Low back pain in a young athlete.
An athletic office worker presented with acute onset low back pain after lifting some office furniture. The pain was non-radiating and localised to the lower lumbar spine. Clinical examination was unremarkable. Lumbosacral plain radiography revealed a left L5 pars defect (Fig. 1).
The pain improved after a period of immobilisation in a corset. The patient continued his sporting activities. He re-presented 18 months later with persistent low back pain similar to the initial presentation. Repeat plain radiography and a CT examination of the lumbar spine (Fig. 2) showed bilateral L5 pars defects.
Spondylolysis is a defect in the pars interarticularis believed to be due to stress fracture,secondary to chronic low-grade trauma from repetitive spinal hyperextension and rotation.It occurs most commonly at the L5 level (1).The incidence rises with certain sporting activities. Pars defects are commonly asymptomatic and may be an incidental finding associated with other causes of low back pain.However the defect is a recognized cause of low back pain. Wiltse et al.have classified Spondylolysis and Spondylolisthesis, as follows (2): I Dysplastic: Congenital abnormalities of the upper sacrum or the arch of L5 permit the olisthesis to occur. II Isthmic: The lesion is in the pars interarticularis. Three types can be recognised. (a) Lytic-fatigue fracture of the pars, (b) Elongated but intact pars, (c) Acute fracture. III Degenerative: Due to long-standing intersegmental instability. IV Traumatic: Due to fractures in other areas of the bony hook than the pars. V Pathological: There is generalised or localised bone disease. Isthmic Type IIc (Acute pars fracture) is always secondary to severe trauma. Olisthesis may be present, but far more frequently there are pars fractures with only spondylolysis. They are acute fractures, not fatigue fractures, but the line of difference may be a fine one at times. A diagnosis of spondylolysis is based upon both clinical impression and radiographic imaging. Lumbosacral radiographs, including oblique views, should be obtained on all patients in whom this diagnosis is suspected. The characteristic broken neck of the "Scottie dog", which is the fracture of the pars interarticularis, is the pathognomonic finding (3). Spondylolysis can be missed in up to 20% of cases if oblique views are not obtained. Computed tomography (CT) is superior to plain radiography for consistent and accurate demonstration of spondylolysis. It is described, as the "incomplete ring" sign on axial slices at the level of the pedicle/lamina. CT, when performed with a reverse gantry angle and thin sections such that the scan plane is perpendicular to the fracture, is the investigation of choice for identifying radiographically occult lyses. (1) CT also identifies the accompanying features of spondylolysis such as facet joint changes, spondylolisthesis, disc herniation and foraminal or lateral recess stenosis and also gives the best indication of the potential for a defect to heal, based on the demonstration of callus formation around the fracture. The inclusion of Spondylolysis in the differential diagnosis of mechanical low back pain in adolescents should lead to earlier diagnosis,treatment and return to desired activities.
Lumbar Spondylolysis
1. In the lateral and oblique lumbar spine X-ray views, a distinct fissure or fracture line is visible in the pars interarticularis of the fifth lumbar vertebra (L5), presenting a “Scottie dog” collar break sign.
2. CT axial images show a defect in the L5 pars interarticularis. An “incomplete ring” sign involving the pedicle and lamina area can be clearly identified.
3. No evident vertebral compression changes or obvious signs of bony destruction are noted. Adjacent facet joints may display mild degenerative changes or irregular joint space; however, the main radiological feature remains the fracture line or fissure in the pars interarticularis.
4. No obvious displacement is observed, or only mild anterior slippage (depending on the specific findings), suggesting that if there is spondylolisthesis, it is very mild.
Based on the typical radiographic “Scottie dog collar break” sign and the faint fracture line in the pars interarticularis, together with a history of repeated lumbar hyperextension or rotational stress in a young athlete, this diagnosis is highly suspected.
In highly active young individuals, disc-related lower back pain must also be considered. However, imaging shows no definitive disc herniation or severe nerve root compression. Further clinical correlation is needed to rule out this possibility.
Some athletes may develop chronic facet joint strain due to high-intensity physical activity. Although X-rays do not clearly indicate facet hypertrophy or significant inflammatory changes, it should still be considered in the differential diagnosis.
Combining the patient’s clinical presentation (22-year-old male athlete with activity- or posture-related low back pain) and the imaging findings (L5 pars interarticularis defect), the most likely diagnosis is “L5 Spondylolysis, suspected Isthmic Type II.” Whether there is significant vertebral slippage (Spondylolisthesis) requires further comprehensive imaging evaluation and measurement, but the primary concern at present is the fracture/fissure in the pars interarticularis.
1. Conservative Treatment:
– Reduce or avoid repetitive spinal hyperextension, rotation, and other inciting movements. Use a brace or lumbar support if necessary to decrease excessive stress on the pars interarticularis.
– Oral non-steroidal anti-inflammatory drugs (NSAIDs) may be used to alleviate pain and inflammation. Short-term muscle relaxants can be considered if marked muscle spasms occur.
– Physical therapy can help relieve local tension through methods such as heat therapy, ultrasound, and electrical stimulation, thus improving muscle spasms and pain.
2. Rehabilitation Training Path (FITT-VP Principle):
– F (Frequency): 3–4 rehabilitation sessions per week. Start with low load during the initial phase to ensure sufficient rest and healing time for the injured area.
– I (Intensity): Begin with low-intensity core stability exercises, such as planks and supine hip lifts, to progressively strengthen the supporting muscles around the fracture site.
– T (Time): Around 20–30 minutes per session, with adjustments based on pain and tolerance.
– T (Type): Focus on core strength training, lumbar and back muscle strengthening, and flexibility exercises (e.g., Pilates, small-range extension exercises, isometric lumbar strengthening). Later, introduce aerobic exercises (such as swimming or cycling) to improve overall fitness but avoid excessive load or high-impact activities.
– V (Volume): Adjust the total volume according to the patient’s progress. If pain subsides and function improves well, gradually increase the volume each week or every two weeks in small increments.
– P (Progression): As symptoms improve, gradually increase lumbar and back muscle strength and functional training. Reassess the healing of the pars interarticularis. If there is no clear pain or functional limitation, gradually resume sport-specific movements.
3. Surgical Treatment:
– Surgical intervention may be considered if there is no improvement after several months of conservative therapy or if significant spondylolisthesis or nerve compression (such as sciatica or neurological deficits) is present.
– Possible surgical procedures include pars repair or lumbar fusion, depending on clinical symptoms, preoperative imaging evaluation, and intraoperative findings.
4. Special Considerations:
– If severe pain, numbness, weakness, or other signs of nerve compression worsen during rehabilitation, stop exercise immediately and seek medical attention.
– For young athletes, collaborating with sports medicine or athletic training teams during later rehabilitation phases can help modify training programs to prevent recurrent excessive loading and guide proper exercise posture and load distribution.
Disclaimer:
This report is a reference analysis based on existing imaging findings and medical history. It does not replace a face-to-face consultation or a professional physician’s clinical advice. If you have any concerns or if your symptoms worsen, please consult a qualified medical professional for further evaluation and treatment.
Lumbar Spondylolysis
