Repair of pars interarticularis defect with a modified cable-screw construct

Operative treatment of symptomatic spondylolysis is not common. Multiple surgical techniques have been described for direct repairs of the pars defects. Reported success rates are high, although few reports describe successful return to sports in athletes. The purpose of the study was to assess the outcome after bone grafting and fixation of pars interarticularis defects utilizing a modification of the previously described techniques of Scott and of Songer. A retrospective single-arm cohort study was performed at a single center. This article reports on three athletes with symptomatic spondylolysis or grade I spondylolisthesis unresponsive to conservative management who were treated with bone grafting and a screw-cable repair. The outcome measure was the return to sports activities. A retrospective chart and radiographic analysis was conducted on three athletes. Patients were assessed for return to sports, clinical evidence of return to functional activities, and radiographic evidence of healing of the pars defects. All three patients proceeded to radiographic and clinical success. All patients reported resolution of their preoperative pain and return to sports. One patient did require occasional anti-inflammatory drugs for episodic low back pain. The use of this modified cable-screw technique for symptomatic spondylolysis provided excellent clinical, radiographic, and functional results in this small cohort.     

Back pain in athletes

The athlete with back pain presents a clinical challenge. Self-limited symptoms must be distinguished from persistent or recurrent symptoms associated with identifiable pathology. Athletes involved in impact sports appear to have risk factors for specific spinal pathologies that correlate with the loading and repetition demands of specific activities. For example, elite athletes who participate in longer and more intense training have higher incidence rates of degenerative disk disease and spondylolysis than athletes who do not. However, data suggest that the recreational athlete may be protected from lumbar injury with physical conditioning. Treatment of athletes with acute or chronic back pain usually is nonsurgical, and symptoms generally are self-limited. However, a systematic approach to the athlete with back pain, involving a thorough history and physical examination, pertinent imaging, and treatment algorithms designed for specific diagnoses, can facilitate symptomatic improvement and return to play. There are no reliable studies examining the long-term consequences of athletic activity on the lumbar spine.     

Percutaneous nucleotomy in elite athletes

Percutaneous nucleotomy in elite athletes is considered a minimally invasive treatment of lumbar disc herniation. However, long-term effectiveness has not been established by careful follow-up studies. This article evaluates the outcome of percutaneous nucleotomy in elite athletes who have undergone the procedure. Thirty elite athletes with lumbar disc herniation who underwent percutaneous nucleotomy and had been followed for at least 2 years were compared with a matched group of 42 nonathletes. The outcome in athletes was worse than in nonathletes. Early return to vigorous sports activity in less than 3 months correlated with increased symptoms. Similarly, more extensive resection of disc material was associated with an unexpected rapid worsening of the outcome and the lower rate of return to preoperative sports. Patient selection and postoperative management of athletes and nonathletes undergoing percutaneous nucleotomy should be the same, and the procedure in athletes is probably not worthwhile if they do not obey postoperative management such as the timing of return to sports activity.     

The role of intense athletic activity on structural lumbar abnormalities in adolescent patients with symptomatic low back pain

Purpose

To determine if adolescent athletics increases the risk of structural abnormalities in the lumbar spine.

Methods

A retrospective review of patients (ages 10–18) between 2004 and 2012 was performed. Pediatric patients with symptomatic low back pain, a lumbar spine MRI, and reported weekly athletic activity were included. Patients were stratified to an “athlete” and “non-athlete” group. Lumbar magnetic resonance and plain radiographic imaging was randomized, blinded, and evaluated by two authors for a Pfirrmann grade, herniated disc, and/or pars fracture.

Results

A total of 114 patients met the inclusion criteria and were stratified into 66 athletes and 48 non-athletes. Athletes were more likely to have abnormal findings compared to non-athletes (67 vs. 40 %, respectively, p = 0.01). Specifically, the prevalence of a spondylolysis with or without a slip was higher in athletes vs. non-athletes (32 vs. 2 %, respectively, p = 0.0003); however, there was no difference in the average Pfirrmann grade (1.19 vs. 1.14, p = 0.41), percentage of patients with at least one degenerative disc (39 vs. 31 %, p = 0.41), or disc herniation (27 vs. 33 %, p = 0.43). Body mass index, smoking history, and pelvic incidence (51.5° vs. 48.7°, respectively, p = 0.41) were similar between the groups.

Conclusion

Adolescents with low back pain have a higher-than-expected prevalence of structural pathology regardless of athletic activity. Independent of pelvic incidence, adolescent athletes with low back pain had a higher prevalence of spondylolysis compared to adolescent non-athletes with back pain, but there was no difference in associated disc degenerative changes or herniation.

     

Idiopathic scoliosis and spondylolysis in the female athlete. Tips for treatment

Idiopathic scoliosis and spondylolysis can be common back problems in female athletes. Diagnosis and treatment can be difficult. With the notable trend toward increasing participation of women and girls in organized sports, it is necessary to know which sports carry additional risks for participants to have these two conditions develop and to determine treatment modalities. In general, idiopathic scoliosis is more prevalent in females and even may be higher in the athletes. Treatment options may include observation, the use of a brace, and surgery. In determining treatment, the type of sport and caliber of athlete must be considered in conjunction with the severity of the curve. Spondylolysis or a stress fracture of the posterior vertebral elements can be a common cause of back pain in an athlete. In many sports that are dominated by females (gymnastics, dancing, figure skating), the athletes carry a high risk of having spondylolysis or a stress fracture. Knowing the risk factors permits precise diagnosis and appropriate treatment. Treatment options include the use of a brace and surgery. In the current study, an extensive review of the literature in conjunction with the extensive experience of a well-established sports medicine clinic at the authors' institution is presented.     

Cervical spondylolysis in a judo player: a case report and biomechanical analysis

Study design  A case report and a biomechanical study using a finite element method. Objectives  To report a case with the cervical spondylolysis and to understand the biomechanics of the cervical spine with spondylolysis at C6. Summary of background data  Cervical spondylolysis, although not a common spinal disorder, can occur in athletes. Presently, the exact pathology, natural history and biomechanics are not known. Thus, treatment strategies for this disorder in athletes are in controversy. To treat and/or advise patients with cervical spondylolysis, the cervical spine biomechanics regarding this disorder should be understood. Methods  A case of a 12-year-old male judo player is presented. The patient presented with occipital and upper neck pain. Plain radiographs, reconstructed CT scan and MRIs of this patient were reviewed. Biomechanically, stress distributions were analyzed in response to 73.6 N axial compression and 1.5-Nm moment in flexion, extension, lateral bending, and axial rotation using a FE model of the intact ligamentous C3 to C7 segment. Bilateral spondylolysis was created in the model at C6. The stress results from the bilateral defect model were compared to the intact model predictions. Results  Plain radiographs showed bilateral C6 spondylolysis, and grade I spondylolisthesis. MRI showed mild disc degeneration at C6/7. With conservative treatment, the symptoms disappeared. In the spondylolysis model, the maximum Von Mises Stresses at C6/7 increased in all cervical spine motions, as compared to the intact case. Specifically, in axial rotation, the stress increase was 3.7-fold as compared to the intact model. The range of motion at C6/7 increased in the spondylolysis model as well. Again, during axial rotation, the increase in motion was 2.3-fold when compared to the intact model. Conclusions  Cervical spondylolysis can cause biomechanical alterations, especially in axial rotation, leading to increased disc stresses and range of motion. The increased stresses in the disc and the hypermobility would be a dangerous condition for athletes participating in contact sports such as judo. Thus, we recommended that judo players with cervical spondylolysis should change to non-contact sports, such as jogging.     

Management of lumbar spondylolysis in the adolescent athlete: a review of over 200 cases

BACKGROUNDSpondylolysis is a defect of the pars interarticularis of vertebrae, most commonly seen at L5 and L4. The etiology of spondylolysis and isthmic spondylolisthesis is generally considered to be a result of repetitive mechanical stress to the weak portion of the vertebrae. A higher incidence of spondylolysis is observed in young athletes. Symptomatic spondylolysis can be successfully treated conservatively, but there is currently a limited consensus on treatment modalities and a lack of large-scale clinical trials.PURPOSEThe purpose of the present study was to investigate the optimal treatment algorithm for symptomatic spondylolysis in adolescent athletes and evaluate the functional outcomes of those undergoing the nonoperative treatment.STUDY DESIGNA retrospective review.PATIENT SAMPLETwo hundred one adolescent patients ranging from age 10 to 19 involved in athleticsOUTCOME MEASURESInjury characteristics (age, mechanism, time), sports played, bone stimulator use, bony healing at 3 months on computed tomography (CT) scans, return to sports, corticosteroid injection use.METHODSTwo hundred one adolescent athlete patients (62 females and 139 males) diagnosed with spondylolysis between 2007 and 2019 were retrospectively reviewed. Diagnosis was based on plain radiography followed by magnetic resonance imaging. All patients were treated conservatively with cessation of sports activity, thoracolumbosacral orthosis, and external bone stimulator for three months after diagnosis. CT scans were obtained for the 3-month follow-up visits to assess bony healing. Subsequently the patients received 6 weeks of rehabilitation focused on core strengthening. Symptomatic patients after the treatment were referred for steroid injections and continued with the rehabilitation protocol.RESULTSThe most common age of injury was 15 years old, following a strong normal distribution. The most commonly played sport was football, followed by baseball/softball. The primary mechanism of injury was weight training closely followed by a football injury. The first quarter of the calendar year had the highest incidence of injuries with the most injuries occurring in March and the least occurring in December. One hundred fifty-two athletes reported using bone stimulators as prescribed, and these patients showed a significantly higher rate of bony healing on follow-up CT scans than those who did not use bone stimulators. One hundred ninety-seven patients (98%) returned to sports or similar level of activities. Thirty-seven patients (18%) received facet or epidural steroid injections due to continued pain and one patient underwent a surgical procedure. Follow-up CT scans showed 49.8% bony healing.CONCLUSIONSConservative treatment of spondylolysis in adolescent athletes with cessation of sports, thoracolumbosacral orthosis, and bone stimulator followed by rehabilitation was associated with excellent outcomes in terms of return to sports.     

Direct repair of spondylolytic defects in young competitive athletes.

BACKGROUND CONTEXT: Operative treatment of symptomatic spondylolysis is rare. A variety of surgeries have been described. In general, reported operative success rates are high, although in most studies the successful return to sport of the competitive athlete is not detailed. PURPOSE: To review outcome, specifically return to sport, in a group of competitive athletes after direct pars repair for symptomatic spondylolysis. STUDY DESIGN/SETTING: This was a retrospective case series of a single surgeon. PATIENT SAMPLE: Series of four athletes who underwent direct pars repair over an 18-month period. OUTCOME MEASURES: Return to their sport. METHODS: Chart review of all patients who had undergone a single-level pars repair over an 18-month period. All patients had normal discs above the level of the repair. Postoperative clinical course was determined for all patients. RESULTS: The patients participated in different sports. All were able to return to their presymptomatic level of activity with no restriction. One had periodic low back pain that required nonsteroidal anti-inflammatory medicine as needed. The others were entirely asymptomatic. CONCLUSIONS: This small series suggests that with specific inclusion criteria, a select group of motivated athletes can expect to return to their sport after direct pars repairs for symptomatic spondylolysis that has failed conservative treatment.     

Spondylolysis: returning the athlete to sports participation with brace treatment

Between 1988 and 1995, 73 adolescent athletes treated with the Boston Overlap Brace for spondylolysis were reviewed to evaluate improvement in pain score and activity level. A favorable clinical outcome was achieved in 80%. Girls and boys who participated in high-risk sports were five times more likely to have an unfavorable clinical outcome than those who participated in low-risk sports (odds ratio = 5, 95% confidence interval = 2.4-7.5, P = .003). In addition, acute onset of pain and hamstring tightness were associated with a worse outcome. Athletes with symptomatic spondylolysis treated with an antilordotic brace can expect improvement in their clinical course and return to sports participation in 4-6 weeks.     

Lumbar spine injuries in pediatric and adolescent athletes

During the past two decades, there has been a significant increase in sports participation by pediatric athletes. Spinal injuries thus have become a great concern. The unique nature of the pediatric spine should be well-recognized and low back pain in a pediatric athlete should therefore be taken seriously and evaluated thoroughly. In this review article, sports-related lumbar spine problems will be covered including overuse injuries, spondylolysis, pars stress fractures, spondylolysthesis, and lumbar disc herniation. Early identification of these problems will eventually minimize these injuries.     

Return to sports activity by athletes after treatment of spondylolysis

AIM: To clarify the efficacy of conservative and surgical treatment of spondylolysis in athletes.METHODS: PubMed was used to perform a search of the literature for studies published during the period from 1990 to 2009 that reported data on the outcome of conservative or surgical treatment of spondylolysis in athletes. The articles were examined for data on the percentage of athletes who returned to sports activities and the interval between the start of treatment and their return.RESULTS: Five studies were identified. Two studies were concerned with conservative treatment and the other three with surgical treatment (wire fixation or screw fixation with bone graft). The percentages of athletes who returned to sports activities ranged from 80.0% to 89.3% and from 81.9% to 100%, respectively, and the intervals until their return ranged from 5.4 to 5.5 mo and from 7 to 12 mo, respectively.CONCLUSION: The percentages of athletes who returned to sports activities after conservative and surgical treatment appeared to be satisfactory, but the interval until their return to sports activities was longer after surgery than after conservative treatment.     

Outcome of surgical treatment of medial tibial stress syndrome

BACKGROUND: Medial tibial stress syndrome is a common chronic sports injury characterized by exercise-induced pain along the posteromedial border of the tibia. The reported outcomes of surgical treatment of this condition have varied. METHODS: Of seventy-eight patients who underwent surgery for medial tibial stress syndrome, forty-six (thirty-one men and fifteen women) returned for follow-up. The outcomes of the surgery were determined by comparing preoperative and postoperative pain levels as indicated on a visual analog pain scale and ascertaining the ability of the athletes to return to presymptom levels of exercise. RESULTS: The mean duration of postoperative follow-up was thirty months (range, six to sixty-three months). Surgery significantly reduced pain levels (p < 0.001) by an average of 72% as indicated on the visual analog pain scale. An excellent result was achieved in 35% of the limbs; a good result, in 34%; a fair result, in 22%; and a poor result, in 9%. Despite the success with regard to pain reduction, for a variety of reasons only nineteen (41%) of the athletes fully returned to their presymptom sports activity. CONCLUSIONS: Surgery can significantly reduce the pain associated with medial tibial stress syndrome. Despite this reduction in pain, athletes should be counseled that a full uninhibited return to sports is not always achieved.     

Lumbar spondylolysis - Current concepts review

Lumbar pars interarticularis (PI) injury or spondylolysis occurs only in humans. This represents a stress fracture of the PI. Excessive loading in repetitive hyperextension is a significant risk factor and occurs most commonly at L5 followed by L4. It is bilateral in 80% of symptomatic cases but can be unilateral defect as well which runs a more benign course. Symptoms of low back pain relating to this lesion are more common in young athletes involved in trunk twisting sports. Like other stress fractures, the pain may come on abruptly or more insidiously over time and only related to certain activities. The pathologic progression starts with a stress reaction in the pars, progressing to an incomplete stress fracture, and then a complete pars fracture. Diagnosis is dependent on clinical examination and radiological imaging studies (plain radiography, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans). Treatment is dependent on symptoms as well as radiographic stage of the lesion. Conservative management is the mainstay of treating early lesions. A comprehensive rehabilitation program incorporates core spinal stabilization exercises. Athletes should not return to sports until pain free. Professional sporting individuals are at increased risk of failure of resolution of symptoms that may require early surgical repair of the PI defect. Modified Buck's technique & pedicle screw-hook constructs for direct repair has a high success rate in patients who have persistent low back pain. Minimally invasive lumbar pars defect repair has given similar successful outcome with added advantage of minimizing muscle injury, preserving the adjacent joint and reduced hospital stay. Functional outcome is evaluated using the Visual Analogue Scale (VAS) for back pain, Oswestry Disability Index (ODI) and 36-Item Short-Form Health Survey (SF-36). Preoperative ODI and SF-36 physical component scores (PCS) are significant predictor of a good functional outcome.     

Chronic exertional compartment syndrome in a collegiate soccer player: a case report and literature review

Chronic exertional compartment syndrome is a relatively rare condition among running athletes. In those who engage in repetitive activity, it can cause severe, debilitating leg pain. The diagnosis can be made with a thorough workup that includes history and physical examination, radiologic studies (x-rays, magnetic resonance imaging, bone scan), and compartment pressure monitoring. Most patients do not respond well to nonoperative intervention. Fasciotomy provides satisfactory relief of symptoms and helps patients return to their sports. We present the case of a high-level collegiate soccer player with chronic exertional compartment syndrome.     

Disc degeneration and associated abnormalities of the spine in elite gymnasts. A magnetic resonance imaging study.

The thoracolumbar spine was examined by magnetic resonance imaging (MRI) and the history of back pain was analyzed in 24 male elite gymnasts (age range, 19-29 years) and in 16 male nonathletes (age range, 23-36 years). Disc degeneration, defined as reduced disc signal intensity, was significantly more common in athletes (75%) than in nonathletes (31%). The gymnasts also had a higher incidence of other abnormalities of the thoracolumbar spine, and there was a significant correlation between reduced disc signal intensity and the other abnormalities among the gymnasts. There were also significant correlations between back pain and reduced disc signal intensity and abnormal vertebral configuration when the gymnasts run a high risk of developing severe abnormalities of the thoracolumbar spine, and they often have a history of back pain.     

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.     

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.     

Verletzungen des Schultereckgelenks bei Sportlern

Acromioclavicular joint (ACJ) dislocation is a common injury to the shoulder girdle, especially in contact and high velocity sports. Besides the severity of the injury, and particularly in competitive and elite athletes and the type of sports, individual career plans and in and out of season injuries have to be taken into account when advising treatment for athletes. Conservative treatment is reserved for low-grade dislocations and in-season athletes. The aim is fast pain relief and a safe return to competitive sport. High-grade ACJ dislocations in athletes should be treated surgically. Arthroscopic and arthroscopically-assisted techniques can offer a lower risk of infection, a higher patient acceptance in terms of cosmetic perspectives and the potential to treat concomitant glenohumeral lesions and may avoid potential disadvantages of open techniques, such as secondary obligatory implant removal and extensive soft tissue preparation with a relevant approach morbidity.     

Review of Achilles Tendon Reattachment Using Double-Row Knotted and Knotless Techniques in the Management of Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy represents a chronic degenerative condition affecting the insertion of the Achilles. Surgery is indicated in recalcitrant cases and often involves extensive debridement followed by subsequent repair of the insertion. In the present study, we evaluate the results of knotted and knotless double-row suture systems for Achilles reattachment. Despite the popularity of double-row repairs, there is a relative paucity of clinic data regarding efficacy of the available implants. In a retrospective cohort study, 38 patients (40 Achilles tendons) who received double-row repairs between November 2012 and December 2016 were evaluated. In addition to demographic information, preoperative pain scores and symptom duration were recorded. Perioperative and postoperative records were reviewed, and telephone interviews were conducted to assess patient satisfaction, functional status, postoperative pain, and information regarding surgical complications. At a mean follow-up of 32.5 months, 35 (92.1%) patients reported satisfaction with the outcome. Decreased pain levels were reported in 38 (95%) ankles, with 21 (52.5%) ankles being rated pain-free postoperatively. Of the patients working prior to surgery, 20 (95.2%) were able to return to normal work duties, and all 11 (100%) patients who engaged in sports preoperatively were able to return to the same level of activity. Two patients developed postoperative infections, one of which required operative debridement. No Achilles avulsions were encountered. No significant differences were noted between the 2 operative techniques. Considering the available biomechanical data, along with high patient satisfaction rates and low rate of complications, double-row repair offers a viable option for recalcitrant insertional Achilles tendinopathy.     

Results of lumbosacral fusion for degenerative disc disease with and without instrumentation. Two- to five-year follow-up.

Functional and surgical outcomes are reported in two consecutive groups of patients who underwent one- and two-level lumbosacral fusion. The first group underwent standard posterolateral lumbosacral fusion, and the second group underwent lumbosacral fusion with compression U-rod instrumentation. Fusions were carried out over all painful, abnormal levels documented by discography. the pseudarthrosis rate without instrumentation was 35%, in contrast to 6% with instrumentation. In both groups of patients with chronic low-back pain secondary to degenerative disc disease, solid lumbosacral fusion was associated with decreased pain and higher return to work rates. Poorest results were associated with prolonged periods of preoperative disability and long-term disability claims.