- Bony defect at the pars interarticularis (the isthmus of bone between the superior and inferior facets)
- Can be unilateral or bilateral
- Bilateral form has a much higher likelihood of slippage or spondylolisthesis than the unilateral form
- The slipping forward of one vertebra upon another
- Spondylolysis can contribute to spondylolisthesis, which is noted in ∼5% of the population. It is 2–4 times more common in males.
- Of those with spondylolysis, 50% will have some degree of spondylolisthesis develop during their lifetime, and 50% of those will be symptomatic:
- Literature does not associate athletic activity with increased slippage.
- Spondylolisthesis predisposes to nerve root impingement and frequently sciatica.
- Type 1—dysplastic: Congenital defect of the neural arch or intra-articular facets is often associated with spina bifida occulta.
- Type 2—isthmic: Stress fracture from repetitive microtrauma through the neural arch
- Type 3—degenerative: Long-standing segmental instability
- Type 4—traumatic
- Type 5—pathologic: Leneralized or focal bone disease.
- Spondylolisthesis is divided into four grades based on degree of slippage (Meyerding grading system):
- Grade I: Up to 25% of the vertebral body width
- Grade II: 26%–50% of vertebral body width
- Grade III: 51%–75% of vertebral body width
- Grade IV: 76%–100% of vertebral body width
- The most common location for spondylolisthesis is L5 displaced on the sacrum (85%–95%), followed by L4 on L5.
- Spondylolysis is one of the most common causes of serious low back pain in children, although it is most often asymptomatic.
- Symptoms most often present during adolescent growth spurt from age 10–15 yr.
- Seen commonly in athletic teens; particularly in sports involving back hyperextension (eg, gymnastics, diving, football).
- Acute symptoms are related to trauma.
Unknown; theories include congenital pars anomalies, alterations in bone density, and recurrent subclinical stress injury.
Signs and Symptoms
- Onset often gradual, unless traumatic
- Often associated with feeling of stiffness or spasm in paravertebral muscles
- Pain in the back and proximal legs aggravated by standing and walking
- Sitting or forward bending relieves pain.
- Pain occurs after varying amounts of exercise, with standing, or with coughing:
- Aggravating factors can include repetitive hyperextending movements.
- Alleviating factors can include rest, although the course is variable and slow and usually requires sitting or stooping positions.
- Systemic/neurologic symptoms: minimal, unless there is significant trauma or “slip.”
- Hyperlordotic posture:
- Trunk may appear shortened.
- Rib cage approaches iliac crests.
- Hamstring tightness:
- Knees flexed to allow patient to stand upright
- Only “typical” finding is one-legged hyperextension:
- Standing on one leg and leaning backward reproduces pain on ipsilateral side.
- Palpation may reveal step-off with a prominent spinous process of L5 in significant spondylolisthesis.
- Neurologic exam is usually normal:
- If abnormal, pain and sensorimotor loss is in a dermatomal distribution.
- Consider herniation or spondylolisthesis.
- Spondylolysis in a child <10 yr is rare; these patients should be watched for:
- Constant pain lasting several weeks
- Pain occurring spontaneously at night
- Pain that interferes repeatedly with school, play, or sports
- Pain associated with marked stiffness, limitation of motion, fever, or neurologic signs
- Pain at the lumbosacral junction
Diagnostic Tests and Interpretation
There are no required laboratory studies.
- Lumbosacral spine radiographs:
- Lateral and oblique radiographs of spine most helpful.
- Spondylolysis will manifest as a radiolucent defect in the pars interarticularis, visible as a “collar” or “broken neck” on the oblique view “Scottie dog”:
- Secondary radiographic signs may include sclerosis of the contralateral pedicle and spina bifida occulta at the level of the spondylolysis.
- Majority (80%–95%) found at L5–S1 level, 15% at L4–L5.
- Spondylolisthesis will manifest as forward slipping of one vertebral body on another (seen on lateral view).
- Single photon emission computed tomography (SPECT)—better specificity for linking back pain to spondylolysis.
- CT scan:
- Pathology more clearly demonstrated than on plain films
- Can identify other spinal pathology
- Plays an important role for orthopedics in management decisions through identification of new stress fractures and healing of old stress fractures.
- If a CT scan is obtained in the ED, sagittal reconstructions should be performed and the CT scanner should be at minimum a 16-slice scanner.
- Outpatient evaluation unless history of recent trauma.
- MRI—exact role not yet clarified in literature:
- Useful for defining root impingement and foraminal narrowing.
- May be useful in the assessment of acuity of abnormality.
- Can identify alternate pathologic diagnoses.
- Lower threshold for ordering imaging studies.
- Progressive slipping more likely to occur than in adults.
- Tuberculosis (Pott disease)
- Bone or spinal cord tumor
- Retroperitoneal infection
- Injury to muscles or joints of back
- Congenital hip dislocation
- Ruptured intervertebral disc
- Vascular claudication
- Osteoid osteoma
Spinal precautions are not needed unless there is a history of recent trauma.
Vigorous attempts at traction should not be pursued.
- Pain control and muscle relaxants as clinically needed
- Supportive therapy if symptoms are mild
- Restrict activities if repetitive trauma is likely aggravating cause (eg, sports) for 3–6 wk, followed by reintroduction of activity when asymptomatic.
- Consider antilordotic braces (controversial) or physical therapy.
- Orthopedic consult or referral if symptoms are moderate to severe or unresponsive to supportive care
- Surgical intervention typically consists of spinal fusion in the flexed position:
- 50% of symptomatic patients with spondylolisthesis may require surgery.
- All symptomatic patients with grade III or IV spondylolisthesis should probably undergo surgery.
- Exercises are not of proven benefit.
- Activity restriction is not necessary if minimal or no symptoms.
- Literature suggests good outcome for young athletes with conservative treatment.
- Muscle relaxants:
- Example—methocarbamol: 1,000–1,500 mg PO q.i.d. (peds: safety and effectiveness for children <12 yr of age not established)
- Diazepam: 2–10 mg PO t.i.d. – q.i.d.
- Cyclobenzaprine: 5–10 mg PO t.i.d. (peds: safe for ages >15 yr old)
- Example—ibuprofen: 200–800 mg PO t.i.d.–q.i.d. (peds: 5–10 mg/kg PO q6h)
- Opioids (doses can vary on oral medications):
- Example—morphine sulfate: 0.1 mg/kg up to 2- to 4-mg increments IV.
- Acetaminophen/hydrocodone: 5/500 mg 1–2 tabs PO q.i.d.
- Acetaminophen/oxycodone: 5/325 mg 1–2 tabs PO q.i.d.
- Acetaminophen/codeine: 300/30 mg 1–2 tabs PO q.i.d. (peds: 0.5–1 mg/kg codeine PO q4–6h; max 60 mg per dose codeine; 1g per dose, 75 mg/kg/day up to 4 g/day >3 yr old)
- Inability to walk
- Inability to cope at home due to pain or social situation
- New or progressive neurologic deficit
- Orthopedic follow-up arranged
- Social support system in place
- Pain control
- Patient education
Close follow-up is mandatory.
- Castillo M, Mukherji S. Spinal imaging: Overview and update. Neuroimaging Clin N Am. 2007;7(1):92–93.
- Congeni J, McCulloch J, Swanson K. Lumbar spondylolysis. A study of natural progression in athletes. Am J Sports Med. 1997;25(2):248–253.
- Debnath UK, Freeman BJ, et al. Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes. J Bone Joint Surg. 2003;85(2);244.
- Iwamoto J, Takeda T, Wakano K. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports. 2004;14(6):337.
- Miller SF, Congeni J, Swanson K. Long-term functional and anatomical follow-up of early detected spondylolysis in young athletes. Am J Sports Med. 2004;32(4):928.
- Nachemson A. Newest knowledge of low back pain. Clin Orthop. 1992;279:8.
- Satndaert CJ. Spondylolysis. Phys Med Rehab Clin North Am. 2000;11(4):785–801.
- Skinner H. Disorders, diseases and injuries of the spine. In: Current Diagnosis and Treatment in Orthopedics. Norwalk, CT: Appleton & Lange, 1995:206–211.
- Vitek G. Spine conference spondylolysis and spondylolisthesis. Ortho News Mag. May 1995. Available at: http://www.nmis.com/onm/html/sponconf-spon.htm.
- Weinstein J, Wiesel S. Lumbar and lumbosacral spondylolisthesis In: The Lumbar Spine: The International Society for the Study of the Lumbar Spine. Philadelphia: Saunders, 1990:471–545.
- 738.4 Acquired spondylolisthesis
- 756.11 Congenital spondylolysis, lumbosacral region
- 756.12 Spondylolisthesis, congenital
- 240221008 spondylolysis (disorder)
- 80712009 congenital spondylolysis of lumbosacral region (disorder)
- 274152003 spondylolisthesis (disorder)
- 13236000 congenital spondylolisthesis (disorder)
Lisa G. Lowe Hiller
© Wolters Kluwer Health Lippincott Williams & Wilkins
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