Spondylolysis (Back Stress Fracture)
Article by John Miller
What is Spondylolysis?
Spondylolysis is a back stress fracture. It is a common causes of structural back pain in children, adolescents and active young adults. Spondylolysis is a non-displaced stress fracture of a spinal vertebra, also known as a pars stress fracture.
A spondylolysis in a child or adolescent most commonly results from a defect or stress fracture in the pars interarticularis of the vertebra. The pars interarticularis is the part of the vertebra between the superior and inferior facets.
Approximately 90-95% of cases of spondylolysis occur at the L5 vertebral level. The stress lesion usually completely heals. In about 25% of cases where fracture nonunion occurs, a fibrous mesh connective tissue is laid down rather than bone.
Spondylolysis is classified as dysplasic (congenital - born with eg spina bifida occulta), isthmic (stress fracture from sport), degenerative (older adults - arthritis related), or traumatic. The majority are isthmic.
If your spondylolysis deteriorates and allows the vertebral body to slip forwards, it is known as a spondylolisthesis. This occurs in about 50% of cases. A spondylolisthesis is more common in individuals with bilateral spondylolysis, mechanical instability and females.
What are the Symptoms of Spondylolysis?
Spondylolysis sufferers usually report:
What Causes Spondylolysis?
Sports that have been identified with a high incidence of spondylolysis include:
Merlino & Perlisa (2012) studied 4200 young athletes with back pain - 13.9% had spondylolysis identified radiologically.
What Age Does Spondylolysis Occur?
Spondylolysis tends to occur in two distinct stages of your skeletal development:
The condition is more common in males; 2:1.
How is Spondylolysis Diagnosed?
The diagnosis of spondylolysis is made based on your back symptoms, a physical examination, as well as X-rays of the spine. Oblique X-rays of the lumbar spine are often obtained to evaluate for possible spondylolysis or spondylolisthesis.
SPECT bone scan appears to be the most sensitive investigation to pick up active spondylolysis. CT scan and MRI scan can be used to assess for a possible spondylolysis. A bone scintigraphy can also be useful in differentiating an acute stress reaction (spondylolysis) from a chronic defect.
The most common finding on physical examination is low back pain and pain with extension of the lumbar spine. Hamstring tightness is another very common finding in patients with spondylolysis.
Most patients will not have neurological symptoms or referred pain to the leg.
What is Spondylolysis Treatment?
The treatment for spondylolysis is initially conservative and aims to reduce your pain and facilitate healing.
Managing Your Pain & Inflammation
Pain is the main reason that spondylolysis sufferers seek treatment. Pars inflammation is thought to be the main reason why you experience pain, so managing your inflammation is important in the early phase.
Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These include: ice, tens machine, acupuncture, de-loading taping techniques, soft tissue massage and temporary use of a supportive brace to off-load the injury site.
You can reduce your inflammation by avoiding the activities that cause your pain (eg extension) and using ice therapy and treatment techniques or exercises that unload the inflammed structures. You may be prescribed non-steroidal anti-inflammatory medication such as ibuprofen to assist your inflammation reduction.
Bracing is controversial. An anti-lordotic brace is sometimes recommended in patients unable to quickly settle their pain. Peer & Fascione (2007). Your physiotherapist will guide you.
Relaxed freestyle or hydrotherapy exercises are beneficial in early injury repair due to lesser body-weight in the buoyancy of water. This allows more movement without causing pain. Water running may also be helpful to maintain your cardiovascular fitness.
Restoring Normal Joint Motion & Posture
As your pain and inflammation settles, your physiotherapist will turn their attention to restoring your normal back joint range of motion and posture. Stiff joints adjacent to the spondylolysis often require mobilising to deload the pars interarticularis stress. Samsell (2010).
Normalise Muscle Flexibility
Tight leg and back muscles will need to be assessed and stretched to allow full and normal movement of your legs and back. Your leg and buttock muscle groups are often tight and shortened. Myofascial massage is helpful. Standaert (2011).
Restore Normal Muscle Strength & Coordination
Back pain researchers have discovered the importance of your deep abdominal core muscle recruitment patterns with a normal order of: deep, then intermediate and finally superficial abdominal muscle firing patterns in normal pain-free backs. Standaert (2011).
PhysioWorks has developed a Back Pain Core Stabilisation Program to assist their spondylolysis patients to regain normal core muscle control. Your physiotherapist will assess your core muscle recruitment pattern and prescribe the best exercises for you specific to your needs. They may recommend that you undertake an ultrasound guided exercise program where you can view your deep core muscle contractions on a TV monitor.
Pilates appears a useful exercise regime. Peer and Fascione (2007). Instruction from a physiotherapist with knowledge of what pilates postures could exacerbate your spondylolysis is preferred.
Graded Return to Sport
The next stage of your rehabilitation is aimed at safely returning you to your desired activities. Everyone has different demands will determine what specific treatment goals you need to achieve.
Due to the cause of spondylolysis being predominantly caused by sport, ideally your sports physiotherapist should use their knowledge of biomechanics and the demands of your sport to guide your return to sport.
Your physiotherapist will tailor your spondylolysis and spondylolisthesis rehabilitation to help you achieve your own functional goals.
What is the Prognosis for Spondylolysis?
The treatment results for spondylolysis is based on your history and symptoms. In most cases, spondylolysis symptoms will resolve within 6 to 12 weeks.
Non-surgical conservative treatments successfully relieve pain in approximately 80-85% of children and adolescents with acute spondylolysis. However, the potential for recurrence is high in individuals who do not address the risk factors that led to the initial injury. Stanitski (2006).
Preventing a Recurrence
Spondylolysis is a condition that will recur if you overstress your lower back. The main reason it is thought to recur is due to poor muscle control or insufficient rehabilitation. Fine tuning your back mobility and core control and learning self-management techniques will ultimately help you to achieve your goal of safely returning to your previous sporting or leisure activities without back pain or sciatica that is commonly associated with spondylolysis and spondylolisthesis.
Exercise is like cleaning your teeth. Exercise prevents problems.
Surgery for spondylolysis is extremely rare if you are suffering back pain without any neurological signs.
Please consult your physiotherapist or doctor for their professional opinion on how best to manage your spondylolysis.
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