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Journal of the American Board of Family... Dec 2022Spondylolysis and isthmic spondylolisthesis are commonly implicated as organic causes of low back pain in this population. Many patients involved in sports that require... (Review)
Review
INTRODUCTION
Spondylolysis and isthmic spondylolisthesis are commonly implicated as organic causes of low back pain in this population. Many patients involved in sports that require repetitive hyperextension of the lumbar spine like diving, weightlifting, gymnastics and wrestling develop spondylolysis and isthmic spondylolisthesis. While patients are typically asymptomatic in mild forms, the hallmark of symptoms in more advanced disease include low back pain, radiculopathy, postural changes and rarely, neurologic deficits.
METHODS
We conducted a narrative review of the literature on the clinical presentation, diagnosis, prognosis and management of spondylolysis and isthmic spondylolisthesis.
RESULTS
A comprehensive physical exam and subsequent imaging including radiographs, CT and MRI play a role in the diagnosis of this disease process. While the majority of patients improve with conservative management, others require operative management due to persistent symptoms.
CONCLUSION
Due to the risk of disease progression, referral to a spine surgeon is recommended for any patient suspected of having these conditions. This review provides information and guidelines for practitioners to promote an actionable awareness of spondylolysis and isthmic spondylolisthesis.
Topics: Humans; Spondylolisthesis; Low Back Pain; Spondylolysis; Lumbar Vertebrae; Radiography
PubMed: 36526328
DOI: 10.3122/jabfm.2022.220130R1 -
The Spine Journal : Official Journal of... Oct 2022Spondylolysis is a defect of the pars interarticularis of vertebrae, most commonly seen at L5 and L4. The etiology of spondylolysis and isthmic spondylolisthesis is... (Review)
Review
BACKGROUND
Spondylolysis is a defect of the pars interarticularis of vertebrae, most commonly seen at L5 and L4. The etiology of spondylolysis and isthmic spondylolisthesis is generally considered to be a result of repetitive mechanical stress to the weak portion of the vertebrae. A higher incidence of spondylolysis is observed in young athletes. Symptomatic spondylolysis can be successfully treated conservatively, but there is currently a limited consensus on treatment modalities and a lack of large-scale clinical trials.
PURPOSE
The purpose of the present study was to investigate the optimal treatment algorithm for symptomatic spondylolysis in adolescent athletes and evaluate the functional outcomes of those undergoing the nonoperative treatment.
STUDY DESIGN
A retrospective review.
PATIENT SAMPLE
Two hundred one adolescent patients ranging from age 10 to 19 involved in athletics OUTCOME MEASURES: Injury characteristics (age, mechanism, time), sports played, bone stimulator use, bony healing at 3 months on computed tomography (CT) scans, return to sports, corticosteroid injection use.
METHODS
Two hundred one adolescent athlete patients (62 females and 139 males) diagnosed with spondylolysis between 2007 and 2019 were retrospectively reviewed. Diagnosis was based on plain radiography followed by magnetic resonance imaging. All patients were treated conservatively with cessation of sports activity, thoracolumbosacral orthosis, and external bone stimulator for three months after diagnosis. CT scans were obtained for the 3-month follow-up visits to assess bony healing. Subsequently the patients received 6 weeks of rehabilitation focused on core strengthening. Symptomatic patients after the treatment were referred for steroid injections and continued with the rehabilitation protocol.
RESULTS
The most common age of injury was 15 years old, following a strong normal distribution. The most commonly played sport was football, followed by baseball/softball. The primary mechanism of injury was weight training closely followed by a football injury. The first quarter of the calendar year had the highest incidence of injuries with the most injuries occurring in March and the least occurring in December. One hundred fifty-two athletes reported using bone stimulators as prescribed, and these patients showed a significantly higher rate of bony healing on follow-up CT scans than those who did not use bone stimulators. One hundred ninety-seven patients (98%) returned to sports or similar level of activities. Thirty-seven patients (18%) received facet or epidural steroid injections due to continued pain and one patient underwent a surgical procedure. Follow-up CT scans showed 49.8% bony healing.
CONCLUSIONS
Conservative treatment of spondylolysis in adolescent athletes with cessation of sports, thoracolumbosacral orthosis, and bone stimulator followed by rehabilitation was associated with excellent outcomes in terms of return to sports.
Topics: Adolescent; Adrenal Cortex Hormones; Adult; Athletes; Child; Female; Humans; Lumbar Vertebrae; Male; Retrospective Studies; Spondylolysis; Steroids; Young Adult
PubMed: 35504566
DOI: 10.1016/j.spinee.2022.04.011 -
BMC Musculoskeletal Disorders May 2017Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study... (Review)
Review
BACKGROUND
Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.
METHODS
A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.
RESULTS
Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.
CONCLUSIONS
This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.
Topics: Evidence-Based Medicine; Humans; Intervertebral Disc Degeneration; Intervertebral Disc Displacement; Low Back Pain; Pain Measurement; Spinal Stenosis; Spondylolisthesis
PubMed: 28499364
DOI: 10.1186/s12891-017-1549-6 -
Acta Ortopedica Mexicana 2020Lumbar degenerative spondylolisthesis is the result of the progression from degenerative changes in the intervertebral disc and facet joints that lead to destabilizing... (Review)
Review
Lumbar degenerative spondylolisthesis is the result of the progression from degenerative changes in the intervertebral disc and facet joints that lead to destabilizing one or more vertebral segments. It is characterized by the anterior sliding of the vertebral body secondary to the sagittalization of the facet joints. Wiltse, Newman, and Macnab classified it as type III. It is a pathology typical of elderly patients that predominate in women with a ratio of 5:1 compared to men; the most affected segment is L4-L5, the listhesis rarely exceeds 30% slip. It may or may not generate clinical manifestations, and the severity of these does not always correlate with the degree of sliding. The cardinal symptom is lumbar pain with or without radicular pain. Neurogenic claudication occurs in 75% of patients; it is caused by blood hypoperfusion secondary to the compression of the nerve roots, manifesting as pain in the lower limbs with variable walking distances. For the diagnosis of degenerative spondylolisthesis, comprehensive evaluation with static, dynamic radiographic studies in a standing position and magnetic resonance imaging are essential. The conservative treatment is the first-line therapy; it includes analgesics, anti-inflammatories, physiotherapy.
Topics: Aged; Female; Humans; Intervertebral Disc; Intervertebral Disc Degeneration; Lumbar Vertebrae; Male; Spondylolisthesis; Zygapophyseal Joint
PubMed: 33634638
DOI: No ID Found -
Acta Bio-medica : Atenei Parmensis Jan 2022Degenerative spondylolisthesis (DS) is a condition leading to the slippage of one vertebral body over the one below due to degenerative changes resulting in spinal... (Review)
Review
Degenerative spondylolisthesis (DS) is a condition leading to the slippage of one vertebral body over the one below due to degenerative changes resulting in spinal stenosis and producing neurogenic claudication, with or without low back pain. DS prevalence is age and gender specific. Other risk factors mainly include a history of occupational driving, intense manual activity and sedentary work. Diagnosis for patients with DS include detailed history, physical examination and imaging through standing lateral radiographs and MRI. Most patients with symptomatic DS and absence of neurologic deficits should perform better with conservative treatment, whereas, patients with neurological symptoms, are more prone to undergo progressive functional deterioration without surgery. There is a lack of agreement on the best surgical management in patients with DS and symptomatic stenosis. There is a contradictory data that does not permit for a recommendation for or against the addition of fusion to decompression. There is also controversy on which fusion technique is best. Spinal minimally invasive surgery is a promising approach for DS promoting early recovery and enhanced quality of life by reducing skin incision, muscular damage and perioperative pain with significant improvements in clinical results and high satisfaction rates.
Topics: Humans; Lumbar Vertebrae; Magnetic Resonance Imaging; Quality of Life; Spinal Stenosis; Spondylolisthesis; Treatment Outcome
PubMed: 35075090
DOI: 10.23750/abm.v92i6.10526 -
Acta Ortopedica Mexicana 2020There are various approaches and surgical techniques with the objective of nerve root decompression, restrict mobility, and fusion of the listhesis. Among the... (Review)
Review
There are various approaches and surgical techniques with the objective of nerve root decompression, restrict mobility, and fusion of the listhesis. Among the techniques, posterior interbody fusion combines direct and indirect root decompression with the fusion between vertebral bodies, placing an autologous bone graft between transverse apophysis and vertebral bodies. Transforaminal lumbar and posterior interbody fusion, on the same way, look to decompress and fuse but with a different approach to the spine. The anterior approach for interbody fusion provides a better fusion rate. Lateral lumbar interbody fusion is considered less invasive, with an anterolateral transpsoas approach. The lumbar fusion technique in degenerative spondylolisthesis must be individualized. Non-fusion decompression is considered a less invasive procedure. Various studies suggest that decompression has better results when fusion is added. Surgery had several potential benefits and greater improvement in those patients who fail conservative management. An optimal technique is not conclusively identified.
Topics: Decompression, Surgical; Humans; Lumbar Vertebrae; Spinal Fusion; Spondylolisthesis; Treatment Outcome
PubMed: 34020526
DOI: No ID Found -
Scientific Reports Apr 2020Lumbar spondylolysis generally occurs in adolescent athletes. Bony union can be expected with conservative treatment, however, the fracture does not heal in some cases....
Lumbar spondylolysis generally occurs in adolescent athletes. Bony union can be expected with conservative treatment, however, the fracture does not heal in some cases. When the fracture becomes a pseudoarthrosis, spondylolysis patients have the potential to develop isthmic spondylolisthesis. A cross-sectional study was performed to determine the incidence of spondylolysis and spondylolisthesis, and to elucidate when and how often spondylolisthesis occurs in patients with or without spondylolysis. Patients undergoing computed tomography (CT) scans of abdominal or lumbar regions for reasons other than low back pain were included (n = 580). Reconstruction CT images were obtained, and the prevalence of spondylolysis and spondylolisthesis were evaluated. Of the 580 patients, 37 patients (6.4%) had spondylolysis. Of these 37 patients, 19 patients (51.4%) showed spondylolisthesis, whereas only 7.4% of non-spondylolysis patients showed spondylolisthesis (p < 0.05). When excluding unilateral spondylolysis, 90% (18/20) of spondylolysis patients aged ≥60 years-old showed spondylolisthesis. None of the patients with isthmic spondylolisthesis had received fusion surgery, suggesting that most of these patients didn't have a severe disability requiring surgical treatment. Our results showed that the majority of bilateral spondylolysis patients aged ≥60 years-old show spondylolisthesis, and suggest that spondylolisthesis occurs very frequently and may develop at a younger age when spondylolysis exists.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Athletes; Child; Cross-Sectional Studies; Disease Progression; Female; Humans; Japan; Lumbar Vertebrae; Lumbosacral Region; Male; Middle Aged; Prevalence; Spondylolisthesis; Spondylolysis; Tomography, X-Ray Computed
PubMed: 32317683
DOI: 10.1038/s41598-020-63784-0 -
The New England Journal of Medicine Apr 2016The comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
The comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown.
METHODS
In this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression-alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores indicating more disability related to back pain). Patients were followed for 4 years.
RESULTS
A total of 66 patients (mean age, 67 years; 80% women) underwent randomization. The rate of follow-up was 89% at 1 year, 86% at 2 years, and 68% at 4 years. The fusion group had a greater increase in SF-36 physical-component summary scores at 2 years after surgery than did the decompression-alone group (15.2 vs. 9.5, for a difference of 5.7; 95% confidence interval, 0.1 to 11.3; P=0.046). The increases in the SF-36 physical-component summary scores in the fusion group remained greater than those in the decompression-alone group at 3 years and at 4 years (P=0.02 for both years). With respect to reductions in disability related to back pain, the changes in the Oswestry Disability Index scores at 2 years after surgery did not differ significantly between the study groups (-17.9 in the decompression-alone group and -26.3 in the fusion group, P=0.06). More blood loss and longer hospital stays occurred in the fusion group than in the decompression-alone group (P<0.001 for both comparisons). The cumulative rate of reoperation was 14% in the fusion group and 34% in the decompression-alone group (P=0.05).
CONCLUSIONS
Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health-related quality of life than laminectomy alone. (Funded by the Jean and David Wallace Foundation and others; SLIP ClinicalTrials.gov number, NCT00109213.).
Topics: Aged; Aged, 80 and over; Decompression, Surgical; Disability Evaluation; Female; Follow-Up Studies; Humans; Laminectomy; Lumbar Vertebrae; Male; Middle Aged; Postoperative Complications; Reoperation; Spinal Fusion; Spinal Stenosis; Spondylolisthesis; Treatment Outcome
PubMed: 27074067
DOI: 10.1056/NEJMoa1508788 -
Orthopaedics & Traumatology, Surgery &... Apr 2019The objectives of this study were to define the role for surgery in the treatment of chronic low back pain (cLBP) and to develop a new classification of cLBP based on... (Review)
Review
BACKGROUND
The objectives of this study were to define the role for surgery in the treatment of chronic low back pain (cLBP) and to develop a new classification of cLBP based on the pattern of injury.
HYPOTHESIS
Surgery may benefit patients with cLBP, and a new classification based on the injury pattern may be of interest.
METHOD
A systematic literature review was performed by searching Medline, the Cochrane Library, the French public health database (Banque de Données en Santé Publique), Science Direct, and the National Guideline Clearinghouse. The main search terms were "back pain" OR "lumbar" OR "intervertebral disc replacement" OR "vertebrae" OR "spinal" AND "surgery" OR "surgical" OR "fusion" OR "laminectomy" OR "discectomy".
RESULTS
Surgical techniques available for treating cLBP consist of fusion, disc replacement, dynamic stabilisation, and inter-spinous posterior devices. Compared to non-operative management including intensive rehabilitation therapy and cognitive behavioural therapy, fusion is not better in terms of either function (evaluated using the Oswestry Disability Index [ODI]) or pain (level 2). Fusion is better than non-operative management without intensive rehabilitation therapy (level 2). There is no evidence to date that one fusion technique is superior over the others regarding the clinical outcomes (assessed using the ODI). Compared to fusion or multidisciplinary rehabilitation therapy, disc replacement can produce better function and less pain, although the differences are not clinically significant (level 2). The available evidence does not support the use of dynamic stabilisation or interspinous posterior devices to treat cLBP due to degenerative disease (professional consensus within the French Society for Spinal Surgery). The following recommendations can be made: non-operative treatment must be provided for at least 1 year before considering surgery in patients with cLBP due to degenerative disease; patients must be fully informed about alternative treatment options and the risks associated with surgery; standing radiographs must be obtained to assess sagittal spinal alignment and a magnetic resonance imaging scan to determine the mechanism of injury; and, if fusion is performed, the lumbar lordotic curvature must be restored.
DISCUSSION
This work establishes the need for a new classification of cLBP based on the presumptive mechanism responsible for the pain. Three categories should be distinguished: non-degenerative cLBP (previously known as symptomatic cLBP), in which the cause of pain is a trauma, spondylolysis, a tumour, an infection, or an inflammatory process; degenerative cLBP (previously known as non-specific cLBP) characterised by variable combinations of degenerative alterations in one or more discs, facet joints, and/or ligaments, with or without regional and/or global alterations in spinal alignment (which must be assessed using specific parameters); and cLBP of unknown mechanism, in which the pain seems to bear no relation to the anatomical abnormalities (and the Fear-Avoidance Beliefs Questionnaire and Hospital Anxiety and Depression Scale may be helpful in this situation). This classification should prove useful in the future for constituting well-defined patient groups, thereby improving the assessment of treatment options.
LEVEL OF EVIDENCE
II, systematic review of level II studies.
Topics: Chronic Disease; Humans; Intervertebral Disc Degeneration; Low Back Pain; Lumbar Vertebrae; Neurosurgical Procedures; Spondylolysis
PubMed: 30792166
DOI: 10.1016/j.otsr.2018.11.021 -
The New England Journal of Medicine Apr 2016The efficacy of fusion surgery in addition to decompression surgery in patients who have lumbar spinal stenosis, with or without degenerative spondylolisthesis, has not... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
The efficacy of fusion surgery in addition to decompression surgery in patients who have lumbar spinal stenosis, with or without degenerative spondylolisthesis, has not been substantiated in controlled trials.
METHODS
We randomly assigned 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at one or two adjacent vertebral levels to undergo either decompression surgery plus fusion surgery (fusion group) or decompression surgery alone (decompression-alone group). Randomization was stratified according to the presence of preoperative degenerative spondylolisthesis (in 135 patients) or its absence. Outcomes were assessed with the use of patient-reported outcome measures, a 6-minute walk test, and a health economic evaluation. The primary outcome was the score on the Oswestry Disability Index (ODI; which ranges from 0 to 100, with higher scores indicating more severe disability) 2 years after surgery. The primary analysis, which was a per-protocol analysis, did not include the 14 patients who did not receive the assigned treatment and the 5 who were lost to follow-up.
RESULTS
There was no significant difference between the groups in the mean score on the ODI at 2 years (27 in the fusion group and 24 in the decompression-alone group, P=0.24) or in the results of the 6-minute walk test (397 m in the fusion group and 405 m in the decompression-alone group, P=0.72). Results were similar between patients with and those without spondylolisthesis. Among the patients who had 5 years of follow-up and were eligible for inclusion in the 5-year analysis, there were no significant differences between the groups in clinical outcomes at 5 years. The mean length of hospitalization was 7.4 days in the fusion group and 4.1 days in the decompression-alone group (P<0.001). Operating time was longer, the amount of bleeding was greater, and surgical costs were higher in the fusion group than in the decompression-alone group. During a mean follow-up of 6.5 years, additional lumbar spine surgery was performed in 22% of the patients in the fusion group and in 21% of those in the decompression-alone group.
CONCLUSIONS
Among patients with lumbar spinal stenosis, with or without degenerative spondylolisthesis, decompression surgery plus fusion surgery did not result in better clinical outcomes at 2 years and 5 years than did decompression surgery alone. (Funded by an Uppsala institutional Avtal om Läkarutbildning och Forskning [Agreement concerning Cooperation on Medical Education and Research] and others; Swedish Spinal Stenosis Study ClinicalTrials.gov number, NCT01994512.).
Topics: Aged; Decompression, Surgical; Disability Evaluation; Female; Follow-Up Studies; Humans; Intention to Treat Analysis; Lumbar Vertebrae; Male; Middle Aged; Postoperative Complications; Radiography; Reoperation; Spinal Fusion; Spinal Stenosis; Spondylolisthesis; Treatment Outcome
PubMed: 27074066
DOI: 10.1056/NEJMoa1513721