Spondylolysis and Spondylolisthesis in the Pediatric Patient

An interview with HSS surgeon Daniel W. Green, MD


John S. Blanco, MD

John S. Blanco, MD

Associate Attending Orthopaedic Surgeon, Hospital for Special Surgery
Associate Professor of Orthopaedic Surgery, Weill Cornell Medical College

Daniel W. Green, MD, MS, FAAP, FACS

Daniel W. Green, MD, MS, FAAP, FACS

Associate Attending Orthopedic Surgeon, Hospital for Special Surgery
Associate Professor of Orthopaedic Surgery, Weill Cornell Medical College

Roger F. Widmann, MD

Roger F. Widmann, MD

Chief, Pediatric Orthopaedic Surgery, Hospital for Special Surgery
Attending Orthopaedic Surgeon, Hospital for Special Surgery
Professor of Clinical Orthopaedic Surgery, Weill Cornell Medical College

  1. Back Pain? Or Something More Serious?
  2. What is Spondylolysis?
  3. Causes, Symptoms, and Diagnosing Spondylolysis
  4. Conservative (Non-surgical) Treatment and Recovery
  5. Surgical Treatment of Spondylolysis
  6. Spondylolisthesis
  7. Looking to the Future

Back Pain? Or Something More Serious?

Many young athletes pushing themselves to excel in sports like football or gymnastics may experience minor sports-related aches such as muscle or back pain. When persistent back pain interferes with participation in a favorite sport, however, it may be an indication of the presence of spondylolysis. Left untreated, spondylolysis can develop into spondylolisthesis and sideline an athlete for more than just a sporting season.

Today there are a number of highly effective nonsurgical treatments that are used to treat spondylolysis. And for those who are still experiencing pain after receiving nonsurgical care, effective surgical options are also available that help young athletes get back in the game.

What is Spondylolysis?

Spondylolysis is diagnosed when a stress fracture develops in the pars interarticularis of the lumbar spine, a location that is vulnerable to injury from the repetitive flexion, extension, and rotation that characterizes many sports.

The injury to the pars (also referred to as a pars defect) may occur at one or both sides of a given vertebral level of the spine; most commonly at the lumbar vertebrae L5 and L4.


Figure 1: Side view of spinal column


Figure 2: Top view of spinal column

Traditionally, spondylolysis has been associated with gymnastics, rowing, and football. But according to Daniel W. Green, MD, Associate Attending Orthopedic Surgeon at Hospital for Special Surgery (HSS), “We’re seeing greater numbers of patients with spondylolysis in almost every major sport, including gymnastics, but also skating, fencing, basketball, football, and baseball.”

Causes, Symptoms, and Diagnosing Spondylolysis

The increased intensity with which adolescent athletes approach their sports—versus a more moderate approach twenty years ago—and a tendency to play sports year-round may be contributing factors. (In addition to young athletes, spondylolysis is also seen with greater-than-average frequency in young people who work on family farms, and who regularly lift heavy loads.)

In addition to back pain, symptoms of spondylolysis can include leg pain—which is commonly due to hamstring tightness—and muscle spasm. Patients or their parents sometimes incorrectly believe this to be sciatica. The patient’s posture and gait may also be affected.

Assessment begins with physical examination and x-rays. Sophisticated imaging techniques that provide more detail may also be used to help confirm the diagnosis and to distinguish stress fractures from stress reactions—a condition that can be a precursor to spondylolysis.

“At HSS, we use both SPECT (Single Photon Emission Computed Tomography) bone imaging and MRI that is formatted specifically for musculosketal imaging. The latter is particularly important in yielding information about the pars and the posterior elements of the spine,” Dr. Green explains. “MRIs obtained from facilities that do not specialize in musculoskeletal injury are more likely to be formatted and aligned to look at the disk, and therefore may not give us all the information we need.”

Conservative (Non-surgical) Treatment and Recovery

The majority of young athletes diagnosed with spondylolysis can be treated successfully with conservative management, which always begins with a period of rest, and eliminating vigorous sports and heavy weightlifting. In younger patients with acute symptoms of spondylolysis, bracing is recommended.

Once the pain subsides, Dr. Green usually initiates a physical therapy program, focusing on lower extremity flexibility along with gentle trunk and core strengthening. In the third phase of treatment, the patient prepares to return to sports with more aggressive conditioning such as running. In the fourth or final phase of treatment, the patient is allowed to return to sports.

However, Dr. Green adds, the parents are asked to modify the child’s activities during the first season back to sports. “This can mean that the child participates in one sport season and plays on one team, instead of three or four different teams and year-round competition, as they may have done in the past.” Treatment and recovery may be as short as three months or take as long as a year, he notes. The long-term goal is a full return to sports without restriction.

Although the outlook is good, the diagnosis can come as a shock to young patients. Dr. Green says:

Most of these kids are very successful athletes whose daily routine for years has been based on a particular sport. They’re very surprised to learn they have a stress fracture and that you’re recommending that they refrain from sports during recovery. To us it’s a relatively short period, but to a young person, three to six months can seem like a very long time, especially if they are anticipating participation in competition or other events.

Surgical Treatment of Spondylolysis

In the vast majority of cases, spondylolysis can be treated effectively through the conservative methods described. However, in patients who continue to experience pain after six months of bracing, surgical intervention may be recommended.

Treatment consists of either an arthrodesis, in which the affected vertebra is fused to the adjacent vertebra, thereby restricting motion, or direct repair of the pars defect. While the latter approach preserves more motion in the spine, fusion has a higher rate of healing and a lower rate of re-operation.

Spondylolisthesis

The primary concern with leaving spondylolysis untreated is that in some cases, the condition progresses to spondylolisthesis, a diagnosis which is made when the affected vertebra slips forward relative to the vertebra below. In its mild form, this condition can also be treated conservatively  If slippage exceeds 50% of the width of the vertebra, the patient may experience significant pain and may be in danger of nerve injury.

Generally, surgical stabilization is recommended, which involves fusion and the use of surgical instrumentation to facilitate in healing.

“In the population of young athletes with spondylolysis, only about 5% will progress to spondylolisthesis,” notes Dr. Green. “But there are other causes of spondylolisthesis, particularly in adults; the condition may result from spine surgery which destabilizes the area, a tumor, or severe arthritis, or it may be congenital in origin.”

Looking to the Future

Treatment of children at risk for spondylolysis (and for spondylolisthesis that evolves from untreated spondylolysis) may benefit from ongoing research at HSS. Working together with scientists in the Department of Orthopedic Biomechanics at HSS, Dr. Green and his colleagues are studying anatomic predisposition of the spine to spondylolysis in order to further understand the causes of the condition. Dr. Green is also working with Richard Herzog, MD, Chief of the Division of Teleradiology, on a clinical imaging study on patients with stress reactions in the lower lumbar spine. 

If you would like more information about treatment of spondylolysis and spondylolisthesis at HSS, please visit the Physician Referral Service or call 1(877) 606-1555.

Summary prepared by Nancy Novick

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