Acute lumbar spondylolysis in intercollegiate athletes.

STUDY DESIGN: A retrospective case series. OBJECTIVE: The purpose of this study was to describe a unique group of intercollegiate athletes who are skeletally mature and who developed symptomatic acute lumbar spondylolysis and to study long-term return to play outcome of nonoperative and surgical repair of L3 and L4 spondylolysis in skeletally mature athletes. BACKGROUND: Traditionally, symptomatic acute lumbar spondylolysis is a defect found in skeletally immature athletes, most commonly in the pars interarticularis of L5, less commonly in the L3/L4 region, and even less commonly in skeletally mature athletes as described in this group. METHODS: Eight intercollegiate athletes (2 women and 6 men, ages ranging from 19 to 21 y) with acute lumbar spondylolysis were diagnosed by means of computed tomography (CT) and single photon emission-CT bone scan. L3 lesions were present in 5 patients, and L4 lesions were present in 3 patients. All patients were treated initially nonoperatively with a protocol of bracing and activity modification. The healing progress was assessed through repeat CT scan. Patients who failed to respond to nonoperative procedures underwent direct repair of their pars defect through variable angle pedicle screw and sublaminar hook. Outcomes were measured by completion of the Oswestry Low Back Pain Disability Questionnaire (mean follow-up 6.5 y) and return to athletic participation. RESULTS: All patients successfully returned to full athletic competition. Two patients showed radiographic healing and resolution of pain following 3 months of nonoperative treatment. Five patients required surgical repair of the pars defect. All of these patients eventually returned to unrestricted participation in athletics. CONCLUSIONS: This study shows that this subgroup will generally respond well to surgical correction of the pars defect and return to uninhibited competition following conservative treatment and/or surgical repair.

Upper extremity stress fractures and spondylolysis in an adolescent baseball pitcher with an associated endocrine abnormality: a case report.

Lower extremity stress fractures are relatively common among competitive athletes. Stress fractures of the upper extremity, however, are rare and most have been reported in the literature as case reports. We present a case of an adolescent baseball pitcher who had both proximal humeral and ulnar shaft stress fractures, as well as spondylolysis of the lumbar spine. This particular patient also had an underlying endocrine abnormality of secondary hyperparathyroidism with a deficiency in vitamin D. A bone mineral density panel demonstrated a high T score (+2.79 SD above the mean) and the patient's biologic bone age was noted to be 2 years ahead of his chronologic age. The patient was treated with a course of vitamin D and calcium supplementation. After treatment, both the vitamin D and parathyroid hormone returned to normal levels. The upper extremity stress fractures and spondylolysis were managed conservatively and he was able to return to full activity and baseball. For patients who present with multiple stress fractures not associated with consistent high levels of repeated stress, a bone mineral density panel should be considered. If vitamin D deficiency is present, a course of oral supplementation may be considered in the management. An endocrinology consult should also be considered in patients who present with multiple stress fractures. Conservative management of upper extremity stress fractures and spondylolysis was successful in returning this patient back to his previous activity level.

Elite male adolescent gymnast who achieved union of a persistent bilateral pars defect.

An adolescent 15-yr-old male competitive gymnast presented to a university-based multidisciplinary spine institute with a persistent low-back pain for 18 mos. Although the results of x-rays were negative, his pain rendered him unable to compete in his sport any longer. A computed tomography scan was performed, which showed a bilateral pars fracture at L5, without spondylolisthesis. A nuclear medicine bone scan revealed negative findings, confirming chronic nonunion. The patient completed a 4-wk course of physical therapy 6 mos before our intervention, without any relief of pain or radiologic evidence of healing. The patient was treated with a bone stimulator for 4 hrs/day and was recommended to wear a warm-and-form-type brace. Isometric core trunk exercises were also initiated. Only after 6 wks of treatment, the subject showed clinical improvement at the follow-up visit. Computed tomography scan performed 12 wks after the initial scan showed complete union of the fracture correlating with clinical improvement. Two years later, the athlete remains completely pain-free, is training regularly, and is able to compete on a national and, possibly, international level.