Lumbar spondylolysis
Mitsutoshi Hayashi
Mitsutoshi Hayashi
Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association
Lumbar spondylolysis
Lumbar spondylolysis may result in low back pain, and often seen in sports that repeat anteroposterior flexion and rotation of the trunk.
Disease Overview
Lumbar spondylolysis is more likely to occur among junior high school students involved in sports. It does not have nerve pain like hernia, but it is predisposed to occur due to excessive sports activities. Prolonged follow-up is necessary as it is the low back pain caused by fissure of lumbar spine.
Cause and mechanism of onset
Anatomy
The bone continuity of the pedicle of vertebral arch is disrupted between the lumbar superior articular process and lumbar inferior articular process. Thus, it should be considered the same as bone fracture (Photos 1 and 2).
Photo 1: Oblique position of lumbar spine spondylolysis
Photo 2: Dorsal aspect of lumbar spondylolysis
Cause
The lumbar spine is weak due to congenital heredity, and it is developmentally separated. It is an acquired stress fracture on zygapophyseal region caused by stress due to repetitive sports movement on the lumbar region. It often occurs due to excessive training at the growth stage. In addition, the patient with bilateral (left and right) lumbar spondylolysis should pay more attention because it is likely to turn to the lumbar spondylolisthesis in the future.
Diagnosis
Diagnosis
X-ray photo of lumbar spine (Photo 3) shows a separated part, particularly in the 45-degree oblique view. Separated part shows a characteristic image and produces a typical separation picture called a collar of a terrier dog. Characteristic images show a typical separation of the collar of terrier dog. CT may identify the separated part more easily. On the other hand, MRI shows no findings, and it is more helpful to distinguish the symptom from lumbar disc herniation (protrusions of the disc).
Photo3: Segregation
Frequent site
It is likely to occur in the fifth lumbar vertebra and often bilaterally.
Most common sports
It is common in many sports with frequent anteroposterior flexion and rotation of the trunk such as baseball, volleyball, basketball, football (soccer), Judo, rugby, and weightlifting.
Peak age and gender of onset
It often occurs in 13 to 14-year-old athletes, and the onset among boys is overwhelmingly dominated.
Symptoms
Low back pain, buttock pain, and dull pain in the lateral thigh (severe distress, dizziness) are common symptoms. Low back pain is likely to increase when the back is bent backward (sometimes increased by bending forward). It may occur on both sides. It is more likely to occur by not only prolonged exercise but also prolonged standing, sitting, and half-standing positioning. However, it is not accompanied by neuroparalysis like lumbar disc herniation. Aching pain increases the tone of the erector spinae muscles.
Differential Diagnosis
Lumbar disc herniation causes a sharp pain, such as sciatica, that tends to cause perception disorder and paralysis of movement in lower extremity on one side.
Treatment and rehabilitation
Treatment
Conservative treatment is generally the first choice. Even when conservative treatment is chosen, the duration of rest depends on whether the patient is treated for bone union (for 6 to 12 months) or for pain relief (for 1 to 3 months). Sports activities that stress the trunk may be suspended for 3 to 6 months. In practice, the athletes and their surroundings tend not understand that long period of rest is necessary for recovery, and early return often results in recurrence of the symptoms. Therefore, complete explanation and understanding of the condition is essential. Aching pain can be treated with physical therapy, such as hot packs, low-frequency waves, and interference waves, and with anti-inflammatory analgesics. A wide lower back belt (corset) may also help protect the trunk. Once aching pain is relieved after a period of rest, basic exercises, such as stretching the trunk and exercising the ventrodorsal muscles, are allowed to restart. Surgery is adequate for cases in which the athlete wishes to persist competition for prolonged time, and it is resistant to conservative treatment, in which the aching pain may remain for prolonged period. Osteoplasty or spinal fusion may be performed if the separation is highly instable.
Typical example
This was an actual case of a 14-year-old, male, junior high school student involved in judo. He practiced judo for 4 years, first stage level, 5 days a week, 2 and a half hours a day, without muscular force training and stretching.
His main complaints: Low back pain and buttock pain.
Present medical history. He developed a pain in the lumbar region about a year ago after judo exercises. Recently, it became a serious back pain affecting the whole lumbar while he continued without treatment, and it became difficult for him to keep standing not only during sports but also in daily life. He sought a diagnosis at a sports orthopedic clinic. Holding the same posture and prolonged walking were getting difficult for him.
Symptoms at the initial diagnosis: numbness of the foot (-), finger floor distance minus 30 cm, and sciatica (-), with straight leg raising (SLR) slightly decreased at 80 degrees on both sides. Range of motion in anteroposterior flexion of the trunk decreased and it was difficult for him to stand up or bend down. He was able to move without trunk movement.
Family history: There was no significant family history.
Diagnosis: The X-ray revealed separation of fifth lumbar vertebra on both sides (collar of a terrier dog). The fracture of articular process in lumbar (bone continuity was disrupted) was confirmed by CT.
Treatment: In the initial stage, the patient was prohibited from any activity involving the trunk, such as judo, for a month. Since the strong back pain was relieved two weeks later, he started mild stretching of the trunk and water walking exercise . He also started ventrodorsal training and running a month later. Six months later, low back pain appeared with prolonged practice, but it improved by daily rotational stretching of the trunk and strengthening of the ventrodorsal muscles.
Hitoshi Takahashi
Hitoshi Takahashi
Associate Professor, the Department of Regional Medicine, Teikyo Heisei University
A certified athletic trainer from the Japan Sport Association, a practitioner of acupuncture and a massage practitioner
Trainer's edition
Prevention
To reduce the strain on the lumbar spine, it is important to ensure the range of motion while maintaining flexibility of the trunk and the hip joint muscles, and strengthen the trunk muscles. Particular attention should be given to the limitation in a range of motion of hip joint, because the lumbar spine may compensate the movement (retroflexion of lumbar spine may compensate a limitation of hip joint extension), and that stress may contribute to the development of lumbar spondylolysis.
On-site evaluation and first aid
Points of evaluation at sports sites
Lumbar spondylolysis is characterized by retroflexion pain of the trunk and tenderness and recessus of the spinous processes (Photo 1). Retroflexion movements need to be checked whether the person does retroflexion with only the lumbar spine when seeing from the lateral side (Photo 2). In addition, growing athletes need to be careful if they have low back pain that lasts for more than a week. Athletes who are suspected of having the lumbar spondylolysis based on these assessments should seek medical attention.
Photo 1: Spinous process can be checked from the direction of the buttock to seek the tenderness.
Photo 2: Retroflexion movements need to be checked whether the person does retroflexion of the trunk with only the lumbar spine when seeing from the lateral side.
Reconditioning
Athletic rehabilitation
During the acute phase, when symptoms such as pain and muscle tightness are severe, physical therapy or stretching may help relieve symptoms. Physical therapy during the acute phase would be icing therapy (cryotherapy). Heat therapy, such as hot packs, may be used when the symptom become stable and in a chronic phase. On the other hand, stretching may be performed on the lower back, buttock, and thigh regions. Make sure to be careful not to increase hip joint extension or lumbar spine lordosis, which induces pain, in each movement (Photos 3 to 6).
Photo 3: Stretching the lower back
A: At sitting position, flexing the upper body roundly the entire back with the knees slightly flexed, with the legs open in a sitting position. With the legs opening in a sitting position and the knees slightly flexed, the upper body is flexed so that the entire back is rounded.
B: Using balls is effective.
Photo 4: Stretching the buttocks
Placing the upper body on the foreleg and stretch the left buttock in the photograph). Changing the position of the foreleg also changes the feeling of stretching.
Photo 5: Stretching the quadriceps
Make sure to be careful not to have pain by avoiding the lower back from diverting.
Photo 6: Stretching the hamstrings
The upper body is flexed as the athlete hunches the entire back.
When the symptoms subside, athletic rehabilitation progresses to the next stage. One of the causes of the lumbar spondylolysis is that retroflexion of the trunk is not done with pelvic retroversion or hip joint extension, but only with the lumbar spine. Thus, in athletic rehabilitation, stretching the hip joint extension and training of the abdominal muscles to encourage pelvic retroversion should be performed to reduce the strain on the lumbar spine during retroflexion of the trunk. Hip joint extension stretching is conducted in stages to the extent that pain is not present (Photo 7).
Photo 7: Stretching hip joint
A: Self-stretching
Extension is done gradually from the neutral position
B: Stretching with partners
A trainer should stabilize the patient’s pelvis and conduct the stretching (The photo shows stretching on the left side for explanation, but he/she originally should be positioned on the same side with the athlete).
The exercise to tilt the pelvis backward is initially performed by the trainer while checking the movement (Photo 8-A). As the patient gets used to it, it can be done by himself/herself (Photo 8-B) and gradually proceed to the abdominal muscle training (Photo 9).
Photo 8: Exercise to tilt the pelvis backwards
A: The trainer puts his/her hands on the lower back and let him/her press the hands with the lower back.
B: The hands is placed on the lower back, and the lumbar region compresses the hands with contraction of the abdominal muscles. The athlete memorizes the movement that tilt the pelvis backward by a contraction of the abdominal muscle. The upper body is lifted to the extent that the navel can be seen.
Photo 9: Training of the Abdominal Muscles
A: Sit-up
B: Crunch
Conditioning
For athletes with not only the lumbar spondylolysis but also low back pain, the important points of conditioning are to maintain flexibility around the trunk and hip joint, and to increase the trunk muscles.
