Main and contralateral side stages of lesion affected bone union in the conservative treatment of adolescent lumbar spondylolysis: a multivariable analysis of 217 patients and 298 lesions in a retrospective cohort study.

BACKGROUND: Factors affecting bone union in the conservative treatment of adolescent lumbar spondylolysis remain controversial. We aimed to examine these factors along with advances in diagnostic imaging using multivariable analysis of a sufficient number of patients and lesions. METHODS: In this retrospective study, high-school-aged patients or younger (n = 514) who were diagnosed with lumbar spondylolysis from 2014 to 2021 were investigated. We included patients with acute fractures who showed signal changes around the pedicle on magnetic resonance imaging and who completed conservative treatment. The following factors were investigated at the initial visit: age, sex, level of lesion, main side stage, presence and stage of contralateral side lesion, and presence of spina bifida occulta. The association of each factor with bone union was evaluated through a multivariable analysis. RESULTS: Altogether, 298 lesions in 217 patients (174 boys and 43 girls; mean age: 14.3 years) were included in this study. Multivariable logistic regression analysis of all factors showed that the main side progressive stage was more likely associated with nonunion as compared to the pre-lysis (OR: 5.86; 95% confidence interval [CI]: 2.00-18.8; p = 0.0011) and early stages (OR: 3.77; 95% CI: 1.72-8.46; p = 0.0009). Regarding the contralateral side stage, the terminal stage was more likely to be associated with nonunion. CONCLUSION: In the conservative treatment of lumbar spondylolysis, the factors affecting bone union were the main and contralateral side stages. Sex, age, level of lesion, or spina bifida occulta had no significant effects on bone union. The main, progressive, and contralateral side terminal stages were negative predictors of bone union. Trial registration This study was retrospectively registered.

Effects of low-intensity pulsed ultrasound on pain and functional disability in patients with early-stage lumbar spondylolysis: A randomized controlled trial.

BACKGROUND: Low Intensity Pulsed Ultrasound (LIPUS) is beneficial in accelerating fracture recovery, enhancing their capacity to execute tasks of daily life and, as a result, their autonomy. OBJECTIVE: To compare the outcomes of routine physical therapy and routine physical therapy along with LIPUS in patients with early-stage lumbar spondylolysis. METHODS: Thirty-four (29 males and 5 females) patients exhibiting symptomatic low back pain for at least four weeks were recruited and randomly divided into control group (CG) and intervention group (IG) group. Randomization was done by using goldfish bowl method and allocation was done by using sealed envelope method. Parallel assignment was done. Numeric Pain Rating Scale (NPRS) was utilized for the measurement of pain and Oswestry Disability Index (ODI) for functional disability. Patients were assessed at baseline, at the end of 12th and 20th week. Interventions were applied by two physical therapists (one male and one female) having more than eight years of clinical experience for 10 weeks on alternate days. RESULTS: Intervention group reported significant percentage change of 47% at 12th week and 65% at 20th week for pain and 42% at 12th week and 81% at 20th week for functional disability compared with 40% at 12th week and 37% at 20th week for pain and 3% at 12th week and 25% at 20th week follow-up for functional disability from baseline in control group. CONCLUSION: Low-intensity pulsed ultrasound has significantly reduced pain and functional disability in patients with early-stage lumbar spondylolysis by using following parameters; 1.1-MHz oscillation frequency, 1-kHz pulsed frequency, 100-mW/cm2 spatial intensity, 2 ms pulse duration, 100Hz pulse repetition rate, 20% pulse duty cycle, and 20-min duration on alternate days.

Role of low-intensity pulsed ultrasound on lumbar spondylolysis: A systematic review.

OBJECTIVE: To systematically review the role of low-intensity pulsed ultrasound on lumbar spondylolysis. METHODS: Literature search was conducted on PubMed, Embase, CINAHL, Web of Science, PEDro and Scopus databases to identify relevant studies published between 2010 and 2020 by using medical subject headings and applying Booleans, such as low-intensity pulsed ultrasound OR interventional ultrasound AND lumbar spine OR lumbar region AND spondylolysis OR stress fracture. Unpublished studies were hand-searched in the journals, abstracts of conferences were reviewed, and citation index was used for searching experts in the field and then contacting them for information. Studies included were the ones that had at least one of the following outcomes: bone union rate, treatment period to bone union and time to return to previous activities. RESULTS: Of the 243 studies identified, 228(94%) were full text articles and only 2(0.8%) studies were critically appraised for qualitative synthesis based on bone union rate, treatment period to bone union, and time to return to previous activities. CONCLUSIONS: Low-intensity pulsed ultrasound was found to be effective for bone union and a useful therapy for quick return to playing sports in patients with lumbar spondylolysis.

Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up.

OBJECTIVE: The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. METHODS: The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. RESULTS: The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years. CONCLUSION: Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Radiographic Outcomes of Immobilization using Boston Brace for Pediatric Spondylolysis.

BACKGROUND AND AIMS: Spondylolysis is a common cause of lower back pain during youth. The aim of this study is to report the bony union rate and risk factors for non-union of the lumbar spondylolysis of pediatric patients treated with a rigid thoracolumbosacral orthosis (Boston brace). MATERIALS AND METHODS: A retrospective review of 68 children (mean age = 13.9 years) treated for spondylolysis with a thoracolumbosacral orthosis. Patient charts and imaging studies were evaluated to identify the bony union rate of the spondylolysis after a minimum of 3 months of immobilization (mean = 4.2 months). Laterality, grade, level, and presence of high signal intensity in the magnetic resonance imaging were evaluated as prognostic factors. RESULTS: Sixty-eight patients presented with 110 defects. Of them, 46 (42%) were incomplete fractures, 38 (35%) complete fractures, and 26 (24%) pseudoarthrosis. Of these defects, 38 (82.6%), 11 (28.9%), and 0 (0.0%) had bony union at the end of the treatment (p < 0.001). Unilateral defects healed significantly better than bilateral ones (relative risk = 1.71, 95% confidence interval = 1.16-2.54, 17/26 (65%) vs 32/84 (38%), p = 0.014). High signal intensity in the magnetic resonance images before the treatment predicted healing (relative risk = 13.24, 95% confidence interval = 1.93-91.01, 48/87 (55%) vs 1/24 (4.3%), p < 0.001). The level of the spondylolysis (L5 vs above L5) did not affect the healing rate. CONCLUSION: The union rates of spondylolysis with a thoracolumbosacral orthosis were similar as compared to earlier studies done with a low thoracolumbosacral orthosis. The grade of the defect, laterality, and presence of high signal intensity increased the probability of bony union. A high thoracolumbosacral orthosis (underarm) does not seem to improve the healing rate of pediatric spondylolysis defects.

Low-Intensity Pulsed Ultrasound for Early-Stage Lumbar Spondylolysis in Young Athletes.

OBJECTIVE: To examine the effect of low-intensity pulsed ultrasound (LIPUS) on early-stage spondylolysis in young athletes. DESIGN: Case-control study. SETTING: A single outpatient orthopedic and sports clinic. PATIENTS: A total of 82 young athletes (80 boys and 2 girls; mean age, 14.8 years; range, 10-18 years) with early-stage lumbar spondylolysis were enrolled in this study. All patients were examined by plain radiography and magnetic resonance imaging. INTERVENTIONS: Patients received either standard conservative treatment combined with LIPUS (n = 35) or without LIPUS (n = 47), according to the sequence of admission. The standard conservative treatment included thoracolumbosacral brace, sports modification, and therapeutic exercise. MAIN OUTCOME MEASURES: The time required to return to previous sports activities was analyzed by using Kaplan-Meier methods with the log-rank test. RESULTS: The baseline parameters of both groups were not significantly different. The median time to return to previous sports activities was 61 days [95% confidence interval (CI): 58-69 days] in the group treated with LIPUS, which was significantly shorter than that of the group treated without LIPUS (167 days, 95% CI: 135-263 days; P < 0.01). CONCLUSIONS: These results suggest that LIPUS combined with conservative treatment for early-stage lumbar spondylolysis in young athletes could be a useful therapy for quick return to playing sports.

Return to play after conservative and surgical treatment in athletes with spondylolysis: A systematic review.

PURPOSE: Analyze the return to sports rate and timing after conservative and surgical treatment in athletes with spondylolysis. METHODS: Comprehensive search using Pubmed, Cochrane Library and SPORTDiscus databases to identify English language studies that assessed the return to sports after conservative or surgical treatment of symptomatic spondylolysis in athletes. The main outcome of interest was the return to sports rate and timing, as well as, the follow-up clinical and functional outcomes. RESULTS: A total of 14 trials (592 participants) were included. Eight and seven studies reported the outcomes of conservative and surgical approach, respectively. A total of 92% (n = 492) and 88% (n = 100) of athletes return to sports at any level, and 89% (n = 185) and 81% (n = 103) returned to their pre-injury level of sports for conservative and surgical approaches, respectively. The time to return to sports was 4.6 and 6.8 months for conservative and surgical approaches, respectively. CONCLUSIONS: Conservative management (bracing, sports modification and physiotherapy) of athletes with spondylolysis show excellent return to sports rates at any level and at the pre-injury level at a mean of 4.6 months. Those who fail the conservative treatment can be successfully managed with surgical treatment with a high rate of return to sports at 6.8 months. LEVEL OF EVIDENCE: Level IV, Systematic review of level IV studies.

Spondylolysis 2019 update.

PURPOSE OF REVIEW: Provide a comprehensive overview of lumbar spondylolysis, a frequent cause of lower back pain in children and adolescents, from evaluation to management. RECENT FINDINGS: With the surge of structured sports participation in the pediatric population, spondylolysis is a common ailment that afflicts many young athletes due to rigorous competition that taxes the growing spine with repetitive extension and rotation. SUMMARY: Spondylolysis is a fracture through the pars interarticularis. When a child presents with lower back pain, spondylolysis should be at the top of the differential. A thorough history and physical examination are essential. In addition, radiographs of the lumbar spine, anterior posterior and lateral views, MRI and, selectively, computed tomography are useful adjuncts to uncover a pars injury. Timely diagnosis facilitates early treatment which includes rest, optimizing bone health, brace treatment, and physical therapy. If delayed or untreated, spondylolysis may result in nonunion or pars defect. If symptomatic, patients may need surgery to fuse the lumbar facet joints or repair the par interarticularis.

Radiographic analysis of the listhesis associated with lumbar isthmic spondylolysis.

BACKGROUND: In cases of spondylolysis, hypoplasia of L5 mimicking spondylolisthesis has been described, mainly based on MRI; however, the treatment implications have not been analyzed specifically. OBJECTIVE: Assess the impact of hypoplasia of the L5 vertebral body in the constitution of the spondylolisthesis associated with isthmic spondylolysis. MATERIAL AND METHODS: A retrospective radiographic study in the standing position was performed with 104 patients with L5 isthmic spondylolysis and 24 control subjects. RESULTS: Measurements of vertebral endplate length showed that the standard apparent posterior listhesis (APL) is made up of true listhesis (TL) and false listhesis (FL). FL is induced by hypoplasia of the L5 vertebral body relative to the S1 endplate. TL results from disk failure and leads to anterior listhesis (AL), which alters the balance of spinal curvatures. CONCLUSIONS: By integrating the potential for false listhesis into the classification systems for spondylolisthesis, we can adapt the treatment algorithms. TYPE OF STUDY: Retrospective radiography study. LEVEL OF EVIDENCE: IV Retrospective review of cases.

Acquired spondylolysis and spinopelvic sagittal alignment.

Acquired spondylolysis represents an uncommon complication of spine surgery, of an unknown incidence and etiology. We studied patients presenting this rare entity, with the purpose to investigate the incidence, imaging findings, patients' clinical characteristics, as well as to provide an interpretation of the mechanisms that may lead to this phenomenon. The presented working hypothesis, regarding etiology, suggests that there is a relation between variations in spinopelvic sagittal alignment and acquired spondylolysis. Between January 2010 and January 2015, six patients presented spondylolysis after short-segment transforaminal lumbar interbody fusion, at a mean time of 43 months after surgery. The preoperative intactness and postoperative defect of pars interarticularis were documented with computed tomography scans in all patients. Standard radiographical spinopelvic parameters were measured before and after surgery. The optimum values of lumbar lordosis (LL) and pelvic incidence minus lumbar lordosis modifier (PI-LL mismatch) were calculated as well. The incidence of acquired spondylolysis was 0.95% among patients with short-segment lumbar fusion. Patients presented high-grade PI with a vertically orientated sacral endplate, while LL was found 9° greater and PI-LL mismatch 9° lower than the respective optimum values, indicating a non-harmonized alignment. In conclusion, acquired spondylolysis, though rare, may occur in patients with high-grade PI and sacral slope, and suboptimal spinopelvic sagittal alignment after lumbar spine surgery, thereby highlighting the importance of detailed preoperative planning in spine surgery, along with the study of sagittal balance.

Lumbar spondylolysis: A report of four cases from two generations of a family.

Spondylolysis is a major cause of back pain in children and adolescents. The prevalence of spondylolysis depends on the sex, race, and congenital abnormality. These biases suggest hereditary predisposition as an etiology of spondylolysis. However, no conclusive evidence still exists regarding the inheritance for spondylolysis. Herein, we report rare cases with familial occurrence of lumbar spondylolysis. In two generations of a Japanese family, three brothers including identical twins complained of back pain related to sports activities. Clinical, radiographic, and computed tomographic examinations identified spondylolysis at L4 and L5 in all these boys. The father experienced long-term back pain and had spondylolisthesis at L4-L5 and healed spondylolysis at L5. The daughter and mother did not show any lumbar spondylolysis. The frequent development of spondylolysis at L4, a rarely affected segment, in four of six family members (66.7%) support that lumbar spondylolysis has an underlying genetic etiology, primarily autosomal dominant inheritance.

Management of Lumbar Conditions in the Elite Athlete.

Lumbar disk herniation, degenerative disk disease, and spondylolysis are the most prevalent lumbar conditions that result in missed playing time. Lumbar disk herniation has a good prognosis. After recovery from injury, professional athletes return to play 82% of the time. Surgical management of lumbar disk herniation has been shown to be a viable option in athletes in whom nonsurgical measures have failed. Degenerative disk disease is predominately genetic but may be accelerated in athletes secondary to increased physiologic loading. Nonsurgical management is the standard of care for lumbar degenerative disk disease in the elite athlete. Spondylolysis is more common in adolescent athletes with back pain than in adult athletes. Nonsurgical management of spondylolysis is typically successful. However, if surgery is required, fusion or direct pars repair can allow the patient to return to sports.

Benign Natural History of Spondylolysis in Adolescence With Midterm Follow-Up.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To use the Micheli Functional Scale to assess adolescent patients with spondylolysis treated conservatively at midterm follow-up. SUMMARY OF BACKGROUND: Spondylolysis is a common source of back pain for adolescents and is generally managed with bracing and physical therapy. There is little data regarding the results of conservative management of spondylolysis over time. METHODS: Four major academic pediatric institutions performed a retrospective chart review of patients from 5 to 21 years of age with the initial diagnosis of spondylolysis. Inclusion criteria were patients who initially underwent conservative management and had a minimum of 2 years' follow-up. The patients were contacted and asked to complete the Micheli Functional Scale Survey. RESULTS: A total of 295 patients with the diagnosis of spondylolysis were identified and contacted. Sixty-one subjects with spondylolysis completed the follow-up survey. Sixty of 61 respondents (98%) answered questions regarding their current pain level. Thirty-five of 60 (58.3%) reported no pain (0/10) and 47/60 (78%) rated their pain at 3 or less, whereas 22% (13/60) rated their pain as 4 or higher. There was no correlation with pain ratings on the follow-up survey and radiographic healing at initial management. Of the 61 patients, 50 returned to sports (82%), 8 did not return (13%), and 5 returned to most but not all of their sports (8%). No correlation was observed between radiographic healing and return to sports (p = .4885). CONCLUSION: Using a validated functional scale, this study demonstrated that with conservative management of spondylolysis a majority of patients at an average of 8 years out self-report a return to sports (90%), though many reported continued pain (42%) and interference with activities (67%). There was no correlation observed between radiographic evidence of healing and pain or return to sports with a mean follow-up of 8 years. LEVEL OF EVIDENCE: Multicenter retrospective case series.

Review of Pediatric Spondylolysis and Spondylolisthesis.

Pediatric spondylolysis and spondylolisthesis present with a wide spectrum of pathology and clinical findings, including back pain, leg pain, crouch gait, or neurological deficit. The treatment of spondylolysis alone is typically conservative with bracing, non-steroidal anti-inflammatory drug, and activity restriction, but refractory pain can be successfully surgically managed with intralaminar compression screw, wires, or pedicle screws with rods and laminar hook constructs. The treatment of dysplastic spondylolisthesis is aggressive to prevent neurological deficit, whereas even high-grade isthmic slips can be treated safely with nonoperative measures if no significant neurological deficits are present. However, patients with higher slip angles tend to progress and require fusion. More long-term data are needed to compare the outcomes of operative versus nonoperative treatment of high-grade slips. Although more evidence will be helpful in guiding surgical treatment, fortunately, the vast majority of these patients are successfully managed nonsurgically.

Treatment for spondylolysis and spondylolisthesis in children.

PURPOSE: To review outcome of 44 children who underwent conservative or surgical treatment for spondylolysis or spondylolisthesis. METHODS: Records of 25 male and 19 female children aged 5 to 14 (mean, 10.2) years who underwent conservative (n=39) or surgical (n=5) treatment for spondylolysis (n=19) or spondylolisthesis (n=25) were reviewed. Conservative treatment involved application of a thoracolumbosacral orthotic brace for all day except bedtime until symptoms resolved and then physiotherapy including exercises to strengthen the abdominal and back muscles and stretching exercises of the hamstrings and hip flexors. Surgery (instrumented posterolateral fusion [n=4] or Wiltse posterolateral fusion [n=1]) with allografts was indicated in patients with refractory pain (n=2) or nerve root irritation (n=1) and in patients with iatrogenic spondylolisthesis (n=2), followed by application of the brace for 3 months and then physiotherapy. Outcome was assessed using the Seitsalo scoring system. RESULTS: The mean follow-up period was 6.5 (range, 3-10) years. No patient developed any postoperative complication. Outcome was excellent in 35 patients, good in 8, and fair in one. All 5 patients who underwent posterolateral fusion for refractory spondylolisthesis achieved good outcome. In 11 patients with spondylolysis, the pars defect healed. None of the spondylolysis progressed to spondylolisthesis. All displacements remained stable, without any progression. CONCLUSION: Conservative treatment is effective for most patients with spondylolysis or spondylolisthesis. Instrumented posterolateral fusion is indicated in patients with persistent symptoms and for iatrogenic cases.

The effectiveness of surgical versus conservative treatment for symptomatic unilateral spondylolysis of the lumbar spine in athletes: a systematic review.

BACKGROUND: Spondylolysis is a common cause of low back pain in athletes. Historically, spondylolysis injuries were thought to be mostly bilateral; however advances in lumbar spine imaging have shown that in certain athlete groups, unilateral spondylolysis is highly prevalent. It remains unclear whether athletes with unilateral spondylolysis who undergo surgical repair are able to return to sports as effectively or faster than if they had conservative treatment. OBJECTIVES: To determine the effectiveness of surgical fixation performed after a trial period of conservative management, compared to the effectiveness of conservative management only for unilateral spondylolysis in athletes. TYPES OF PARTICIPANTS:   Athletes with symptomatic unilateral spondylolysis of the lumbar spine.  Types of intervention(s):  Surgical interventions which attempted a direct repair of the pars interarticularis, compared to conservative management.  Types of studies:  Experimental and epidemiological study designs were considered for inclusion. The majority of the studies reviewed consisted of descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies.  Types of outcomes:  The primary outcome of interest in this review was the ability to return to sport. The effectiveness of surgery on pain and overall function were secondary outcomes of interest. SEARCH STRATEGY: A three-step search strategy that aimed to find both published and unpublished studies was utilized. The search was limited to studies published in the English language between 1 January 1970 and 1 September 2013. METHODOLOGICAL QUALITY: The studies were critically appraised using one of the standardized critical appraisal instruments from The Joanna Briggs Institute. DATA COLLECTION: Details describing each study and results on effectiveness in promoting the outcomes of interest were extracted from papers included in the review using the standardized data extraction tool from The Joanna Briggs Institute. DATA SYNTHESIS: Due to heterogeneity in the included studies, the results for similar outcome measures were not pooled in statistical meta-analysis. A narrative and tabular format was used to synthesize the results of identified and included studies. RESULTS: Five studies reporting results for the outcomes of interest were critically appraised and included in the review. One study was a quasi-experimental design, while the other four were case series studies. Due to the paucity of data, studies were included regardless of whether their participants were exclusively athletes with unilateral spondylolysis or adults (athletes and non-athletes) with unilateral and bilateral spondylolysis. Sub-group analysis was used to distinguish the findings for the main participant group of interest, namely athletes with unilateral spondylolysis. CONCLUSIONS: The limited evidence on the effectiveness of surgical treatment versus conservative treatment for unilateral spondylolysis in athletes does not allow any conclusions to be drawn about the relative effectiveness of surgery versus conservative treatment for facilitating rapid return to sport or a high level of post injury sporting level/performance. It does suggest, however, that for adult athletes for whom conservative treatment has not been successful, surgery is likely to enable return to sport, reduce pain and promote overall function.

Surgical Management of 3-Level Lumbar Spondylolyses.

Three-level lumbar spondylolyses are extremely rare. So far, only 11 cases were reported in the literature. Treatment of multilevel spondylolyses has not been consistent. Conservative treatment is commonly considered first in most patients, but those who remain symptomatic may benefit from operative treatment. We report here 3 cases of 3-level lumbar spondylolyses that were treated successfully with direct isthmic repair in 2 cases and a combined surgery of isthmic repair and interbody fusion in 1 case. Our clinical results indicated that direct defect repair using the screw-hook technique is a simple and safe procedure for the motion segment with normal disc. If the involved disc shows degenerative change, fusion surgery should be consideredSurgical treatment of multilevel spondylolyses varies between fusion, direct isthmic repair, and combined management associating 2 procedures at different levels. The success of management of the 3 patients with 3-level spondylolyses depends on the choice of appropriate treatment for every patient.

What's new in pediatric orthopaedics.

This past year has seen an increase in the quality of studies in pediatric orthopaedics, and the completion of BrAIST demonstrated that high-level studies of important questions can be addressed in pediatric orthopaedics. The current commitment of improving quality of care for children promises a healthy future for pediatric orthopaedics.

Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review.

OBJECTIVE: To provide evidence-based data about the aetiology, incidence, diagnosis and treatment of isthmic lumbar spondylolysis and low-grade spondylolisthesis and return to athletic activities in fine athlete. DESIGN: This is a comprehensive literature review. A thorough MEDLINE search in the period from 1973 to 2014 with the keywords: athlete, spondylolysis, low-grade spondylolisthesis, treatment and return to athletic activities was conducted. RESULTS: A total of 228 articles were initially enrolled from the search, and 74 case series and reviews were finally included because they referred to incidence, diagnosis, treatment and return to play in fine athletes with symptomatic isthmic spondylolysis and low-grade (Meyerding I and II) spondylolisthesis. There were 13 studies reporting surgical treatment (194 patients of average age 19 years) and 14 studies with conservative treatment (589 patients of average age 15.7). The percentage of athletes who were successfully treated with conservative or operative treatment was 85 and 87.8%, respectively. CONCLUSION: Conservative treatment including physiotherapy and bracing is the mainstay in the treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in fine athletes. If consequent treatment fails, the operative treatment (pars repair and short fusion) is decided. Return to play following surgery varies from 6 to 12 months with prohibition in collision sports. Return to play is mostly depended on specific sport activity.

Effectiveness of three types of lumbar orthosis for restricting extension motion.

Spinal orthoses are implemented to restrict lumbar motion. Several studies have compared the effectiveness of various types of lumbar orthoses on restricting motion, but none have compared the effect of different back supports on restricting extension. This study sought to evaluate the effectiveness of three types of lumbar orthosis in regard to their ability to restrict motion during extension. Range of motion was quantified using the Spinal Mouse system to measure flexion and extension, and the load distribution of the back support was measured using a pressure sensor. Ten subjects (8 men, 2 women) were assessed under the following five experimental conditions: custom-made stay (CMS), aluminum stay (AS), plastic stay (PS), corset only, and no brace. None of the stays changed the flexion angle, and none of the supports prevented flexion bending. The mean extension angle after immobilization with the CMS, AS, PS, corset only, and no brace was 27.5° ± 8.5°, 33.4° ± 11.0°, 34.3° ± 9.4°, 37.8° ± 10.7°, and 42.6° ± 10.5°, respectively. The load in the CMS was concentrated at the vertical ends of the stay, with a mean load of 11.5 ± 2.4 N at the top and 8.9 ± 2.4 N at the bottom. The loads at the top and bottom of the support were 7.2 ± 4.3 and 5.3 ± 3.1 N with the AS and 5.8 ± 2.3 and 4.4 ± 1.7 N with the PS, respectively. All supports allowed similar flexion motion. Although the CMS, AS, and PS all restricted extension compared with no brace, the CMS was the most effective for restricting trunk extension motion.