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Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine

Lumbar Spine Anatomy

  • lamina
    Screenshot-2017-01-28-10.28.57-300x159 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE

    Scotty Dog X-ray Overlay

    • superior/inferior articular processes (aka facet joint)
    • spinous process
    • transverse process
  • Scotty dog (on oblique x-rays) – Look for pars defect

    nose – transverse process

    • front leg – inferior articular process
    • neck – pars interarticularis
    • ear – superior articular process
  • Biomechanics of soccer kick
    • approach
    • limb swing -hyperextension
    • foot plant – hyperextension
    • hip flexion, knee extension, and foot contact
    • follow through
  • Spinehealth.com pars defect video
    Screenshot-2017-01-28-10.28.57-300x159 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.30.19-300x203 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE

    Illustration of a Pars Fracture

Natural History of Spondylolysis and Spondylolisthesis – Literature Review

  • Frederickson JBJS 1984

    • 500 1st grade asymptomatic children
    • 34% follow up at age 18
    • 22 children (4.4%) had unilateral pars defect at age of 6
      • 5.2% at 12, 6% at adult age
    • Pitfalls: 2/3 lost to follow up
    • up to 10% adult incidence has been reported
  • Jackson et al. AJSM 1981

    • one-legged hyper extension test correlated with stress fractures, uptake on bone scan
    • can’t see them all on x-ray
    • Average return to play of 7.3 months
    • normal bone scan associated with healing
  • Campbell et al. 2005 Skeletal Radiology

    Screenshot-2017-01-28-10.28.57-300x159 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.30.19-300x203 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.28.19-300x172 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE

    Diagram of the Scotty Dog View

    • SPECT overall with excellent agreement with MRI
    • proposed protocol getting MRI first, and then if not sure after that get the CT scan
  • Masci et al. 2006 – BJSM

    • 71 young athletes with low back pain
    • all underwent bone SPECT and MRI of lower spine
    • one legged hyperextension test neither sensitive or specific for detecting spondylolysis
    • found discordance between MRI and SPECT in 40/50 cases with active spondylolysis
    • MRI had reduced sensitivity
    • Bone Scan (SPECT) should be first line
    • focused CT should be considered
  • Gregg et al. 2009 – PTIS

    • male and age less than 20 associated with spondylolysis
    • single leg hyperextension test lacked specificity and sensitivity
  • Sundell et al. 2013

    • prospective case series of 25 adolescent athletes
    • studies several physical exam tests
    • no single physical exam test could distinguish between pathologies
    • no correlation between physical exam and spondylolysis
  • Helen et al. 2016 – Manual Therapy

    • no patient history or physical exam have diagnostic utility to inform clinical practice for spondylolysis

Imaging Pearls

  • Note that the pars bone is very thin and most imaging does not focus on that specific bone
  • MRI is not as sensitive in reality
  • On bone scan, it is difficult to differentiate between Pars and pedicle, also impossible to know exactly what is causing the increased turnover on bone scan
  • SPECT CT scan is probably the best test (you do have to consider the extra radiation in the SPECT as compared to the MRI

Treatment

  • Dhemecourt et al – Orthopedics 2002
    • 73 athletes treated with Boston Overlap Brace
    • favorable outcome in 80%
    • expect clinical improvement in 6-8 weeks (after wearing for 23 hours a day)
  • Iwamoto et al. 2004 – Scandinavian journal
    • 104 athletes with pars defects on radiographs
    • 40 athletes treated with activity restriction and bracing
    • 85% returned at average of 5 months
    • 85% were L5 defects
    • baseball and soccer at 27.9 and 13.5% respectively
    • did not look at gymnastics or football
  • O’Sullivan et al. 1997 – Spine
    • 44 patients with low back pain and radiographic evidence of spondylolysis
      • randomly assigned to exercise vs. control
      • exercise group: abdominal drawing in maneuver (10 contractions with 10 second hold) – “flexion bias”
        • specific training of deep abdominal muscles with co-contraction of lumbar multifid proximal to the pars defect
    • exercise group had improved VAS pain score and lower pain descriptor scores
      • Oswestry disability score better for exercise group as well
  • Chosa et al 2004 – Orthopaedic Research
    • most effective exercises:
      • abdominal hollowing
      • abdominal bracing
      • avoid end rage extension and end range rotation
    • used 3D motion model as well
      • extension and rotation had highest stress at pars region
    • take home – focus on deep core muscles but avoid rotation and extension
  • Debnath et al. 2003 JBJS – clinical outcome and return to sport after surgical treatment
    • prospective study of 22 professional athletes
    • Buck’s fusion better than Scott’s fusion
    • mean duration of symptoms 9 months before surgery, time to return to sport was 7 months after surgery
    • across studies, 63-100% successful outcome with surgical treatment
  • Summary

    • 6% of general population have pars defect
    • L5 most common level
    • Single leg hyperextension test not useful
    • Bone scan (with SPECT) or MRI is imaging of choice
      • board answer is triple phase bone scan with SPECT study
    • Rest rehab with core work +/- bracing, avoid rotation and extension

 

Screenshot-2017-01-28-10.28.57-300x159 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.30.19-300x203 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.28.19-300x172 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.30.44-350x158 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE

Screenshot-2017-01-28-10.28.57-300x159 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.30.19-300x203 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.28.19-300x172 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.30.44-350x158 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.29.40-350x323 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE

Screenshot-2017-01-28-10.28.57-300x159 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.30.19-300x203 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.28.19-300x172 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.30.44-350x158 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.29.40-350x323 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE   Screenshot-2017-01-28-10.29.52-350x151 Pars Defects, Spondylolysis, Spondylolisthesis | Lumbar Spine BOARD REVIEW SPINE

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