Pars interarticularis stress and disc degeneration in cricket's potent strike force: the fast bowler.

Cricket fast bowlers are the potent strike force in a multidiscipline team. They subject their spines to repetitive sagittal plane and rotatory movements over many years. The effect of this repetitive stress has not previously been analysed. This study examined 20 former fast bowlers to determine the incidence of spondylolysis, spondylolisthesis and degenerative change. Fast bowlers are noted to have an increased incidence of spondylolysis. A mixed front/side bowling style involving more lumbar hyperextension or rotation has significant association with spondylolysis when compared with side-on bowling styles. There was a high incidence of radiological thoracolumbar degenerative facet joint and disc disease in former fast bowlers.     

Spinal abnormalities in young fast bowlers.

The action of fast bowling in the game of cricket is known to cause injuries to the lumbar spine. We studied a group of 16- to 18-year-old fast bowlers, selected for special training in Western Australia. All 24 had MR scans of the spine, 22 had radiographs and CT scans; in 20 the bowling technique was analysed biomechanically. There was a high incidence of back pain and this was always associated with a radiological abnormality. Pars interarticularis defects were diagnosed in 54% and intervertebral disc degeneration in 63%. Bowling actions which involved counter-rotation were associated with a higher incidence of both injuries.     

Treatment of Bowler’s Neuroma with Digital Nerve Translocation

Bowler’s thumb presents as paresthesias or a neuroma involving the ulnar digital nerve of the thumb. Over 95 million people enjoy bowling worldwide with nearly 3 million certified league bowlers in the United States. While the incidence of Bowler’s thumb is unknown, it is an unrelenting nuisance for bowlers, and symptoms can be severe enough to prevent further sport participation. The condition can be managed nonoperatively with rest and splinting, but successful nonoperative treatment frequently requires discontinuation of bowling. The pressure on athletes to resume sports participation sooner and the possibility of nonoperative treatment failure mandate the need for development of a dependable surgical procedure for this condition. We present a case report of a successful surgical treatment by transposing the ulnar digital nerve dorsal to the adductor pollicis. The patient returned to manual labor and resumed bowling and is symptom free 3 years postsurgery.     

Back injuries in young fast bowlers--a radiological investigation of the healing of spondylolysis and pedicle sclerosis.

OBJECTIVE: To demonstrate the efficacy of various radiological diagnostic modalities in assessing lower back pain in young fast bowlers. METHODS: Ten cricketers who presented to either a physiotherapist or a doctor with suspected spondylolysis underwent an X-ray, a single photon emission computed tomography (SPECT) bone scan and a computed tomography (CT) scan to assess the severity of the injury. Three and 12 months after the initial CT scan, second and third CT scans were performed in order to assess whether healing had taken place. After the initial radiological investigation the subjects diagnosed with spondylolysis or pedicle sclerosis underwent prescribed intervention and rehabilitation which included physiotherapy modalities, postural correction, and specific individually graded flexibility, stabilisation, strengthening and cardiovascular programmes. RESULTS: Radiographs were normal in 8 subjects, while 2 had evidence of sclerosis. The isotope scan showed increased uptake in all of the subjects. The CT scans showed no fracture (N = 3), partial fractures (N = 3), complete fractures (N = 2) and old fractures bilaterally (N = 2). When the follow-up CT scan was carried out at 3 months, 1 of the subjects had developed a partial fracture of the left pars interarticularis on the inferior border, which showed complete union when CT scanned at 12 months. At 3 months the partial and complete fractures showed progressive healing in 2 subjects, with complete healing in all the other cases. Complete healing was achieved in all subjects at 12 months, with the exception of 1 subject who showed near-complete union, with a small area of fibrous union on the inferior border and 2 old bilateral fractures that remained un-united. RESULTS: From the results it is evident that when a young fast bowler presents with backache after bowling, it would be appropriate to do an X-ray, a bone scan and a CT scan to make the diagnosis. Discontinuing the fast bowling and following an active rehabilitation programme should result in spontaneous resolution and healing of the fractures. If it is not detected early a fibrous or non-union fracture could result.     

Injury and lumbar reposition sense in cricket pace bowlers in neutral and pace bowling specific body positions

Background and contextThe cricket pace bowling action consists of a complex sequence of forceful actions, involving practiced, particular movements of the lumbar spine. The nature and repetition of the pace bowling action is known to be associated with a high incidence of low back injuries.PurposeThis study aimed to establish whether lumbar proprioception (as measured by joint position sense) in the neutral lumbar spine position as well as lumbar positions corresponding to those at front foot placement and ball release positions of the cricket pace bowling action were related to previous injury and injury sustained during the cricket season under review. Injuries specifically sustained during the bowling action and those specific to the low back were explicitly investigated.Study settingLongitudinal study with participants tested at the start and monitored over the duration of a cricket season.Participant sampleSeventeen male cricket pace bowlers between the ages of 18 and 26 years participated in this study.Outcome measuresPhysiological outcome measures were used. Lumbar position sense was established using electrogoniometry.MethodsLumbar reposition error was measured in three positions (neutral lumbar spine, front foot placement, and ball release bowling positions). In each position, lumbar orientation was determined in the sagittal (flexion-extension) and coronal (left-right lateral flexion) planes. Wilcoxon matched-pairs ranks and Kruskal-Wallis tests were used to establish the relationship between variables.ResultsReposition error was associated with general injuries sustained in the past and during the cricket season under review, low back injuries, as well as injuries sustained during the bowling action (p<.05).ConclusionLumbar position sense, as a measure of proprioception, was related to injury in general, injuries sustained during the bowling action, and, especially, low back injury sustained in the past. Low back injury prevention methods are particularly needed because of the high load nature of the pace bowling action. If the proprioception of the lumbar spine is improved in pace bowlers, their risk of lumbar injury can potentially be reduced.     

腰椎滑脱发生部位性别年龄的分布特征

目的探讨腰椎滑脱好发部位、性别、年龄的分布特征。方法随机取我院（同济医院）骨科2000年1月至2006年12月期间腰椎滑脱手术病例共149例,剔除合并脊柱外伤、先天、手术后、病理性疾病等12例,对其余137例从发病部位、性别、年龄等各方面进行统计学分析。结果女性退行性腰椎滑脱总的发病数是男性的2.48倍;男女各年龄段不同部位、性别腰椎滑脱发病数呈非正态性分布;L4峡部裂性滑脱平均年龄与L5峡部裂性滑脱平均年龄之间有显著性差异;腰椎退行性滑脱发生的平均年龄为51.88岁,比峡部裂性滑脱（46.47岁）发生晚,两者有显著性差异。结论腰椎滑脱发生性别、年龄有显著性差异。女性退行性滑脱的发生率大于男性,40~60岁为腰椎滑脱的高发时段,峡部裂组发生平均年龄早于退行变组。     

Spondylolisthesis and related disorders. A correlative study of 105 patients

A close relation exists among the alterations in the lumbosacral spine designated as spondylolysis, isthmic spondylolisthesis, degenerative spondylolisthesis, and prespondylolisthesis. While the former two conditions are probably caused by faulty development and subsequent minor traumata or repeated stresses, the third condition is caused by degenerative changes associated with anatomic variations; the fourth condition is a static insufficiency leading to faulty alignment. In 105 patients, the initial preferred management of these conditions was conservative. Thirty-four patients who developed persistent symptoms of spinal instability and/or intractable neurologic deficits were treated surgically. The results were generally successful.     

腰椎滑脱部位性别年龄的关系分析

目的 :探讨腰椎峡部裂滑脱和退行性滑脱在发生部位、好发年龄和性别分布三方面差异。方法 :随机取 2 0 0 1年 1月～ 2 0 0 4年 1月期间手术的峡部裂滑脱和退行性滑脱共 76例 ,从发病部位、性别、年龄三方面进行统计学分析。结果 :腰椎滑脱不同类型在滑脱部位方面存在显著性差异 ,L5峡部裂发病率高于L4,L4退变性滑脱发病率高于L5。不同性别在滑脱部位方面无显著性差异。 40～ 5 0岁为腰椎滑脱的高发时段 ,退变组平均年龄大于峡部裂组。结论 :腰椎峡部裂滑脱和退行性滑脱在发生部位、好发年龄、性别分布三方面存在差异 ,为鉴别诊断和治疗提供帮助。     

Bone Density and Cross-sectional Geometry of the Proximal Femur Are Bilaterally Elevated in Elite Cricket Fast Bowlers

The skeleton of a cricket fast bowler is exposed to a unique combination of gravitational and torsional loading in the form of substantial ground reaction forces delivered through the front landing foot, and anterior-posterior shear forces mediated by regional muscle contractions across the lumbo-pelvic region. The objectives of this study were to compare the hip structural characteristics of elite fast bowlers with recreationally active age-matched controls, and to examine unilateral bone properties in fast bowlers. Dual-energy X-ray absorptiometry of the proximal femur was performed in 26 elite male fast bowlers and 26 normally active controls. Hip structural analysis (GE Lunar; enCORE version 15.0) determined areal bone mineral density (BMD) of the proximal femur, and cross-sectional area, section modulus (Z), cross-sectional moment of inertia, and femoral strength index at the narrow region of the femoral neck. Mean femoral neck and trochanter BMD were greater in fast bowlers than in controls (p?<0.001). All bone geometry properties, except for cross-sectional moment of inertia, were superior in fast bowlers (p?<0.05) following adjustment for height and lean mass. There were no asymmetries in BMD or bone geometry when considering leg dominance of the fast bowlers (p?>?0.05). Elite fast bowlers have superior bone characteristics of the proximal femur, with results inferring enhanced resistance to axial compression (cross-sectional area), and bending (Z) forces, and enhanced strength to withstand a fall impact as indicated by their higher femoral strength index. No asymmetries in hip bone properties were identified, suggesting that both torsional and gravitational loading offer significant osteogenic potential.     

Magnetic resonance imaging of the lumbar spine in asymptomatic professional fast bowlers in cricket

Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.     

腰椎滑脱椎体终板Modic改变的分布情况及影响因素

目的探讨腰椎滑脱椎体终板Modic改变的分布情况,分析峡部裂性滑脱与退变性滑脱终板Modic改变相关影响因素。方法回顾性分析2005年10月～2011年10月收治的264例腰椎滑脱症患者的影像学资料。比较不同类型腰椎滑脱Modic改变的类型,分析不同类型腰椎滑脱中Modic改变与腰椎滑脱程度、椎间盘退变、体重指数、劳动量的相关性。结果退变性滑脱113例,其中ModicI型7例（6．2％）,ModicⅡ型38例（33．6％）;峡部断裂性滑脱151例,其中ModicI型12例（7．9％）,Modic1I型23例（15．2％）,Modicm型28例（18．5％）。腰椎滑脱伴Modic改变的患者中,滑脱节段Modic改变发生率显著高于非滑脱节段。不同类型腰椎滑脱中Modic改变与滑脱程度、椎间盘退变、体重指数、劳动量存在明显相关性（P〈0．05）。结论腰椎滑脱中Modie改变与滑脱程度、椎间盘退变、体重指数、劳动量存在相关性;Modic改变在退变性滑脱中Ⅱ型较多,在峡部裂性滑脱中以Ⅲ型多见,并且Modic改变易发生在滑脱节段。     

Two types of laminolysis in adolescent athletes

Bony defects in the spine are divided into three main types: spondylolysis, pediculolysis, and laminolysis. Lumbar spondylolysis is a well-known stress fracture that occurs frequently in adolescent athletes. Pediculolysis means stress fracture of the pedicle, which sometimes occurs subsequent to unilateral spondylolysis. Laminolysis is a rarely reported stress fracture similar to spondylolysis and pediculolysis that sometimes causes low back pain (LBP). However, its pathomechanism has not been elucidated. Recently, we encountered four adolescent athletes with symptomatic laminolysis. Mean age was 15.8 (range 15–17) years. All subjects reported severe LBP exacerbated by extension of the lumbar spine, and radiology revealed two types of laminolysis: hemilaminar type and intralaminar type. To elucidate the mechanisms of each type, we reviewed a biomechanical study, and found that the hemilaminar type was thought to be subsequent to contralateral spondylolysis, while the intralaminar type might be a result of a stress fracture due to repetitive extension loading.     

Rotational instability of the lumbar spine--a three-dimensional motion study using bi-plane X-ray analysis system

The purpose of this study is to investigate the rotational instability of the lumbar spine using bi-plane X-ray analysis system and to clarify mechanical etiology of the lumbar instability. The following results were obtained. (1) The range of rotational motion was about 2 to 3 degrees at each motion segment in the normal lumbar spine. The rotational motion was significantly large in spondylolysis, spondylolisthesis, and degenerative spondylolisthesis. (2) The rotational instability and the flexion-extension instability correlated to each other in spondylolysis and spondylolisthesis. However, in degenerative spondylolisthesis, the rotational instability and the antero-posterior instability were correlated to each other. (3) Instantaneous axis of rotation (IAR) was located at the posterior part of the intervertebral disc in the normal L4 vertebra, and more posteriorly in the L5 vertebra, while the IAR was located anteriorly in spondylolysis, and posteriorly in degenerative spondylolisthesis. (4) When the trunk was twisted, the lumbar lordotic angle was generally decreased, and the lumbar spine showed scoliotic curvature convex to the twisted direction. The apex was located at the L4/5 intervertebral level. Highly significant increases in flexion motion associated with rotation were observed at the pathological levels of spondylolysis and degenerative spondylolisthesis.     

Injuries to the lower back in elite fast bowlers: acute stress changes on MRI predict stress fracture

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded. In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.     

Translamino-pedicular screw fixation with bone grafting for symptomatic isthmic lumbar spondylolysis.

Anterior or posterolateral spondylodesis has been reported and used widely as a surgical treatment for lumbar spondylolysis or spondylolisthesis. Although spinal fusion is necessary when there is extensive vertebral slippage or spinal instability, the direct repair of the defect is thought to be anatomical, logical, and less invasive as a surgical treatment for symptomatic lumbar spondylolysis or a minimal degree of spondylolisthesis. This operation, with a few modifications, has been performed since 1985 in our clinic. The results, using Henderson's criteria, were excellent in 64.5% and good in 25.8% of the patients thus treated. For younger patients with symptomatic lumbar spondylolysis, direct repair of the defect using translamino-pedicular instrumentation with bone grafting is recommended, as degenerative changes have not usually occurred in the vertebral discs.     

Low-back pain in athletes

While most occurrences of low-back pain in athletes are self-limited sprains or strains, persistent, chronic, or recurrent symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stress lesions. The prevalence of radiographic evidence of disc degeneration is higher in athletes than it is in nonathletes; however, it remains unclear whether this correlates with a higher rate of back pain. Although there is little peer-reviewed clinical information on the subject, it is possible that chronic pain from degenerative disc disease that is recalcitrant after intensive and continuous nonoperative care can be successfully treated with interbody fusion in selected athletes. In general, the prevalence of spondylolysis is not higher in athletes than it is in nonathletes, although participation in sports involving repetitive hyperextension maneuvers, such as gymnastics, wrestling, and diving, appears to be associated with disproportionately higher rates of spondylolysis. Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, independent of radiographic evidence of defect healing. In recalcitrant cases, direct surgical repair of the pars interarticularis with internal fixation and bone-grafting can yield high rates of pain relief in competitive athletes and allow a high percentage to return to play. Sacral stress fractures occur almost exclusively in individuals participating in high-level running sports, such as track or marathon. Treatment includes a brief period of limited weight-bearing followed by progressive mobilization, physical therapy, and return to sports in one to two months, when the pain has resolved.     

Geometry of the vertebral bodies and the intervertebral discs in lumbar segments adjacent to spondylolysis and spondylolisthesis: pilot study

The objective is to evaluate the geometric parameters of vertebral bodies and intervertebral discs in spinal segments adjacent to spondylolysis and spondylolisthesis. This pilot cross-sectional study was an ancillary project to the Framingham Heart Study. The presence of spondylolysis and spondylolisthesis as well as measurements of spinal geometry were identified on CT imaging of 188 individuals. Spinal geometry measurements included lordosis angle, wedging of each lumbar vertebra and intervertebral disc. Last measurements were used to calculate ΣB, the sum of the lumbar L1–L5 body wedge angles; and ΣD, the sum of the lumbar L1–L5 intervertebral disc angles. Using Wilcoxon–Mann–Whitney test we compared the geometric parameters between individuals with no pathology and ones with spondylolysis (with no listhesis) at L5 vertebra, ones with isthmic spondylolisthesis at L5–S1 level, and ones with degenerative spondylolisthesis at L5–S1 level. Spinal geometry in individuals with spondylolysis or listhesis at L5 shows three major patterns: In spondylolysis without listhesis, spinal morphology is similar to that of healthy individuals; In isthmic spondylolisthesis there is high lordosis angle, high L5 vertebral body wedging and very high L4–5 disc wedging; In degenerative spondylolisthesis, spinal morphology shows more lordotic wedging of the L5 vertebral body, and less lordotic wedging of intervertebral discs. In conclusion, there are unique geometrical features of the vertebrae and discs in spondylolysis or listhesis. These findings need to be reproduced in larger scale study.     

Global spinal motion in subjects with lumbar spondylolysis and spondylolisthesis: does the grade or type of slip affect global spinal motion?

STUDY DESIGN: This was a prospective pilot study to investigate the global motion characteristics of the spondylolysis and spondylolisthesis populations. OBJECTIVES: The aim of this study is to determine the influence of a spondylolisthesis or a spondylolysis on global spinal motion and to establish whether this is dependent on the cause of the slip or the degree/grade of the slip. SUMMARY OF BACKGROUND DATA: The condition of spondylolisthesis has been extensively discussed in the literature with respect to its etiology and management. However, the mechanics and movement of the spine in relation to pathology and the effect of this condition on function have received scant attention. METHODS: The motion of the lumbar spine was investigated in 31 patients (19 men, 12 women, mean age 47.7 +/- 17.8 years) who were diagnosed as having either a lumbar spondylolysis or a spondylolisthesis. These patients were compared with a preexisting database of 203 normal subjects (100 men, 103 women, mean age 39.8 +/- 13.4 years). Patients were graded according to the type of spondylolisthesis or spondylolysis they had, and the extent of slip was rated using Meyerding's classification (1932) and measured directly using methods of Boxall et al (1979) and Wiltse et al (1983). RESULTS: Direct measurements of the extent of slip using Boxall et al (1979) and Wiltse et al (1983) methods were found to have no significant correlation with the resultant range of motion (ROM) or the speed of movement. This study suggests that motion parameters are influenced by the grade of slip in patients with spondylolisthesis, and the type of spondylolisthesis i.e., whether isthmic or degenerative. In the A-P flexion-extension plane, the results indicate that subjects with a defect only, i.e., a spondylolysis, and thus no slip present with a spinal hypermobility (P < 0.01). Subjects with an isthmic slip tend to be either slightly hypermobile or within the anticipated range of motion, whereas those subjects with a degenerative slip tend to be hypomobile (P < 0.05). Movements into lateral flexion were restricted in both the isthmic and degenerative spondylolisthesis patients, whereas rotation was only influenced by the level at which the defect occurred. In terms of degree of displacement, in higher grades of displacement, there was a trend towards hypermobility. CONCLUSIONS: The findings of this study suggest that the grade and type of spondylolisthesis do influence global motion parameters. This information may be useful in the clinical assessment of this patient group.     

Spondylolysis and associated spondylolisthesis in Eskimo and Athabascan populations

Roentgenographic and anthropologic studies have shown a high incidence of spondylolysis in Eskimo populations. It is uncertain whether this is related to a genetic predisposition or to environmental factors. This study of recent roentgenograms and demographic characteristics of patients of the authors' institution notes a lower incidence in Eskimo populations than prior skeletal and roentgenographic studies. An attempt is made to quantitate the contributions of environmental factors and genetic predisposition. A higher incidence was found in full-blooded Eskimos than in part-blooded Eskimos. Rural-dwelling Eskimos had a higher incidence than urban-dwelling Eskimos. Eskimo subpopulations had a greater incidence than Athabascan Indians. Eskimos with spondylolysis were significantly more likely to have an associated spondylolisthesis than Athabascans with spondylolysis. Symptoms in the Eskimo population related to spondylolysis and associated spondylolisthesis rarely warrant surgical intervention.     

Symptomatic and asymptomatic spondylolysis and spondylolisthesis in young adults

The lumbar spine was examined radiologically for the presence of spondylolysis and spondylolisthesis in 936 asymptomatic soldiers prior to military placement and in 662 soldiers complaining of low back pain. The overall incidence of spondylolysis was 9.7% in both groups, but bilateral spondylolysis was more prone to be associated with symptoms than a unilateral defect. In the symptomatic group the incidence of spondylolisthesis was 5.3% but only 2.2% in the asymptomatic group. The defect was seen in the oblique views only in 18.7% of the cases of spondylolysis. The precise diagnosis is important for vocational counselling and military placement.