Spine injuries in gymnasts and swimmers. An epidemiologic investigation

Three groups of top level female gymnasts of preelite, elite, national and Olympic caliber were studied without regard to back pain or injury. These athletes were compared to a similar group of national caliber female swimmers. Magnetic resonance imaging scans of each participant were used to document disk or bony abnormalities. The relationship between magnetic resonance imaging findings and age, height, weight, previous injuries, back symptoms, and hours of training per week each year was examined. Nine percent of preelite (1/11), 43% of elite (6/14), and 63% of Olympic level (5/8) gymnasts had spine abnormalities; 15.8% of all swimmers had spine abnormalities. Average hours of training per week and age were found to be associated with abnormalities seen on magnetic resonance imaging. Increased intensity and length of training correlated with previous data that suggests the female gymnast is prone to spine injuries.     

Diagnosis and evaluation of spondylolisthesis and/or spondylolysis on axial CT

A critical review was made of the CT findings in 300 patients who underwent axial CT of the lumbar spine in which spondylolysis and/or spondylolisthesis had been diagnosed. Findings indicate that axial CT is superior to conventional radiographs in several areas: (1) for consistent and accurate demonstration of spondylolysis, (2) for disclosing the various changes in the apophyseal joints associated with degenerative and reverse spondylolisthesis, and (3) for uncovering minimal degrees of spondylolisthesis by the presence of a pseudobulging disk in many cases with equivocal or negative radiographs. Axial CT is a highly accurate method for diagnosing and evaluating spondylolysis and all types of spondylolisthesis.     

Low back pain in elite rhythmic gymnasts

BACKGROUND: Rhythmic gymnastics is a sport that blends the athleticism of a gymnast with the grace of a ballerina. The sport demands both the coordination of handling various apparatus and the flexibility to attain positions not seen in any other sport. To attain perfection and reproducibility of their routines, the athletes must practice and repeat the basic elements of their routines thousands of times. In so doing, the athlete places herself at risk of a myriad of overuse injuries, the most common being low back pain. METHODS: To document the presence and severity of low back pain in elite rhythmic gymnasts, a prospective study of seven national team members was undertaken that documented injuries and complaints with daily medical reports over a 7-wk period. These findings were correlated with a retrospective review of 11 elite level gymnasts followed over a 10-month period whose complaints ultimately required evaluation by a physician. RESULTS: Eighty-six percent of the gymnasts in the prospective study complained of back pain at some point over the course of the study. The only injury recorded that required a time loss from sport was a low back injury. The most common complaint requiring a physician's evaluation was low back pain with the diagnoses varying from muscle strains to bony stress reaction or complete fracture of the pars inter-articularis (spondylolysis). No athlete had a spondylolisthesis or ruptured disk. Two had mild scolioses which did not appear to be associated with their low back pain. CONCLUSIONS: It would appear that rhythmic gymnasts are at relative increased risk of suffering low back complaints secondary to their sport.     

New strategies in the management of low back injuries in gymnasts

Low back pain is an extremely common complaint in competitive gymnasts, and these athletes are at risk for multiple potential structural injuries to the spine. Of particular concern among gymnasts is spondylolysis. Unfortunately, there are no published, controlled trials on the diagnosis or treatment of spondylolysis in adolescent athletes. However, based on the current literature, there would appear to be little role for the use of plain radiography in the diagnosis of symptomatic spondylolysis; nuclear imaging with single photon emission computed tomography (SPECT) appears to represent the best screening tool for diagnosis. Given the limited specificity of nuclear imaging in the spine, it is generally best to follow any positive study with a limited thin-cut computed tomography scan of the region of concern on the SPECT. Treatment should be based on the radiographic stage of the lesion. Relative rest is an essential component of care. Although the rehabilitation of gymnasts with lumbar injuries is poorly studied, the related literature would support incorporating the concepts of dynamic lumbar stabilization and sport-specific training into their rehabilitation programs.     

Painful spondylolysis or spondylolisthesis studied by radiography and single-photon emission computed tomography

Planar bone scintigraphy (PBS) and single-photon emission computed tomography (SPECT) were compared in 19 adults with radiographic evidence of spondylolysis and/or spondylolisthesis. SPECT was more sensitive than PBS when used to identify symptomatic patients and sites of "painful" defects in the pars interarticularis. In addition, SPECT allowed more accurate localization than PBS. In 6 patients, spondylolysis or spondylolisthesis was unrelated to low back pain, and SPECT images of the posterior neural arch were normal. The authors conclude that when spondylolysis or spondylolisthesis is the cause of low back pain, pars defects are frequently heralded by increased scintigraphic activity which is best detected and localized by SPECT.     

Disc degeneration in young gymnasts. A magnetic resonance imaging study

Magnetic resonance imaging (MRI) was performed on 35 young competitive gymnasts and 10 control subjects in order to detect the number of degenerated discs and other lumbar spinal disorders. Lumbar radiographs were obtained from all gymnasts who showed evidence of disc abnormality on MRI. Eleven gymnasts had suffered from episodes of low back pain during exercises and eight were found to have evidence of back trauma. Only 3 of the 35 gymnasts had MRI evidence of degenerated discs associated with Scheuermann's manifestations and spondylolysis. Lumbar radiographs confirmed the diagnosis in these three cases. The results indicate that despite the excessive range of motion and strong axial loading of the lumbar spine that are associated with gymnastic maneuvers, incurable primary damage to the intervertebral discs is uncommon in young gymnasts during growth.     

Back injuries in the pediatric athlete

Pediatric and adolescent athletes presenting with back pain are much more likely to have a pathologic cause for their symptoms than are adult patients. For this reason, it is important for those caring for younger athletes to maintain a high index of suspicion for some of the more common pathologic causes of back pain in this population. Diagnostic evaluation should be undertaken more quickly in pediatric and adolescent athletes. Sports-related diagnoses that must be considered include disc-related back pain, atypical Scheuermann’s kyphosis, spondylolysis, and spondylolisthesis. Patients of this age may also present with conditions not associated with activity, including discitis, classic Scheuermann’s disease, rheumatologic disease, and spinal tumors. History and physical exam provide valuable information to help guide further diagnostic studies which, in turn, will determine necessary treatment. No definitive studies are available regarding the diagnosis and treatment of spondylolysis and spondylolisthesis. Health professionals need to consider the expertise of a local radiologist when deciding upon diagnostic imaging procedures. The athlete’s age and sport played can contribute to the appropriate treatment plan.     

Spondylolysis and spondylolisthesis in the athlete

Spondylolysis and spondylolisthesis are common diagnoses made in the athlete suffering from persistent back pain. Although the etiology of this continuum of conditions is uncertain, genetic predisposition and repetitive trauma have been strongly implicated. Sports in which participants are subjected to repetitive hyperextension across the lumbar spine pose a risk for such injuries. Football lineman, oarsmen, dancers, and gymnasts show high rates of these conditions. Treating the athlete with spondylolysis and/or spondylolisthesis can be a challenge. An inherent drive for return to competition, pressure from coaches and family, and obligations to the team can confound decision making on both the part of the patient and the treating physician. Although this motivation for prompt return to sports must certainly be considered, a safe return to competition is paramount.     

MR imaging of the pars interarticularis

MR imaging of the lumbar spine has become a useful method for the noninvasive evaluation of low back pain. However, bone abnormalities are more difficult to detect than soft-tissue lesions, such as herniated disk. We reviewed 14 MR images of the lumbar spine in adults with spondylolisthesis. These were correlated with CT scans and plain films in all cases. From the CT scans and plain films we found that seven patients had spondylolysis and that seven had other causes for their spondylolisthesis. It was our opinion that the MR images suggested an abnormality of the pars interarticularis in all seven of the cases confirmed to have spondylolysis and in six of the seven patients that did not have spondylolysis. We also studied four cadaver lumbar spine, obtained as blocks of tissue, and scanned in the coronal, sagittal, and axial planes with MR and in the sagittal and axial planes with CT. The tissue blocks were then sectioned in the sagittal plane. Spondylolysis is suggested on sagittal MR images when there is an inability to resolve the marrow signal in the pars as uninterrupted from the superior to the inferior facet. This is caused by a dark signal on all pulsing sequences in the pars resulting from marginal sclerosis at the site of the break. If there is also a gap at the site of the break then there will also be an increased signal in the gap resulting from the presence of soft tissue. We found four situations in which the pars can simulate spondylolysis on sagittal MR images: (1) sclerosis of the neck of the pars: (2) partial volume imaging of the degenerative spur of the superior facet slightly lateral to the pars; (3) partial facetectomy; and (4) osteoblastic metastatic replacement of the marrow of the pars.     

Oblique lumbar spine radiographs: importance in young patients

Spondylolysis is a direct precursor of spondylolisthesis and can lead to crippling back pain. Of 1,743 patients surveyed, including 936 who were asymptomatic and 807 with back pain, 165 (including 91 who were asymptomatic and 74 with back pain) had spondylolysis, which was seen only on oblique lumbar views in 20% of cases. Because of the high false-negative rate of AP and lateral views, oblique views are essential in children and young adults. As spondylolysis is rare above L3, radiographs can be limited to L3-S1. Significantly less spondylolysis was seen in persons older than 30, with back pain usually caused by disk degeneration; thus routine oblique views could be safely omitted in older patients.     

Computed tomography of spondylolisthesis: patterns of associated pathology

Spondylolisthesis was observed in 165 of 2,500 patients with back pain evaluated by CT. In more than two-thirds of these patients a second structural abnormality was found in association with the spondylolisthesis. The nature and location of this second abnormality varied with the type of spondylolisthesis: spondylolytic or degenerative. Spondylolytic spondylolisthesis, caused by a defect in the pars interarticularis, was associated with foraminal stenosis at the level of the defect in the pars and disk protrusion at the interspace immediately above this level. Degenerative spondylolisthesis, caused by facet joint disease, was associated with disk protrusion and spinal stenosis at the same level as the spondylolisthesis. The advantages and limitations of CT in the evaluation of symptomatic patients with spondylolisthesis are discussed.     

Radiographic abnormalities of the lumbar spine in college football players. A comparative analysis.

The purpose of this study was to make a direct comparison between lumbar spine radiographs of incoming college football players and of an age-matched control group to determine whether there is a higher prevalence of lumbar spine abnormalities in football players before competing at the Division I level. We reviewed 187 lumbar spine radiographs. Of these, 104 were taken as a standard part of the preparation physical examination for incoming college football players. The remaining 83 radiographs were taken during routine preemployment physicals at a local factory. Each radiograph was read independently by three separate orthopaedic radiologists in a blinded fashion. Data were collected and statistically evaluated for 13 variables. The rate of spondylolysis was only 4.8% in our group of athletes and 6.0% in the control group (not significantly different). Only in the category of degenerative changes was a significant difference found. The control group had a 16.9% incidence of disk space narrowing and spurring and the football players had a 6.7% incidence. The remainder of the variables were not significantly different between the two groups. Our findings differ from previously published reports and indicate that football players entering college at the Division I level may have a similar prevalence of radiographic lumbar spine abnormalities, including spondylolysis and spondylolisthesis, as age-matched controls.     

腰椎轴向负荷MRI对腰椎退行性疾病诊断的影响

目的 评估仰卧位轴向负荷MRI对腰椎退行性疾病诊断的影响.方法 对30名健康志愿者及89例腰腿痛患者进行了常规仰卧腰大肌放松体位(PRP)和仰卧位轴向负荷(ACE)MRI.89例腰腿痛患者中慢性下腰痛61例,坐骨神经痛19例,神经性跛行9例.观察、分析下腰椎(L3～4、L4～5、15～S1水平)椎管变化情况.结果 30名志愿者90个椎间盘水平ACE检查发现10名(33.3%)共14个椎间盘水平(15.6%)硬膜囊横截面积(DSCA)缩小15 mm2以上.89例患者267个椎间盘水平ACE检查发现38例(42.7%)55个椎间盘水平(20.6%)DSCA缩小15 mm2以上(平均缩小28 mm2).89例患者中ACE检查还发现有26例32个椎间盘突出程度加重,12例16个椎间盘水平椎间孔狭窄,10例11个水平黄韧带增厚,3例3个水平小关节半脱位,3例3个水平椎体滑脱.89例患者中22例(24.7%)ACE检查提供了更多的有效信息,其中7例(7/9)神经性跛行患者、8例(8/19)坐骨神经痛患者及11.5%(7/61)下腰痛患者ACE检查提供了有效信息.结论 与常规检查方法比较,ACEMRI能提供附加有效信息,能发现更多的隐匿性病变,对诊断腰椎退行性病变具有重要意义.     

Common causes of low back pain in children.

Low back pain in children and adolescents is often caused by a serious problem. The diagnostic investigation should begin with a complete patient history, complete physical examination, laboratory testing, and plain radiography. These results should be used to direct further imaging studies. Although most of the painful injuries that children sustain in recreational activities are mild, back pain that lasts for extended periods may be due to various disorders, including spondylolysis and spondylolisthesis, disk herniation, Scheuermann disease, or neoplasms. Low back pain can also be caused by diskitis and osteomyelitis, most commonly found in children younger than 10 years old. Primary osseous neoplasms of the lumbar spine are uncommon, with Ewing sarcoma, aneurysmal bone cyst, benign osteoblastoma, and osteoid osteoma being the most common followed by primary lymphoma. These lesions occur more often between the ages of 5 and 20 years. Other causes of low back pain include spinal cord tumors (eg, ependymoma), congenital disorders of the spine (eg, scoliosis), and systemic disease (eg, sickle cell disease).     

Spondylolysis and spondylolisthesis in military parachutists.

This paper reports on three cases of symptomatic low back pain in three paratroopers in association with bilateral L5 spondylolysis and L5 on S1 spondylolisthesis. The controversy regarding the etiology of this lesion as well as the problems of establishing causality when associated with parachuting injuries are discussed. These cases raise the issue of whether routine lumbar spine roentgenography should be performed as part of the pre-course medical screening prior to an individual undertaking basic parachutist training, and stress the need for further study of the relevance of these lesions in military parachuting.     

Acquired degenerative changes of the intervertebral segments at and suprajacent to the lumbosacral junction. A radioanatomic analysis of the nondiscal structures of the spinal column and perispinal soft tissues

A review of the imaging features of normal and degenerative anatomy of the spine on medical imaging studies shows features that have been largely overlooked or poorly understood by the imaging community in recent years. The imaging methods reviewed included computed tomography (CT) with multiplanar reconstructions and magnetic resonance imaging (MRI). A routine part of the MRI examination included fat-suppressed T2 weighted fast-spin- or turbo-spin-echo acquisitions. As compared to the normal features in asymptomatic volunteers, alterations in the observed CT/MRI morphology and MR signal characteristics were sought in symptomatic individuals. Findings in symptomatic subjects which departed from the normal anatomic features of the posterior spinal elements in asymptomatic volunteers included: rupture of the interspinous ligament(s), neoarthrosis of the interspinous space with perispinous cyst formation, posterior spinal facet (zygapophyseal joint) arthrosis, related central spinal canal, lateral recess (subarticular zone) and neural foramen stenosis, posterior element alterations associated with various forms of spondylolisthesis, and perispinal muscle rupture/degeneration. These findings indicate that the posterior elements are major locations of degenerative spinal and perispinal disease that may accompany or even precede degenerative disc disease. Although not as yet proven as a reliable source of patient signs and symptoms in all individuals, because these observations may be seen in patients with radicular, referred and/or local low back pain, they should be considered in the evaluation of the symptomatic patient presenting with a clinical lumbosacral syndrome. Imaging recommendations, in addition to the usual close scrutiny of these posterior spinal elements and perispinal soft tissues on CT and MRI, include the acquisition of high-resolution multiplanar CT reconstructions, and fat-suppressed T2 weighted fast-spin- or turbo-spin-echo sequence MRI in at least one plane in every examination of the lumbar spine.     

Spondylolysis as a cause of low back pain in swimmers

Low back pain (LBP) has recently become a common complaint in swimmers. The differential diagnosis of LBP in swimmers includes muscle and ligament sprains, Scheuerman disease, herniated disc, facet joint injury, tumors, infections, and spondylolysis. Although spondylolysis or listhesis is a frequent injury in the athlete, mainly in weightlifters, wrestlers, gymnasts, divers and ballet dancers, it is infrequently reported in swimmers. We have recently encountered four adolescent elite swimmers who complained of low back pain and were diagnosed as having spondylolysis. Three of the patients were either breast-strokers or butterfly swimmers. Plain radiography demonstrated the lesion in two patients. Increased uptake in bone scan was noted in all patients. CT was performed only in two patients and revealed the lesion in both. One patient was diagnosed within two weeks, and the diagnosis in the others was deferred for 2-7 months. The patients were treated successfully by reducing the intensity of their training program and the use of a corset for at least three months. Repeated hyperextension is one of the mechanisms for spondylolysis in athletes as is the case in breast-strokers and butterfly style swimmers. LBP in swimmers should raise the suspicion of spondylolysis. Plain radiography and bone scan should be performed followed by SPEC views, CT, or MRI as indicated. If the case is of acute onset as verified by bone scan, a Boston or similar brace should be used for 3 to 6 months in conjunction with activity modification and optional physical therapy. Multidisciplinary awareness of low back pain in swimmers, which includes trainers, sport medicine physicians, and physical therapists, should lead to early diagnosis and appropriate treatment.     

腰椎峡部裂的MRI表现

目的：探讨腰椎峡部裂的MRI诊断价值。方法：回顾性分析24例腰椎峡部裂患者的MRI检查资料。结果：24例腰椎峡部裂的MRI表现为腰椎峡部出现不规则状骨性缺损、脊椎滑脱、椎管前后径增大、椎间盘变形、椎间孔变形等。结论：腰椎峡部裂有特征性的MRI表现,MRI可为临床评价该病提供正确、全面的影像学证据。     

Does football cause an increase in degenerative disease of the lumbar spine?

Degenerative disease of the lumbar spine is exceedingly common. Whether any specific activity increases the likelihood of developing degenerative disc disease (DDD) or facet degeneration (FD) has enormous implications. Within the field of occupational medicine there are specific activities, occupations, and morphologic characteristics that have been related to low back pain. Several specific risk factors have been conclusively linked to low back pain, and in particular DDD and FD. Within the sport of American football, there has long been the feeling that many athletes have or will develop low back pain, DDD, and FD. Proving that certain risk factors present in football will predictably lead to an increase in LBP, DDD, and FD is more difficult. At this time, it can be said that football players, in general, increase their risk of developing low back pain, DDD, and FD as their years of involvement with their sport increase. Because specific spine injuries like fracture, disc herniation, and spondylolysis are more frequent in football players, the resulting DDD and FD are greater than that of the general population. The weightlifting and violent hyperextension that are part of American football are independent risk factors for degenerative spine disease.     

Degenerative disk vascularization on MRI: correlation with clinical and histopathologic findings

 Objective. This prospective study was designed to determine the MRI features, clinical significance, and correlation to histopathologic findings of secondary vascularized degenerative intervertebral disks. Materials and methods. Fifty-three patients with localized painful spine syndrome were investigated prospectively by contrast-enhanced MRI. Pain was not predominantly radiating and there was no clinical evidence of spinal infection. In all patients sagittal SE T1-weighted, fast-SE T2-weighted or turbo-STIR, and T1-weighted frequency-selective fat-suppressed images were obtained. Results. We identified 37 vascularized disks in 26 patients. In 18 patients the changes had occurred spontaneously, in 6, the affected disk had been operated on previously, and 2 patients had spondylolisthesis. In 15 patients, vascularization was accompanied by medullary edema adjacent to the vertebral endplates. In one of the vascularized disks, herniation was also found. In seven patients, ventral diskectomy was performed. Histopathologic findings confirmed disk vascularization in six of seven cases. Conclusions. Degenerative, band-like disk vascularization is a feature which is associated with local pain. It is demonstrated by contrast-enhanced MRI. Degenerative disk vascularization is an important differential diagnosis to bacterial spondylodiskitis. It can be a cause of pain in patients with postdiskectomy syndrome.