Suspecting Lumbar Spondylolysis in Adolescent Low Back Pain

Abstract

Spondylolysis in the athletic adolescent and preadolescent is common enough that primary care practitioners should be familiar with its frequency and its progression from pars interarticularis stress fracture to spondylolysis and to spondylolisthesis. One-half of all pediatric back pain in athletic patients is related to disturbances of the posterior elements including spondylolysis, which presents as low back pain aggravated by activity, frequently with minimal physical findings. Failure to suspect, hence to diagnosis, a pars stress fracture or early spondylolysis is common and a misdiagnosis of lumbosacral strain is often made. A complicating factor in early diagnosis is the fact that plain radiographs, even with oblique films, may not be helpful at the stress fracture stage, and other imaging techniques (bone scan possibly with single photon emission computed tomography [SPECT]) must be used early in the diagnostic process. In the primary care setting, an early diagnosis of posterior element involvement in low back pain either at the stage of pars stress fracture or early spondylolysis can prevent progression of the disease and the need for aggressive intervention for a more significant defect. We present three adolescent and preadolescent athletes with low back pain in whom a high index of suspicion led to the early diagnosis of pars stress fracture or spondylolysis. All three had different stages of spondylolysis, and one illustrates the clinical utility of the one-legged hyperextension test. The ease with which early disease may be treated further supports efforts by primary care practitioners to suspect and diagnose pars stress fracture and early spondylolysis.

Imaging of Back Pain in Children

“…The evolution of spondylolysis has been described in 4 stages 45 : The first stage consists of a stress reaction that is radiologically inapparent but visible on bone scintigraphy and MR imaging. 43 The second stage, early spondylolysis, represents a range of features including hairline fractures and bony resorption evident on CT.…”

Streamlining the Evaluation of Low Back Pain in Children

“…Traditionally, when clinical findings alone cannot sufficiently rule out organic causes of back pain in children, plain film radiography of the lumbar spine (anteroposterior, lateral, and oblique views) is the most common first diagnostic test [12,14,16,22,23,27]. With persistent pain and a negative radiograph, however, the clinician then must choose which test may be needed to rule out suspected disorders.…”

“…Although multiple studies have examined the diagnostic accuracy of MRI, single photon emission computed tomography (SPECT), and plain film radiography in diagnosing specific conditions [2, 3, 5, 6, 10, 11, 19, 22-25, 31, 32], there is no evidence-based consensus regarding which of these tests should be used in evaluating low back pain [6,22,32]. Furthermore, no study to our knowledge has developed an approach that can distinguish children who have OBP (likely to require additional followup and treatment) from those with MBP (not likely to require additional followup and treatment).…”

Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management

“…28,29 Some authors recommend avoiding radiography entirely and proceeding directly to SPECT imaging. 30 Active lesions are most likely found in an adolescent or young adult who is engaged in a high level of physical activity and has an impending or newly acquired pars defect. In a study of young military recruits with a known spondylolysis, 43% of those individuals with a relatively recent onset of back pain were positive on bone scintigraphy.…”