Spondylolysis–Updateon* Diagnosis&Management

Spondylolysis – Update on Diagnosis & Management David W. Kruse, M.D. Orthopaedic Specialty Ins@tute Team Physician -‐ University of California, Irvine Team Physician & Medical Task Force Member -‐ USA Gymnas@cs

DISCLOSURE Neither I, David Kruse, nor any family member(s), have any relevant financial rela
Spondylolysis -‐ Update GOALS & OBJECTIVES 1.  Review of Prevalence & Anatomy 2.  Review/Update controversial aspects of spondylolysis: –  Diagnos@c Imaging –  Bracing

3.  Review goals of rehabilita@on 4.  Review return to play decision-‐making

(1,2,9,13,14,19) Introduc@on

•  Unilateral or Bilateral Defect – Pars Interar@cularis •  Pars Interar@cularis – junc@on of pedicle, ar@cular facets, lamina •  Defect at L5 in 95% of cases •  Prevalence –  General Popula@on: 3-‐10% –  Athle@c Popula@on: 23-‐63%

•  Gymnas@cs, Football, Weight Liìng, Rowing, Volleyball

•  Adolescent Athletes:

–  Most common cause of back pain(13,19)

Anatomy of a Pars Defect

PARS INTERARTICULARIS LAMINA

[www.eorthopod.com]

[Neder Photos]

(1,3,9,13) Pathophysiology •  Mul@factorial –  +/-‐ Pre-‐exis@ng Dysplasia –  Repe@@ve Microtrauma •  Hyperextension, Rota@on, Hyperlordosis

•  Predisposing factors: –  Hyperlordosis, Thoracic kyphosis –  Iliopsoas inflexibility, Thoracolumbar fascial @ghtness –  Abdominal weakness –  Female athlete triad

•  Bony Impingement – Pars of L5 sheared by Inferior ar@cular process L4 and superior ar@cular process S1

Pathophysiology •  Other predisposing factors: –  Hyperlordosis –  Iliopsoas inflexibility –  Thoracolumbar fascial @ghtness –  Abdominal weakness –  Thoracic kyphosis –  Female athlete triad

•  Bony Impingement – Pars of L5 sheared by Inferior ar@cular process L4 and superior ar@cular process S1

Anatomy of Bony Impingement

BONY IMPINGEMENT

(12,13,14,19,20,25) Clinical Presenta@on

•  Three Classic Pa@ent Types:(13,25) 1.  Female, Hyperlordo@c, Hypermobile 2.  Male, Hypomobile/Inflexible, Tight paraspinal 3.  New to a sport, decondi@oned, poor core

Clinical Presenta@on •  Examina@on: –  Hyperlordosis –  Hamstring inflexibility –  Pain on extension (add side-‐bending to affected side -‐ Kemp Test) –  Lumbosacral tenderness and muscle spasm –  Stork test: low specificity(14,20), low sensi@vity(19) –  Various other func@onal/provoca@ve tests(19)

Clinical Exam Sundell, Int J Sports Med, 2013(19) •  Prospec@ve Case Series – Ability of clinical tests to dis@nguish between causes of back pain •  Subjects: –  25 in Case group: >3 weeks LBP, 13-‐20yo, 56% Male –  13 in Control group

•  Methods: –  Both groups: •  Clinical exam protocol •  All underwent MRI L-‐spine

–  Case group: CT of L4/L5

(19) Sundell, Int J Sports Med, 2013

•  Clinical Exam Protocol:

–  Gait padern –  Inspec@on – scoliosis, lordosis, LLD, etc. –  Palpa@on –  Neurological examina@on –  Func@onal tes@ng –  Mul@ple provoca@ve tests (Stork, Percussion, Spring, Coin, Hook/Rocking tests)

•  Results:

–  No clinical test, alone or in combina@on, could dis@nguish between spondy and other e@ologies

Spondylolysis -‐ Imaging

Leone Skeletal Radiol 2011

Imaging Controversy •  Despite spondylolysis being a well recognized and published condi@on for decades...we s@ll don’t have a consensus on imaging…due to the pros and cons for each modality, radia@on exposure in adolescent spines, and growing technology helping MRI to poten@ally become a more sensi@ve op@on.

(1,5,9) Imaging – Radiography

•  A/P and Lateral – Eval DDX & Listhesis •  Oblique – Observe radiolucent pars defect: –  Acute: Narrow, irregular –  Chronic: Smooth, Rounded

•  Appreciable on Lateral view if listhesis present Leone Skeletal Radiol 2011

Imaging -‐ Radiography •  U@liza@on of Oblique Images –  Pro: •  Poten@al for quick confirma@on of clinical suspicion •  If seen – characterize chronicity

–  Con: •  Low sensi@vity –  Miss occult and early stress lesions

•  Addi@onal radia@on •  Most prac@@oners likely to u@lize secondary imaging regardless

Radia@on Exposure(9)

(mSv = milisievert, measurement of radia@on dose)

•  •  •  •  • 

U.S. Natural Background Exposure: 3 mSv/year Chest X-‐ray: 0.1 mSv L-‐Spine X-‐ray, 6 View: 1.5 mSv SPECT: 5 mSv CT: 10-‐20 mSv

(1,5,6,9,12,16) Imaging -‐ SPECT

•  Pros: –  High Sensi@vity and can localize lesion Leone Skeletal Radiol 2011 –  Early diagnosis of ac@ve lesions –  Differen@ate between Acute & Chronic Non-‐ Union: •  Increased Signal: Osseous ac@vity/Healing Poten@al •  Absence of Signal: Nonunion/Low Healing Poten@al

–  Correlates with pain e@ology (improved treatment outcomes16)

Imaging -‐ SPECT •  Cons: –  Poor Specificity -‐ poten@al for false posi@ves •  Posi@ve SPECT shown in asymptoma@c athletes •  DDx for Posi@ve Bone Uptake – Infec@on, Tumor, Arthri@s

–  Radia@on exposure, intravenous injec@on, increased @me for comple@on –  Cannot detect chronic non-‐union –  Cannot dis@nguish if incomplete fx is in healing (osteoblas@c) or developing (osteoclas@c) phase

(9) Imaging -‐ SPECT

→ Due to low specificity, a posi@ve SPECT needs to be followed up with targeted CT imaging →Because of increasingly reliable MR sequencing and the amount of radia@on exposure from combo SPECT & CT scanning, there are increasing recommenda@ons to abandon SPECT screening.


Imaging – Computed Tomography (1,2,5,6,9,14)

•  Pros: Iden@fy anatomical details of a pars defect –  Complete or Incomplete Pars Fracture: •  Most Sensi@ve & Specific independent imaging modality

–  Can help stage the chronicity of the lesion: •  Wide/Sclero@c – Chronic •  Narrow/Non-‐cor@cated margins -‐ Acute

–  Evaluate bony healing, surgical planning –  More specific than SPECT

Imaging – Computed Tomography •  Cons: –  Radia@on exposure –  Not good at:


•  Ac@ve vs. Inac@ve fracture •  Early Stress Reac@on – No Cor@cal Defect

–  Limited evalua@on of associated condi@ons and other differen@al diagnosis

(2,9) Imaging -‐ CT Op@ons

•  Reverse-‐Angle Gantry CT: –  Perpendicular to Pars Lesion(2) –  Decreasing use due to advances in CT technology

•  Newer Technology: –  Rapid, Thin-‐Slice –  Increased anatomical coverage –  Higher spa@al resolu@on –  Sagidal Reconstruc@ons → Results in: High resolu@on 2D reforma@ons, 3D Leone Skeletal Radiol 2011 Rendering

(9,13) Imaging -‐ SPECT + CT

•  Combina@on –  SPECT: highest sensi@vity for bone ac@vity –  CT: highest anatomical specificity

•  Neg CT + Pos SPECT: –  Stress response, Pre-‐lysis –  Early incomplete → Good prognosis for healing and bony union

•  Pos CT + Neg SPECT: –  Non-‐union chronic lesion

(1,5,9,10,11,13,14,24) Imaging -‐ MRI

•  Pros: –  Sensi@ve for early ac@ve lesions –  Reliable for: •  Early/Stress lesions •  Acute complete lesions •  Chronic lesions Leone Skeletal Radiol 2011 –  Absence of radia@on –  Visualiza@on of other spinal disorders

Imaging -‐ MRI •  Cons: –  Lower Sensi@vity – Mostly involving Incomplete Fractures(9,24) –  Lacks ability to grade the lesion, detect bony healing –  Dunn, Skeletal Radiol, 2008(11) •  Compara@ve study of incomplete fxs – MRI vs. CT •  MRI: Limited ability to fully depict cor@cal integrity

Imaging -‐ MRI •  Highly dependent on sequencing…some of the poor sensi@vity documented in the literature poten@ally due to inadequate sequencing: –  Sequencing best suited for other dx (disc) –  Slice thickness inadequate –  Not mul@planar –  Limited edema sensi@ve sequencing

(9,13,14) Imaging -‐ MRI Sequencing

•  Ideal Sequencing: 1.  Edema Sensi@ve – STIR Images (T2 Fat Sat) • 

Visualize bony edema: Ac@ve & Early lesions

2.  Cortex (Marrow) Sensi@ve – T1 (or T2) Non Fat Sat •  • 

Visualize fracture Good for anatomy – Seeing cor@cal bone, high contrast between marrow and signal void of disrupted cortex

3.  Mul@planar – Axial, Sagidal, Coronal Oblique 4.  Thin Slice – ≤ 3mm

MRI – Complete Fracture Leone Skeletal Radiol 2011

T2 – Fat Sat: Edematous Change

T1 Sequencing: Complete Fx Cle`

MRI -‐ Incomplete Fracture

STIR Sequence: Edematous Change

T1 Sequence: Defect Inferior Cortex


CT Imaging: Incomplete Cle` Pedicle

(10) Hollenberg, Spine, 2002 •  Proposed Classifica@on System: –  Grade 0: Normal Pars –  Grade 1: Stress Reac@on – Marrow Edema, Intact Cortex –  Grade 2: Incomplete Stress Fx – Marrow Edema, Incomplete Cortex Fx –  Grade 3: Acute Complete Fx – Marrow Edema, Complete Pars Fx –  Grade 4: Chronic Fx – No Marrow Edema, Complete Pars Fx

•  Dis@nguishes: –  Stress Rxn vs. Ac@ve Fracture vs. Inac@ve Fracture

MRI – Early Acute Lesions Kobayashi, AJSM, 2013(14) •  Prospec@ve study to assess the use of MRI for detec@on of early ac@ve spondy lesions •  Document MRI diagnosis in those cases occult on x-‐ray •  200 athletes with LBP, Ages 10-‐18, 72% Male: –  Unclear or No findings on X-‐ray •  96% No Findings, 6% Unclear Findings

–  MRI performed on all 200 athletes •  Sag T2, Sag STIR, Axial T1, Axial T2, Axial STIR, 4-‐5mm slices

–  CT performed as follow-‐up to MRI if edema present

(14) Kobayashi, AJSM, 2013

•  Results: –  MRI – Noted spondy in 97 of 200 athletes (48.5%) –  Follow-‐up CT – 92 of 97 posi@ve MRI cases: •  Nonlysis Lesions: 43% •  Early Stage: 49% •  Progressive Stage: 8% •  Terminal Stage: 0%


(14) Kobayashi, AJSM, 2013

•  Discussion: –  MRI useful in recogni@on of early ac@ve spondy –  Recommend: •  Use of MRI for ini@al screening aèr nega@ve x-‐ray •  For posi@ve MRI -‐ Should have localized CT for staging

–  No comparison to SPECT regarding sensi@vity for early ac@ve lesions –  For the 51.1% with nega@ve MR: •  No follow up CT → No MRI vs. CT sensi@vity comparison

Addi@onal MRI Compara@ve Studies •  Campbell, et al. Skeletal Radiol, 2005(24) –  Compared MRI to SPECT+CT

•  Concluded Effec@ve & Reliable first-‐line imaging modality •  Concluded MRI can replace SPECT •  Not adequate for grading incomplete defects (3-‐4mm Slices)

•  Masci, et al. BJSM, 2006(20)

–  Compared MRI to SPECT only, CT only, & SPECT+CT

•  MRI equal to CT in detec@on of defect (did not specify complete vs. incomplete) •  MRI decreased sensi@vity compared to SPECT for stress lesion •  Concluded MRI inferior to SPECT+CT for general detec@on of all types of lesions •  High rate in this study of MRI false nega@ves •  MRI sequencing – larger slice thickness, limited planes

(19) Sundell, Int J Sports Med, 2013 •  Prospec@ve Case Series •  Methods: –  Case & Control groups:

•  MRI L-‐spine •  Sag T1, Sag T2, Cor STIR •  Slice thickness not men@oned, No Axial Views

–  Case group: Also received CT of L4/L5, thin-‐slice

•  Results:

–  22/25 case athletes had posi@ve MRI findings –  13/25 case athletes: +MRI Ac@ve Spondy –  Personal communica@on with author:

•  Athletes in case group with (–)MRI for Spondy also had (–)CT

(9) MRI – Ancillary Findings

•  Aid in diagnosis: –  Widened sagidal diameter of spinal canal –  Posterior vertebral body wedging – Lumbar Height Index •  Effect of spondylolisthesis vs. predisposing factor •  Present in cases of spondy without listhesis

–  Reac@ve edema in pedicle adjacent to pars defect

•  Direct Findings + Ancillary Findings → MRI approaches a similar Sensi@vity as CT.

Synopsis of Imaging Debate •  Posi@ves and Nega@ves for all •  Important to know the limita@ons of your imaging op@ons •  Important to know the imaging techniques and sequences u@lized by your imaging centers -‐ MRI

(9,13) Synopsis of Imaging Debate

•  Reasons for SPECT/CT: –  Confidence in the combina@on of: •  Sensi@vity (SPECT) and specificity (CT)

–  MRI nega@ve & athlete not responding to current plan of care –  MRI contraindicated –  Ideal MRI sequencing not available

•  Follow-‐up CT: Grading necessary, assess bony healing

Synopsis of Imaging Debate •  MRI as first-‐line?: –  Visualize stress reac@ons, Acute and Chronic lesions –  No radia@on in pediatric popula@on –  Rule out other pathology –  Know capabili@es of your imaging center

•  MRI’s downside: Lower sensi@vity for incomplete fractures, can’t assess bony healing or grade of the lesion

Poten@al Imaging Protocol •  Clinical Exam + Lumbar X-‐ray (AP & Lat) •  Ini@al screen with MRI: –  Sensi@ve for early ac@ve lesions –  Iden@fy ac@ve vs. inac@ve lesions –  Localize pathology –  Rule out other differen@al diagnosis –  Minimize Radia@on

•  Localized CT -‐ for posi@ve Spondy on MRI: –  Staging of lesion –  Baseline for follow up imaging – bony healing

Spondylolysis -‐ Management

Conserva@ve Management •  Overall:

–  Rest from sport – stop repe@@ve extension/rota@on –  Achieve pain-‐free status •  Rest period with or without bracing

–  Rehabilita@on –  Return to Play transi@on

•  Debate:

–  Ini@al length of @me restricted from sport –  Bracing: •  Decision to u@lize bracing •  Type of brace

–  Time course for full return to sport

Spondylolysis -‐ Bracing(1,5,6,7,8,9,12,17,18) •  Types of Braces:

–  Thoraco-‐lumbar-‐sacral orthosis (TLSO) – an@lordo@c –  Lumbo-‐sacral orthosis (LSO) –  Corset/So` Brace

•  Controversy:

–  Lack of controlled studies – ques@on efficacy –  Similar outcomes despite type of brace •  Maintain lordosis vs. An@lordo@c •  So` corset vs. Hard Shell Ortho@c

–  Bony healing with and without bracing –  Is it the immobiliza@on or the forced compliance with ac@vity restric@on?

Spondylolysis -‐ Bracing(1,5,6,7,8,9,12,17,18) •  Controversy: –  Lack of controlled studies – ques@on efficacy –  Similar outcomes despite type of brace •  Maintain lordosis vs. An@lordo@c •  So` corset vs. Hard Shell Ortho@c

–  Bony healing with and without bracing –  Is it the immobiliza@on or the forced compliance with ac@vity restric@on?

Spondylolysis -‐ Bracing •  Historical Perspec@ve: –  Steiner/Micheli, 1985(7): documented success with bracing protocol •  6 months, 23 hrs/day •  6 months wean from brace

–  Jackson/Wiltse, 1981(18): documented success with ac@vity restric@on only, no bracing

Referenced Bracing Strategy(13,22,23) d’Hemecourt, Orthopaedics, 2000(23) Micheli , Clin Sports Med, 2006(22)

•  Ini@al:

–  Removed from sport, Boston brace 23hrs/day –  Begin physical therapy

•  4 to 6 weeks:

–  If pain-‐free & progressing well in PT •  Return to sport in brace

•  4 months:

–  If bony healing or pain-‐free nonunion: wean brace –  If pain and no healing: consider bone s@m

•  9-‐12 months:

–  If persistent pain and nonunion: surgical fixa@on

(5,7,8,9) Addi@onal Brace Parameters

•  If acute, (+)SPECT/MRI & (-‐)CT: –  3-‐6 months –  Rest from aggrava@ng ac@vity –  Adempt bony healing –  Most recommend brace for acute lesions: mul@ple proposed strategies

•  Chronic Lesions: –  Rest un@l pain-‐free, no brace, then start other conserva@ve measures –  Brace if can’t become pain-‐free

Bracing Literature Update

Sairyo K, J Neurosurg Spine, 2012(15) •  Examine which spondylolysis lesions will go on to bone healing with bracing and how long it takes –  63 pars defects, 37 pa@ents, Ages 8-‐18 –  Followed for bony healing with bracing –  CT & MRI performed: •  Early, Progressive High Signal (MR edema), Progressive Low Signal (no MR edema), Terminal

–  Brace: molded plas@c TLSO –  Repeat CT at 3mo and 6mo

Sairyo K, J Neurosurg Spine, 2012(15) •  Results:

–  Early – 94%, 3.2 mo –  Progressive/High Signal – 64%, 5.4 mo –  Progressive/Low Signal – 27%, 5.7mo –  Terminal – 0%

•  Supports early (CT stage) and ac@ve (MR edema) lesions have best prognosis for bone healing •  Limita@ons:

–  No non-‐braced control group –  Study looking at bone healing, not pain relief or return to sport

(5,12,13) Spondylolysis Rehabilita@on

•  General Principles: –  Start early –  In conjunc@on with pain reducing stage –  Progress through generalized range of mo@on and spine stabiliza@on –  Kine@c chain assessment & resistance training –  Sport-‐specific retraining

Rehabilita@on of the Gymnast (Courtesy of Dr. Larry Nassar -‐ USAG Medical Director)

•  Phase 1: Ini@ate at @me of Dx –  Neutral Spine -‐ Correct Imbalances/Core Stability •  Phase 2: Starts when pain-‐free –  Start into extension, strengthening in extension •  Phase 3: Once tolera@ng extension in PT –  Start sport-‐specific extension work in the gym •  Phase 4: Final progression –  Gymnas@cs-‐specific progression, finish correc@on of baseline imbalances/mechanical deficiencies

Rehabilita@on of the Gymnast •  Common deficiencies in the gymnast: –  Shoulder & Thoracic mobility restric@ons –  Lower Crossed Syndrome: •  Hip flexor/quad/IT band/erector spinae flexibility •  Gluteus medius and core strength

–  Dyskine@c posterior chain firing paderns •  Hamstring, Gluteus, Erector spinae

Kruse, CSMR, 2009

Rehabilita@on of the Gymnast (Courtesy of Dr. Larry Nassar -‐ USAG Medical Director)

Natural Progression Spondylolisthesis(1,4,5,13) •  Bilateral Pars Defect

–  70% associated listhesis –  Cases of low-‐grade slippage have 5% risk of progression

•  Fortunately low documented risk of progression in athletes •  Highest Risk for Progression –  >50% slippage at diagnosis –  Skeletally immature or <16yo –  Significant decreased risk with increased age

•  Follow-‐Up – Skeletally Immature –  Lateral Radiographs Q6-‐12mo

(21) Return To Play

•  Successful comple@on of a comprehensive physical therapy program •  Can accomplish full and pain-‐free range of mo@on •  Return of sport-‐specific strength and aerobic fitness •  Able to perform sport-‐specific skills without pain

References 1.  Foreman P, et al. L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus. Childs Nerv Syst. 2013;29:209-‐16. 2.  Harvey CJ, et. The radiological inves@ga@on of lumbar spondylolysis. Clin Radiol. 1998;53:723-‐28. 3.  Standaert CJ, Herring SA. Spondylolysis: a cri@cal review. Br J Sports Med. 2000;34:415-‐22. 4.  Muschik M, et al. Compe@@ve sports and the progression of spondylolisthesis. J Pediatr Orthop. 1996;16:364-‐9. 5.  Kruse D, Lemmen B. Spine Injuries in the Sport of Gymnas@cs. Curr Sports Med Rep. 2009;8:20-‐28. 6.  Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil. 2007;88:537-‐40.

References 7.  Steiner ME, Micheli LJ. Treatment of symptoma@c spondylolysis and spondylolisthesis with the modified Boston brace. Spine. 1985;10:937-‐40. 8.  Standaert CJ. New Strategies in the management of low back injuries in gymnasts. Curr Sports Med Rep. 2002;1:293-‐300. 9.  Leone A, et al. Lumbar spondylolysis: a review. Skeletal Radiol. 2011;40:683-‐700. 10.  Hollenberg GM, et al. Stress reac@ons of the lumbar pars interar@cularis: the development of a new MRI classifica@on system. Spine. 2002;27:181-‐6. 11.  Dunn AJ, et al. Radiological findings and healing paderns of incomplete stress fractures of the pars interar@cularis. Skeletal Radiol. 2008;37:443-‐50. 12.  Kim HJ, Green DW. Spondylolysis in the adolescent athlete. Curr Opin Pediatr. 2011;23:68-‐72.

References 13.  McCleary MD, Congeni JA. Current concepts in the diagnosis and treatment of spondylolysis in young athletes. Curr Sports Med Rep. 2007;6:62-‐66. 14.  Kobayashi A, et al. Diagnosis of Radiographically Occult Lumbar Spondylolysis in Young Athletes by Magne@c Resonance Imaging. Am J Sports Med. 2013;41:169-‐76. 15.  Sairyo K, et al. Conserva@ve treatment for pediatric lumbar spondylolysis to achieve bone healing using a hard brace: what type and how long? J Neurosurg Spine. 2012;16:610-‐14. 16.  Raby N, Mathews S. Symptoma@c spondylolysis: correla@on of ct and spect with clinical outcome. Clin Radiology. 1993;48:97-‐99. 17.  Steiner M, Micheli L. Treatment of symptoma@c spondylolysis and spondylolisthesis with modified Boston brace. Spine. 1985;10:937-‐43. 18.  Jackson D, Wiltse L. Stress reac@on involving the pars interar@cularis in young athletes. Am J Sport Med. 1981;9:304-‐112.

References 19.  Sundell C-‐G, et al. Clinical Examina@on, Spondylolysis and Adolescent Athletes. Int J Sports Med. 2013;34:263-‐67. 20.  Masci L, et al. Use of the one-‐legged hyperextension test and magne@c resonance imaging in the diagnosis of ac@ve spondylolysis. Br J Sports Med. 2006;40:940-‐46. 21.  Eddy D, Congeni J, Loud K. A Review of Spine Injuries and Return to Play. Clin J Sport Med. 2005;15:453-‐58. 22.  Micheli L, Cur@s C. Stress fractures in the spine and sacrum. Clin Sports Med. 2006;25:75-‐88. 23.  d’Hemecourt P, et al. Spondylolysis: returning the athlete to sports par@cipa@on with brace treatment. Orthopaedics. 2002;25:653-‐57. 24.  Campbell R, et al. Juvenile spondylolysis: a compara@ve analysis of CT, SPECT and MRI. Skeletal Radiol. 2005;34:63-‐73. 25.  Congeni J. Evalua@ng spondylolysis in adolescent athletes. J Musculoskel Med. 2000;17:123-‐29.

Contact Informa@on •  David W. Kruse, M.D. •  Orthopaedic Specialty Ins@tute –  Orange, CA –  714.937.4898

•  [email protected]

Spondylolysis*–Update*on* Diagnosis*&*Management

Spondylolysis–Updateon* Diagnosis&Management