

Overview

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 interarticular 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.

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 spond 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, 11] and may be observed as high as L2.[12, 13] 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.[14]

For excellent patient education resources, see eMedicineHealth's patient education article Low Back Pain.

Epidemiology

Frequency

United States

Lumbosacral spondylolysis (lumbar spondylolysis) is more commonly observed in males,[10] but this difference may not be significant.[15, 16]

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.[17] See the images below.

Long TR (T2-weighted) fat suppressed sagittal magn 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 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 population[16] The athletic population is believed to be more prone to the development of this condition,[17] because the incidence of lumbosacral spondylolysis (lumbar spondylolysis) in competitive athletes is higher than the percentage reported for the nonsports population.[18]

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.[16] 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%).[16] 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%).[18]

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).[16]

 

Presentation

History

See the list below:

  • Among the general population, most cases of lumbosacral spondylolysis (lumbar spondylolysis) are clinically inapparent, and the condition is symptomatic in only 10% of patients.[16] 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,[19] particularly with hyperextension maneuvers such as in gymnastics. In general, patients present without a history of neurologic symptoms.[12]

Physical

See the list below:

  • 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.[12]

    • Sciatica can occur but is rare.[20]

    • 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.[12] 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.[19]

  • 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.[20]

Causes

See the list below:

  • 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).[16]

  • 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.

 

DDx

 

Workup

Laboratory Studies

See the list below:

  • No laboratory studies have been shown to aid in the diagnosis of lumbosacral spondylolysis (lumbar spondylolysis).

Imaging Studies

See the list below:

  • Routine thoracolumbar radiography in an athlete suspected of having a lumbosacral spondylolysis (lumbar spondylolysis) should include anteroposterior (AP), lateral, and oblique views. Flexion and extension lateral radiographs can be added if spondylolisthesis is present or stability is in question.

    • AP radiographic findings are usually normal in spondylolysis.[20]

    • The oblique views are particularly screened for the "Scotty dog" lesion in the pars interarticularis (see the image below).[12] The pars defect is represented by the collar on the Scotty dog.

      Lumbar oblique radiograph showing the "Scotty dog. Lumbar oblique radiograph showing the "Scotty dog." A pars defect is seen at L5.
    • Keep in mind that the oblique view must be of good quality and read by someone experienced in making the diagnosis of lumbosacral spondylolysis (lumbar spondylolysis). Considerable interobserver variation in making this diagnosis has been noted.[19]

    • The 30º cranially angulated AP view and the coned lateral view of the lumbosacral junction are proposed to display the majority of defects. Because the 30º cranially angulated AP view clearly depicts the pars interarticularis of L5 in the frontal plane, it also allows the distinction between unilateral and bilateral defects.[21] Suffice to say, plain radiography is used more to exclude unusual lesions and spondylolisthesis than to make the diagnosis of lumbosacral spondylolysis (lumbar spondylolysis).[17]

  • An athlete who is symptomatic with hyperextension and whose plain radiography results are normal requires additional investigations. A 99-m technetium (99m Tc) ethylene diphosphonate bone scintigraphy identifies pars interarticularis stress fractures that were missed on oblique plain radiography. Those patients who have had recent trauma or strenuous activity and who are symptomatic show increased activity on the spondylolytic area. On the other hand, those with chronic low back pain show normal scans.[22]

    • Technetium bone scanning has its limitations.[23] When compared to single-photon emission computed tomography (SPECT) scanning, the SPECT scanning was found to be more sensitive and better at localization of abnormalities in those athletes with radiographically obvious lumbosacral spondylolysis/spondylolisthesis.[24]

    • Bone scanning has a false-positive rate of 15% when using computed tomography (CT) scanning as the standard to establish the diagnosis of lumbosacral spondylolysis (lumbar spondylolysis).[17] Therefore, SPECT scanning is needed to identify the more subtle stress reactions. Moreover, these scans can aid in establishing the acuity of the lesion or in identifying the site of the problem in an athlete with negative plain radiography results but whose clinical course is suggestive of a pars interarticularis fracture.[22] The main value of SPECT scanning lies in the identification of an acute stress reaction of the pars before its manifestation radiographically.[21]

  • For more information about the defect in the bony structure involved, performing CT scanning through the fracture provides excellent detail (see the image below).

    Sagittally reconstructed computed tomography scan Sagittally reconstructed computed tomography scan of the lumbar spine shows a defect of the pars interarticularis on the left at L5.
  • CT scanning also provides information regarding other features of spondylolysis, such as facet joint changes, spondylolisthesis, and disc herniations, and it also helps prognosticate the potential for a lesion to heal.[25, 26]

  • The technique for CT scanning is crucial, because a lesion is optimally demonstrated when the plane of scanning is perpendicular to the plane of fracture. This is achieved if the CT scan gantry is reversed so that the scanning plane is perpendicular to the fracture.[21] CT scanning is not useful for impending stress fractures.[6]

  • MRI is inferior to CT scanning for direct visualization of defects of the pars interarticularis.[27] However, MRI has utility to rule out disc herniations. (See the images below.)

    Long TR (T2-weighted) fat suppressed sagittal magn 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 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).
  • Sairyo et al evaluated how the stage of a pars defect on CT scan and the presence or absence of high signal change in the adjacent pedicle on T2-weighted MRI were related to bony healing following conservative treatment of lumbar spondylolysis in childhood and adolescence.[28] Twenty-three children (19 boys, 4 girls; mean age 13.5 y) with 41 pars defects were conservatively for at least 3 months, in which they were asked to refrain from sporting activity and to wear a Damen soft thoracolumbosacral type brace.

  • The pars defects were classified as an early, progressive or terminal stage on CT scans. Early-stage lesions were defined as those that had a hairline crack in the pars interarticularis, which became a gap in the progressive stage. Terminal-stage defects were considered equivalent to a pseudarthrosis.[28] On T2-weighted MRIs, the presence or absence of high signal change in the adjacent pedicle were evaluated; then, the defects were divided into high signal change-positive or -negative. Healing of the defect was assessed by CT scanning.[28]

  • The investigators found 13 (87%) of the 15 early defects healed, but of 19 progressive defects, only 6 (32%) healed. None of the seven terminal defects healed. In addition, of the 26 high signal change-positive defects, 20 (77%) healed after conservative treatment, but none of the high signal change-negative defects did.[28] Sairyo et al concluded that early-stage defects on CT scans and high signal changes in the adjacent pedicle on T2-weighted MRIs may be useful predictors of bony healing of a pars defect in children following conservative treatment.

  • In another study, Zehnder et al performed a retrospective radiographic review to assess the relationship between interfacet spacing and pediatric spondylolysis.[29] The investigators compared the anteroposterior lumbar spine radiographs of 41 children with spondylolytic defects with 41 unaffected controls. The vertebral body width and interpedicular distance were recorded, and statistical analysis of the relationships of interfacet distances between the affected and unaffected groups was performed.

  • Zehnder et al noted that the absolute increase in interfacet distance between adjacent levels was significantly smaller at the L4/L5 level in spondylolytic individuals; however, when interpedicular distance was used to standardize for vertebral body size, a significantly smaller increase in the interpedicular distance was noted at the L4/5 level in spondylolytic individuals. The investigators demonstrated similar results when body width was used to standardize for vertebral body size, with a similar, but not significant, trend at the L3/4 level when standardizing with interpedicular distance. Zehnder et al indicated that a likely explanation for the etiology of lumbar pars defects is insufficient caudal increase in lumbar interfacet spacing but noted that further prospective studies are needed to determine if unaffected individuals with a narrowed interfacet spacing are at increased risk of developing spondylolytic defects later in life.[29]

 

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The approach to the treatment of lumbosacral spondylolysis (lumbar spondylolysis) is based on the stage of the bony lesion as guided by radiography and nuclear medicine or SPECT scanning investigations, as well as symptomatology.[12, 30] The complete healing of the bony lesion is the ultimate goal in treating patients with lumbosacral spondylolysis (lumbar spondylolysis).

Acute phase

Some patients present with a spondylolytic defect on plain radiography and also have positive findings on bone scanning. This can represent a recent-onset defect on the pars interarticularis[12] or a healing spondylolysis. Bracing and rest are the cornerstones of treatment for this type of lesion.[30] Pain control and avoiding sports are also part of the acute phase or rehabilitation.

Transcutaneous electrical nerve stimulation (TENS) has had widespread use as a therapeutic adjunct to the pharmacologic management of pain, but its effectiveness in chronic low back pain remains controversial. Khadilkar et al selected 4 randomized controlled clinical trials that met their selection criteria and that compared TENS to placebo for the management of chronic low back pain.[31] The investigators found conflicting evidence in 2 trials regarding whether TENS had any benefit in reducing back pain intensity, whereas 2 trials showed consistent evidence that TENS did not improve back-specific functional status.[31]

In addition, Khadilkar et al found conflicting results in 2 studies regarding generic health status: 1 study showed no improvement on the modified Sickness Impact Profile, whereas another study showed significant improvements on several, but not all subsections of the Short Form-36 (SF-36) Health Survey.[31] Moreover, multiple physical outcome measures lacked statistically significant improvement relative to placebo. The investigators concluded that at present, the evidence does not support the use of TENS in the routine management of chronic low back pain.[31]

Acupuncture has also had widespread use in the management of pain, with conflicting results. Yuan et al conducted a systematic review of randomized controlled trials to explore the evidence for the effectiveness of acupuncture for nonspecific low back pain.[32] Twenty-three trials with 6359 patients met the investigators' inclusion criteria and classified into 5 types of comparisons, 6 of which were of high quality.

Yuan et al found moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief.[32] In addition, the investigators found strong evidence that acupuncture can be a useful supplement to other forms of conventional therapy for nonspecific low back pain, but further investigation is needed. Yuan et al concluded that acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated in the European Guidelines for the treatment of chronic low back pain.[32]

Cherkin et al studied the importance of needle placement and skin penetration in eliciting acupuncture effects for 638 adult patients with mechanical chronic low back pain.[33] The patients were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care, receiving 10 treatments over a 7-week period as administered by experienced acupuncturists.

The investigators reported that individuals receiving real or simulated acupuncture (60%) were more likely than those receiving usual care (39%) to experience clinically meaningful improvements on the dysfunction scale (P< 0.001).[33] Cherkin et al found that although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appeared to be unimportant in eliciting therapeutic benefits—which raises the question of whether acupuncture or simulated acupuncture provides physiologically important stimulation or whether it represents placebo or nonspecific effects.

Physical therapy

A Boston overlapping brace is used to immobilize the pelvis for prevention of hyperextension and is worn in 0° lordosis for 23 hours per day and for as long as the patient is totally symptom free for a minimum of 3 months, after which a repeat bone scan is performed. Hamstring stretching and lumbar flexibility motions are performed in the brace. Most patients are said to have normal findings on scanning within 3-9 months.[12] Aquatic rehabilitation can also be performed in the acute phase.

Exercise programs have also been used in the treatment of chronic low back pain. Sertpoyraz et al compared the effectiveness of an isokinetic exercise program with a standard exercise regimen in 40 patients with chronic low back pain using the parameters of pain, mobility, disability, psychologic status, and muscle strength.[34] The investigators found both isokinetic and standard exercise resulted in significant improvement compared with the baseline that persisted until the end of the first month. However, comparison of both exercise groups at the end of the treatment and at the first month after treatment showed no significant difference. Sertpoyraz et al concluded that isokinetic and standard exercise are equally effective in the treatment of low back pain; however, in terms of ease of use and cost, standard exercise programs were the preferred option for exercise.[34]

Consultations

Consult neurosurgeons, orthopedic surgeons, neurologists, and physiatrists as indicated.

Recovery Phase

Rehabilitation Program

Physical Therapy

Recovery phase

The goals of the recovery phase are the resolution of pain and the healing of the pars defect with either bony union or painless fibrous union if bony union is not possible.

Physical therapy

This phase of rehabilitation consists of a progressively shallower aquatic rehabilitation location so that graded gravitational forces are applied to the spine. Also, lumbar flexibility out of the brace as symptoms resolve is helpful, but inciting activities must still be avoided. Flexibility and strengthening of the paraspinal, iliopsoas, and abdominal muscles along with endurance training of the back (necessitated by deconditioning) are all especially important. One may advance to full participation in a brace as symptoms resolve.

Consultations

Consult neurosurgeons, orthopedic surgeons, neurologists, and physiatrists as indicated.

Other Treatment (Injection, manipulation, etc.)

Electromagnetic field therapy for persistent nonunion may be used in this phase.

Maintenance Phase

Rehabilitation Program

Physical Therapy

Maintenance phase

The single best predictor for a new injury during athletic activity is a history of a previous injury. Patients showing a spondylolytic defect on plain radiography but whose bone scanning result is negative are regarded as having an inactive spondylolytic defect[12] or a pseudoarthrosis or old unhealed fracture.[30]

Physical therapy

Continue bracing for up to 6-9 months is indicated as necessary to heal the pars. These patients benefit from physical therapy that puts emphasis in deep abdominal muscles, specifically the internal oblique and transversus abdominis and the lumbar multifidus,[35] in addition to flexibility exercises for the hamstrings and lower back. Hyperextension movements are to be avoided. One may need SPECT bone scanning or CT scanning to monitor healing.

Surgical Intervention

Some investigators advocate surgery to prevent spondylolisthesis.[30, 36, 37]

Consultations

Consult neurosurgeons, orthopedic surgeons, neurologists, and physiatrists as indicated.

Other Treatment

Lumbar corsets and neoprene belts are also used.[12]

 

Medication

Medication Summary

Tylenol (acetaminophen) and NSAIDs are the mainstays of pain control in those with lumbosacral spondylolysis (lumbar spondylolysis). Moreover, a short course of narcotic analgesics can help those who are in significant acute pain initially.

Muscle relaxants are overprescribed and have not been demonstrated to be of significant help in this condition.

Analgesics

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.

For the relief of moderate to severe pain, a short course of a narcotic analgesic may be warranted. Opiates exert their effects by binding to different opioid receptors throughout the body, which produces a wide range of effects such as analgesia, euphoria, constipation, and respiratory depression.

Acetaminophen (Tylenol, Feverall, Aspirin-Free Anacin)

Effective analgesic-antipyretic but only has weak anti-inflammatory effects. Inhibits prostaglandin synthetase. Well absorbed from gastrointestinal tract. Peak concentrations in serum are reached within 2 h.

Acetaminophen and codeine (Tylenol #3)

Indicated for the treatment of mild to moderate pain.

Hydrocodone and acetaminophen (Lortab, Lorcet-HD, Vicodin, Norcet)

Drug combination indicated for moderate to severe pain. Available in different strengths.

Hydrocodone and ibuprofen (Vicoprofen)

Drug combination indicated for short-term (< 10 d) relief of moderate to severe acute pain.

Propoxyphene/acetaminophen (Darvocet-N100, Wygesic)

Drug combination indicated for mild to moderate pain.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Class Summary

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Naproxen (Anaprox, Naprelan, Naprosyn, Aleve)

For the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of COX, which results in a decrease of prostaglandin synthesis.

Ibuprofen (Motrin, Ibuprin, Advil)

NSAIDS exert their main therapeutic effect on pain and inflammation principally by inhibition of prostaglandin synthesis.

Mefenamic acid (Ponstel)

Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Ketoprofen (Orudis, Oruvail, Actron)

For the relief of mild to moderate pain and inflammation.

Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease.

Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution and closely observe the patient for response.

Celecoxib (Celebrex)

Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.

Muscle Relaxants

Class Summary

Muscle relaxants are overprescribed and have not been demonstrated to be of significant help in cases of lumbosacral spondylolysis (lumbar spondylolysis).

Methocarbamol/aspirin (Robaxisal)

Used mainly as adjunctive treatment of muscle spasm associated with acute painful musculoskeletal conditions. Causes musculoskeletal relaxation by decreasing impulse transmission from the spinal cord to the muscle.

 

Follow-up

Return to Play

Return to play of an athlete with lumbosacral spondylolysis (lumbar spondylolysis) is first begun with low-level sport activities after the follow-up visit at 4-6 weeks, after which gradual increase in intensity as tolerated is allowed under supervision.[38] Return to full activity is permitted only when patients are totally asymptomatic with full range of motion.[12] Patients must also have normal flexibility and normal strength and balance.

Complications

Complications of lumbosacral spondylolysis (lumbar spondylolysis) include a progression to spondylolisthesis (ie, slippage of the vertebrae and its sequelae) as well as delayed diagnosis and nonunion with chronic pain.

Prevention

Because the etiology of lumbosacral spondylolysis (lumbar spondylolysis) is unknown and factors that cause slippage are unknown, prevention suggestions are unavailable. However, athletes must be advised that preventing recurrences may prove difficult if they return to high-level competition.

Prognosis

If treatment is instituted early, lumbosacral spondylolysis (lumbar spondylolysis) can be successfully treated with conservative management.[2] The cure rate for early lumbosacral spondylolysis (lumbar spondylolysis) with activity restriction and a thoracolumbosacral orthosis is 73%, whereas more advanced spondylolyses were found to be less responsive to this regimen.[2]

With history and physical examination findings compatible with lumbosacral spondylolysis (lumbar spondylolysis), athletes with normal findings on plain radiography and bone scanning are most likely to have pathology other than a pars defect. They are presumed to have a chronic back strain, and further investigation of the cause of the back pain is indicated while they are placed on physical therapy. Studies are repeated in 6-8 weeks if patients are still symptomatic with physical therapy.[12] MRI is appropriate in this setting.[30]

Surgical treatment is an option for persistently symptomatic patients who did not achieve bony healing with activity restriction and bracing.[39, 40, 41, 42, 43, 44, 45] Bony union has also been reported with transcutaneous electrical stimulation (TENS) in this group of patients.[46]

Education

All athletes, especially those younger than 18 years, should know that not all sources of back pain are muscular and, therefore, should not be ignored if persistent. This is most important if the athlete is participating in gymnastics, football, dancing, or figure skating.