Direct Repair of Symptomatic Lumbar Spondylolysis Using Rod-Screw-Cable System.

OBJECTIVE: To assess the efficacy of a new direct lysis repair technique using internal fixation with rod, screws, and Songer cable in symptomatic lumbar spondylolysis. METHODS: Between December 2015 and January 2020, patients who were diagnosed with symptomatic lumbar spondylolysis and surgically treated with a rod-screw-cable system were recruited. Pedicle screwing by the Magerl technique was performed in all included patients, followed by direct lysis repair with bone allograft and demineralized bone matrix by stabilizing the posterior lamina and spinous process using a rod-screw-cable system. Clinical outcome was measured using the visual analog scale and Oswestry disability index preoperatively and 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. RESULTS: Sixteen patients were included in this study-11 men and 5 women (mean age: 47 years; range, 26-67 years). The lytic defects were at L4 and L5 in 6 and 10 patients, respectively. The mean follow-up period was 41 months (24-62 months). The visual analog scale values were 7.3, 6.1, 4.3, 3.3, 2.1, and 1.9 preoperatively and 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively, respectively. The Oswestry disability index values were 59.8%, 55.4%, 41.7%, 32.4%, 21.1%, and 16.9% for the same periods, respectively. No patient had an increase in the slip after surgery. There were no significant complications such as implant failure. CONCLUSIONS: Our technique provides rigid intra-segmental repair of spondylolysis without intersegmental motion interference, even if the patient is older or has disc degeneration.

Incidence of lumbar spondylolysis in athletes with low back pain: A systematic evaluation and single-arm meta-analysis.

BACKGROUND: Low back pain (LBP) is a common chief complaint from athletes. Lumbar spondylolysis (LS) is a common sport injury. Severe LS is likely to cause spinal instability, resulting in lumbar spondylolisthesis or lumbar disc herniation, and even damage to the spinal nerve roots. The incidence of LS is approximately 5% in the adult population, and nearly half of young athletes with LBP are diagnosed with LS. This meta-analysis analyzed the incidence of LS in athletes with LBP. METHODS: PubMed, Embase, Cochrane (Cochrane Central Register of Controlled Trials), and Web of Science databases were systematically searched for published case report and retrospective analyses related to the topic from the date of database creation to January 1,2023. Relevant literature was screened and information extracted, and risk of bias was assessed for included studies using the methodological index for non-randomized-studies scale. Single-arm Meta-analysis was performed using R4.04 software. Heterogeneity was quantified by Cochran Q test and Higgins I2. Funnel plots were used to visualize publication bias, and Egger test and Begg test were used to statistical tests. RESULTS: A total of 9 studies (835 patients) were included in this study. Meta-analysis revealed that the prevalence of LS in athletes with LBP was estimated at 41.7%, [95% CI = (0.28-0.55)], but this prevalence varied considerably with the gender and age of the athletes. CONCLUSION: The estimated prevalence of LS in athletes with LBP is 41.7%, and future correlations between the prevalence of LS in adolescent athletes worldwide need to be assessed from different perspectives, including biomechanical, hormonal, anatomical, behavioral, and gender differences.

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.

Current Clinical Concepts: Management of Common Lumbar Spine Posterior Column Disorders in Young, Active Individuals.

Although posterior column disorders, such as spondylolysis and spondylolisthesis, are not commonly encountered in the general population, athletic trainers frequently see these conditions in athletic and active individuals due to the repetitive spinal extension and rotational loads placed on the pars interarticularis while participating in sport. Athletic trainers can successfully evaluate patients with posterior column disorders by performing a complete and comprehensive clinical examination to identify the location of pain, test spinal stability, and recognize compensatory movement patterns. Conservative management typically leads to a successful outcome in this population, with rest, bracing, and the use of therapeutic exercise having the best supporting evidence. In this Current Clinical Concepts review, we outlined the etiology and risk factors frequently associated with disorders of the posterior column. Additionally, we synthesized the literature for common evaluation techniques and interventions associated with the posterior column and provided a proposed rehabilitation progression to use in a younger, athletic population.

Clinical Results of Restoration of Pars Interarticularis Defect in Adults with Percutaneous Intralaminar Screw Fixation.

OBJECTIVE: This study aims to report the clinical outcomes associated with the percutaneous intralaminar screw repair performed for pars defects in adults. METHODS: Adult patients who got their lumbar L5 spondylolysis repaired via modified Buck's procedure between 2017 and 2020 were retrospectively evaluated. The preoperative and postoperative clinical outcomes at 1, 3, 6, and 12 months were evaluated for patients with and without fusion using the visual analog scale, Oswestry Disability Index, and the Short-Form Health Survey 36 (SF-36). At 12 months, the fusion status of all the patients was assessed using bilateral direct X-rays. RESULTS: Thirty patients with spondylolysis were identified (11 men and 19 women). All patients had bilateral L5 pars defects, and at 12 months, the fusion rate was 60% (18/30). There was no difference between the fusion and nonfusion groups in terms of their visual analog scale, Oswestry Disability Index, and SF-36 physical component summary and SF-36 mental component summary scores (P > 0.05). Within-group comparisons of the 2 groups revealed significant changes at follow-up (P < 0.05). CONCLUSIONS: Minimally invasive repair of lumbar spondylolysis with percutaneous intralaminar screw fixation restores the motion segment and can provide early resumption of physical activity with minimal muscle damage, smaller skin incision, and less soft tissue dissection.

Large Lumbar Lordosis and Coronal Deformity Angular Ratio Are Risk Factors for Adolescent Idiopathic Scoliosis in Patients With Lumbar Spondylolysis.

BACKGROUND: The features of lumbar curves in patients with lumbar spondylolisthesis (LS) are unclear. The aim of this retrospective study was to present the clinical and radiologic characteristics of scoliosis due to LS and LS concurrent with main thoracolumbar/lumbar adolescent idiopathic scoliosis (AIS). METHODS: This study was conducted as a single-center retrospective comparative study on 56 pediatric spondylolisthesis patients with main thoracolumbar/lumbar curves. Cases were divided into 2 groups according to the course of scoliosis after spinal surgery of LS. Sagittal spinopelvic parameters and scoliotic characteristics were compared between the 2 groups. RESULTS: The prevalence of scoliosis was 15.3% in pediatric LS patients in our study population. Lumbar lordosis (LL), Cobb angle, apical rotation, and coronal deformity angular ratio (C-DAR) were higher in the LS concurrent with AIS group than in the LS with functional scoliosis group (P < 0.05), while curve span, apical vertebral translation, and central sacral vertical line to C7 plumb line were lower (P < 0.05). Logistic regression analyses and receiver operating characteristic curves showed that LL and C-DAR were significant risk factors of unresolved lumbar curves after spinal surgery for LS, with a cutoff value of 51.5°and 3.5, respectively. CONCLUSIONS: Lumbar scoliosis may develop due to LS, or a concurrent condition to LS. LL and C-DAR are the features that differentiate AIS from functional scoliosis in patients with LS.

Frequency of Hypoplasia of the Vertebral Body at L5, and Its Relationship with Degeneration in Patients with Low Back Pain.

AIM: To explain the association between vertebral body hypoplasia and degenerative changes in the discovertebral complex and facet joints, and to assess the incidence of hypoplasia of the vertebral body at the L5 level. MATERIAL AND METHODS: A retrospective analysis was made of 3,100 patients aged 20?50 years who underwent lumbar MRI with a complaint of back pain, of which 55 were identified with vertebral body hypoplasia. Intervertebral disc degeneration was evaluated in the study using the Pfirrmann and Modified Pfirrmann classification systems, while degenerative changes in the vertebrae endplate were assessed using the Modic classification system. Osteoarthritis of the facet joint was graded at the L4-5 level, and spondylolysis and spondylolisthesis rates were compared between the control group and the hypoplasic group. RESULTS: The incidence of hypoplasia of the vertebral body at the L5 level was found to be 1.8% in the population with back pain in the 20?50-year age group. In the hypoplasia group, disc degeneration was detected at a higher rate than in the control group (p < 0.001). The distribution of Modic signal changes in the superior and inferior endplates of the vertebrae differed significantly between the hypoplasia and control groups (p < 0.001).The rate of spondylolysis was 7.7% in the control group and 65.5% in the hypoplasia group (p < 0.001), and spondylolisthesis was significantly more common in the hypoplasia group (18.4%, p < 0.001). In addition, facet joint degeneration was identified more frequently in the hypoplasia group. Degenerative findings were detected in 74.5% of the right posterior intervertebral joints, and in 70.9% of the left posterior intervertebral joints in the hypoplasia group. CONCLUSION: Vertebral body hypoplasia is a predisposing factor for disc degeneration, facet osteoarthritis and degeneration in the vertebral endplates, and has also been associated with spondylolysis and spondylolisthesis.

Association of spinal anomalies with spondylolysis and spina bifida occulta.

PURPOSE: To investigate the association of spinal anomalies with lumbar spondylolysis and spina bifida occulta (SBO). METHODS: A total of 1190 patients with thoracic, abdominal, and pelvic computed tomography scans available were categorized according to the number of presacral (thoracic and lumbar) mobile vertebrae and the presence or absence of lumbosacral transitional vertebrae (LSTV). The prevalence of spondylolysis and SBO and the association of spinal anomalies with these disorders were evaluated. RESULTS: Normal morphology (17 mobile vertebra with no LSTV) was found in 607 men (86.5%) and 419 women (85.9%) and about 14% of patients had anomalies. Spondylolysis was found in 74 patients (6.2%), comprising 54 men (7.7%) and 20 women (4.1%). SBO involving the lumbar spine was found in 9 men (1.3%) and 2 women (0.4%). Spondylolysis was significantly more common in men with 18 vertebrae without LSTV (21.1%) than in those with 17 vertebrae without LSTV (7.2%) (p = 0.002). The prevalence of spinal anomalies was 55.6% in men and 50.0% in women with SBO that included a lumbar level was significantly higher than in both men (13.5%, p < 0.001) and women (4.8%, p = 0.003) without SBO. CONCLUSION: These findings indicate that there is a relationship between spinal anomalies and both spondylolysis and SBO, which may lead to elucidation of the mechanism of onset of spondylolysis and improve its treatment and prognosis. Awareness that patients with SBO involving the lumbar spine have an increased likelihood of a spinal anomaly may help to prevent level errors during spinal surgery.

Spondylolysis of the Thoracic Spine with Instability: A Rare Cause for Myelopathy.

CASE: A 51-year-old lady with multiple comorbidities presented with T11 spondylolysis in association with thoracic stenosis and myelopathy. Our patient underwent T11-T12 laminectomy, T10-L1 posterior instrumented stabilization, and T11-T12 transforaminal interbody fusion. She had a good neurological recovery, and the radiographs at 1-year follow-up showed good fusion and implant position. CONCLUSION: Spondylolysis is an anatomical defect or stress fracture of the pars interarticularis and usually reported in the lumbar region. This case of T11 spondylolysis in association with thoracic stenosis, spinal instability, and myelopathy is highlighted for its rarity and to reiterate the need for high index of suspicion among surgeons for the timely diagnosis.

Lateral bending differentiates early-stage spondylolysis from nonspecific low back pain in adolescents.

BACKGROUND: Early-stage spondylolysis (ESS) is one of the common causes of acute low back pain (LBP) in adolescents. Although accurate diagnosis of ESS is important for providing appropriate treatment, differentiating ESS from other low back disorders is difficult by physical signs alone. OBJECTIVES: To elucidate the most common characteristic, namely, motion-provoking LBP, in patients with ESS. DESIGN: Retrospective comparative cohort study. METHOD: We included and categorized adolescents (n = 112; age, <18 years) with acute LBP (<1 month) into the ESS (n = 71) and nonspecific LBP (NS-LBP) (n = 41) groups based on magnetic resonance imaging (MRI) findings. Patients were evaluated using a visual analog scale (VAS), Oswestry Disability Index (ODI), and degree of pain using a numerical rating scale (NRS) provoked by hyperextension, hyperflexion, right and left rotations, and lateral bending in standing position.; the value were compared between the 2 groups. A cut-off value of significance was obtained using receiver operating characteristic (ROC) analysis. RESULTS: The mean scores for VAS and ODI and NRS of each test were as follows (ESS/NS-LBP): VAS, 6.5/6.0; ODI, 19.7/24.6; hyperextension, 4.1/4.1; hyperflexion, 2.4/3.0; rotation, 2.1/2.2; and lateral bending, 2.9/2.2. The ESS group had a significantly greater number of LBP cases provoked by lateral bending than the NS-LBP group. A cut-off lateral bending of 3.5 yielded a diagnosis of ESS. CONCLUSIONS: Our results indicate that lateral bending is the greatest motion-provoking characteristic of LBP in patients with ESS.

Gender Dysphoria and Chronic Pain in Youth.

Chronic pain in youth with gender dysphoria (GD) is poorly understood. The aim of our study was to review the clinical presentation of 8 youth with GD in a multidisciplinary chronic pain clinic. A single center retrospective chart review was conducted to obtain information on demographics, clinical care, previous diagnoses, and validated clinical measures. We present the trajectory of pain in this population with treatment of GD. Recognition and treatment of GD in youth with pain may improve pain outcomes.

Axial Low Back Pain in Elite Athletes.

Back pain in sport is a common complaint and seen by athletes, trainers, and treating physicians. Although there are a multitude of pain generators, mechanical sources are most common. Certain sports can lead to increased mechanical and axial loading, such as competitive weightlifting and football. Common mechanical causes of pain include disk herniation and spondylolysis. Patients typically respond to early identification and conservative treatment. In others, surgical intervention is required to provide stability and prevent long-term sequelae.

Age-Specific Characteristics of Lumbopelvic Alignment in Patients with Spondylolysis: How Bilateral L5 Spondylolysis Influences Lumbopelvic Alignment During the Aging Process.

BACKGROUND: To elucidate the influence of spondylolysis on age-related lumbar degenerative changes, age-specific lumbopelvic alignment in patients with or without spondylolysis was examined. METHODS: Sagittal reconstructed computed tomography images of the lumbar spine in consecutive patients (n = 581) undergoing computed tomography scans of abdominal or lumbar regions for reasons other than low back disorders were obtained. Lumbar lordosis (LL), L5-S1 angle, and sacral slope (SS) were measured. Lumbopelvic parameters in patients with or without spondylolysis were evaluated in 3 age groups (<50, 50-69, and ≥70). The influence of bilateral L5 spondylolysis (L5-lysis) and L5 vertebral slip on each lumbopelvic parameter, as well as correlation between cross-sectional area (CSA) of paraspinal muscles and the degree of vertebral slip, were examined by multiple regression analysis. RESULTS: Patients with bilateral spondylolysis showed greater LL and SS than patients without spondylolysis. When analyzing the influence of L5-lysis, only elderly patients (≥70) with L5-lysis showed significantly greater LL and SS than nonspondylolysis (nonlysis) patients. L5-lysis patients more frequently showed L5 vertebral slip than nonlysis patients, and a smaller L5-S1 angle was observed when L5 vertebral slip accompanied L5-lysis. The degree of vertebral slip was significantly correlated with CSA of psoas muscles, but not with CSA of paraspinal extensor muscles. CONCLUSIONS: When patients have L5-lysis, lumbar lordosis and pelvic anteversion occurred age dependently. In elderly patients with L5-lysis, L5 vertebral slip with decrease of the L5-S1 angle occurs frequently. The progression of vertebral slip was correlated with atrophy of psoas muscles, but not that of paraspinal extensor muscles.

Analysis of Clinical and Radiological Outcomes of Posterior Dynamic Stabilization for Direct Repair of Bilateral L5 Pars Interarticularis Defect: Dynamic Assessment of Pars Fusion.

AIM: To evaluate the satisfactory clinical and radiological outcomes of posterior dynamic stabilization for the direct repair of bilateral L5 pars interarticularis defects and pars fusion. MATERIAL AND METHODS: This is a retrospective evaluation of postoperative follow-up results of 13 patients with bilateral L5 pars interarticularis defects without spondylolisthesis. The patients underwent dynamic transpedicular stabilization between 2013 and 2018. Our surgical criteria included unilateral or bilateral L5 spondylolysis; excessive low back pain; low back pain accompanied by leg pain without neurological findings; symptoms lasting at least six months despite conservative treatments, age < 50 years; and lack of significant adjacent disc degeneration. RESULTS: There were seven female and six male patients with a mean age of 38.9 years. All patients achieved satisfactory postoperative results during a mean follow-up period of 22 months. Preoperative visual analog scale score and Oswestry Disability Index value were 8.85 ± 0.69 and 54.46 ± 7.62, respectively, which decreased to 1.31 ± 0.48 and 9.85 ± 3.51, respectively, at the postoperative 24th month. In all patients, the bony fusion of the pars interarticularis at the stabilized segment was confirmed on the computed tomography scan at an average of 22 months postoperatively. CONCLUSION: The posterior dynamic system ensures that the spine moves within physiological limits and carries the load by sharing it with the spine. The advantages of direct pars repair using our technique are the restoration of the posterior structures? normal anatomy, protection of the functional mobility segment, and early functional recovery without degeneration in the adjacent segment. Therefore, when there is no significant instability, patients with spondylolysis can be treated with posterior dynamic stabilization techniques with satisfactory clinical and radiological results.

Symptomatic Unilateral Pediculolysis Associated with Contralateral Spondylolysis and Spondylolisthesis in Adults-Case Report and Review of Literature.

BACKGROUND: The term "pediculolysis" encompasses rare, chronic pedicular changes characterized by pedicle hypertrophy, sclerosis, and pseudoarthrosis, which develop secondary to recurrent microfractures from repeated stress injuries. These stress injuries to pedicles can be insufficiency fractures, commonly reported in elderly patients with associated osteoporosis, or fatigue fractures, which occur in young adolescents involved in heavy sports. These pedicular lesions have been reported in association with defects in other components of the neural arch, including the pars interarticularis and lamina. CASE DESCRIPTION: We have described a rare case of grade 1 spondylolisthesis with left-sided pediculolysis and contralateral pars lysis in a middle-age female patient without associated osteoporosis or comorbidities. She underwent L5-S1 transforaminal lumbar interbody fusion after initial conservative measures had failed. However, her symptoms persisted even after the surgery and necessitated revision surgery, including left L5 medial pediculectomy, neurolysis of the left L5 nerve root, and extension of instrumentation to L4 bilaterally and L4-L5 posterolateral fusion. CONCLUSION: We have reported the present case to bring awareness to spine surgeons regarding the existence of this rare entity even in middle-age individuals. From our experience with the present patient, we believe that for patients with L5 pediculolysis and spondylolisthesis, the option of L5 medial pediculectomy and extension of instrumentation to L4 level should be considered.

Comparison of the sacral table angles by progression stage of lumbar spondylolysis.

STUDY DESIGN: Retrospective study. OBJECTIVES: The purpose of this study was to investigate sacral table angle (STA) values in early-stage spondylolysis. Several studies suggested that the STA of patients with L5 spondylolysis or spondylolisthesis was significantly lower than that of healthy controls. Separation of the pars interarticularis creates shear stress between the upper sacral end plate and L5 vertebra. This was considered the cause of low STA in patients with spondylolysis or spondylolisthesis. However, if a low STA value is obtained in the early stage of L5 spondylolysis, it suggests that low STA does not result in the remodeling of the sacral end plate. METHODS: Patients with L5 spondylolysis and those with low back pain without pars defect were retrospectively identified from a hospital database in 2014-2016. Pars defect of the spondylolysis was classified into three categories based on CT and MRI results: early, progressive, or terminal stage. The STA difference between groups was calculated using one-way analysis of variance and Scheffe F test, which were used for post hoc testing. RESULTS: A total of 84 cases of L5 spondylolysis and 70 cases of low back pain were identified. No significant difference was found between the STAs of the early- or progressive-stage spondylolysis and the terminal-stage L5 spondylolysis and low back pain patients. The STA of the terminal-stage L5 spondylolysis was significantly lower than that of low back pain patients. CONCLUSIONS: In conclusion, patients with early- or progressive-stage spondylolysis do not have low STA. Low STA is seen only in patients with terminal-stage spondylolysis, suggesting that low STA is associated with remodeling changes in response to shear force after onset of spondylolysis. STA value might not important as a prognostic parameter about development of the spondylolysis. LEVEL OF EVIDENCE: Level IV.

Evaluating low back pain in adolescents.

Low back pain in adolescents is a common complaint in primary care. With an average prevalence rate of 40%, adolescent low back pain correlates with greater healthcare use, higher incidences of adult back pain, and negative effects on overall well-being. A thorough history and physical examination can increase early detection and accurate diagnosis while ensuring the judicious use of diagnostic modalities. Although underlying serious pathology is rare in adolescents with low back pain, clinicians should recognize specific signs and symptoms that necessitate urgent evaluation and intervention. This article emphasizes the value of using a thorough history and physical examination to guide the initial diagnostic workup and to enhance the early detection and accurate diagnosis of adolescents who present with low back pain.

Bony stress in the lumbar spine is associated with intervertebral disc degeneration and low back pain: a retrospective case-control MRI study of patients under 25 years of age.

PURPOSE: Abnormal stress in the lumbar vertebra, also known as bony stress, can be a precursor to degenerative changes which may manifest as low back pain (LBP). However, the prevalence of bony stress in the lumbar spine and its relationship with degenerative changes and LBP is unclear. The purpose of this study was to evaluate the prevalence of bony stress in the lumbar spine and its relationship with intervertebral disc (IVD) degeneration, facet osteoarthritis and LBP in patients under 25 years of age. METHODS: A retrospective case-control study of 130 patients under 25 years of age was conducted from a population of 493 patients who had lumbar MRI across three imaging centres over three years. A cohort of 55 consecutive patients with bony stress was identified. A control group of consecutive patients (n = 75) without bony stress was also selected from the population. RESULTS: Bony stress was prevalent in 11% (95% CI [8.4-14.5%]) of patients and was not diagnosed in 36% (95% CI [22-55%]) of these cases. Patients with bony stress had over twofold (OR 2.3, 95% CI [1.1-4.8]) and fivefold (OR 5.3, 95% CI [2.11-13.3]) higher likelihood of having IVD degeneration and LBP, respectively, when compared with the control group. Bony stress was not found to be associated with facet osteoarthritis. CONCLUSION: Bony stress in the lumbar spine was prevalent in 11% of patients under 25 years of age. It was commonly undiagnosed in radiology reports (not reported in 36% of the cases). Being significantly associated and with an increased likelihood of IVD degeneration and LBP, we posit that bony stress is likely a symptomatic and clinically meaningful diagnostic entity in the assessment of LBP. These slides can be retrieved under Electronic Supplementary Material.