MANAGEMENT OF SPONDYLOLYSIS AND SPONDYLOLISTHESIS IN THE PEDIATRIC AND ADOLESCENT POPULATION
Section snippets
CAUSE AND INCIDENCE
Spondylolysis occurs in 6% of the general population.21 Upright posture and ambulation appear to have a role in its development because there are no known cases in nonambulatory patients.92 Spondylolysis in newborns is virtually nonexistent, whereas its incidence by age 6 years is about 5%, close to that seen in the general population. Repetitive loading appears to be a likely contributing cause. It is well described that hyperlordosis, such as seen in Scheuermann's kyphosis,56 as well as
CLINICAL EVALUATION
Many young patients with spondylolysis and spondylolisthesis may be asymptomatic, but some may present with back pain, sometimes associated with a particular activity or injury. Those with symptoms are seen most commonly in the preadolescent growth spurt. Severity of slip may not correlate with the magnitude of symptoms. As noted, athletes whose sports involve repetitive hyperextension, such as divers, gymnasts, and wrestlers, may present with low back pain occurring during sports
CONSERVATIVE MANAGEMENT
Patients with spondylolysis or low-grade spondylolisthesis may be managed by nonoperative means. As with scoliosis, the younger the patient, the greater the risk for progression, and these patients should be observed annually, even if their initial symptoms resolve. Skeletally immature patients with slippage greater than 30% to 50% are at increased risk for progression and should undergo spinal fusion (i.e., conservative treatment has no role in their management).32, 38, 49, 88
Young athletes
SURGICAL MANAGEMENT
The options for surgical management of this disease spectrum range from direct repair of the spondylolytic defect, fusion in situ, reduction and fusion, and vertebrectomy. It is important to understand the indications, the possible complications, and especially the limitations for surgery when selecting the appropriate procedure for a given patient. The surgical options for the treatment of spondylolysis to that of high-grade spondylolisthesis are discussed in the following sections.
COMPLICATIONS
Disk degeneration adjacent to previously fused segments has been reported on frequently70 and is of concern for young patients with spondylolysis or spondylolisthesis. Szypryt et al83 reported that disk degeneration, either at the disk associated with a neural arch defect or the adjacent disk, was uncommon in patients younger than age 25. They found that untreated patients older than age 25 developed a higher prevalence of disk degeneration at the deranged motion segment as well as the adjacent
CONCLUSION
Spondylolysis and low-grade spondylolisthesis are diagnoses that for most patients have a benign prognosis and can be managed nonoperatively. For most symptomatic patients for whom this management fails, fusion in situ yields satisfactory and lasting results and remains the gold standard against which other surgical treatment must be compared. Patients with high-grade slips and slip angles may benefit from instrumented fusion in situ or combined anterior/posterior procedures or may be
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Lumbar spondylolysis - Current concepts review
2021, Journal of Clinical Orthopaedics and TraumaCitation Excerpt :The current consensus favors PI defect as a developmental lesion occurring sometime in childhood. There are two peaks of presentation, i.e. one occurs between 5 and 7 years of age and another peak in teenage years.13 In early teenage period it presents as a continuum of stress reaction which can progress to incomplete and then a complete defect.
Pars interarticularis injury in elite athletes – The role of imaging in diagnosis and management
2018, European Journal of RadiologyCitation Excerpt :This can result in considerable time away from play, and in some cases is career-altering/ending. For these reasons, early diagnosis and treatment of pars injuries in young elite athletes is crucial [35,36]. As with other types of bony stress injury, the prognosis and time to recovery is dependent to the extent and stage of injury at time of diagnosis, the type of sport and the individual progress during rehabilitation.
Posterior surgery in high-grade spondylolisthesis
2014, Orthopaedics and Traumatology: Surgery and ResearchCitation Excerpt :Lower back pain and onset of radiculalgia are indications for surgery in adults. There are presently several anterior or posterior fusion techniques to achieve reduction and intervertebral fusion by posterolateral and intersomatic grafting [3,5–8]. Fusion between the L5 body and sacrum and posterolateral bone graft are essential in severe deformity.
Posterior surgery in high-grade spondylolisthesis
2014, Revue de Chirurgie Orthopedique et Traumatologique
Address reprint requests to Jason A. Smith, MD, 500 Parnassus Avenue, MU320W, San Francisco, CA 94143-0728
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Spinal Disorders Service, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California