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Proportion of patients with spina bifida occulta (SBO) and the corresponding lumbar vertebrae distribution. In 25.0 % patients, SBO of the sacrum was accompanied by lumbar spondylolysis. All of these patients had L5 spondylolysis
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Purpose:
Lumbar spondylolysis is considered a stress fracture of the pars interarticularis that occurs during growth. However, it is sometimes insidious and identified in adults as pseudoarthrosis, the terminal-stage of spondylolysis. The purpose of this study was to identify the clinical features of patients with terminal-stage spondylolysis that...
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Objective: The aim of this study was to determine the prevalence of curable and pseudoarthrosis stages of adolescent lumbar spondylolysis under high school students complaining of and seeking medical consultation for low back pain.
Patients and Methods: We analyzed age, sex, morbidity, presence of spina bifida occulta (SBO), and competitive sport d...
Background: If bone union is expected, conservative treatment is generally selected for lumbar spondylolysis. However, sometimes conservative treatments are unsuccessful. We sought to determine the factors associated with failure of bony union in acute unilateral lumbar spondylolysis with bone marrow edema including contralateral pseudoarthrosis.
M...
Citations
... The earliest article dates back to 1975 [10], and one of recent publications on the problem has been brought out in 2018 [3]. Case series were described in 26 articles with 18 (69.23 %) presenting one case report [3,4,7,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. Three cases of multilevel spondylolysis were reported in two articles (7.73 %) [6,8]. ...
... Although the pathogenesis of lumbar spondylolysis remains controversial, it is widely accepted that spondylolysis has a genetic predisposition to the pars defect [8,10,11] with higher incidence of spondylolysis in athletes and those participating in strenuous exercise [4,7,27]. Computed tomography is the best procedure for clearly visualizing spondylolysis when a pars fracture is present whereas magnetic resonance imaging is not commonly used for the diagnosis [4,19,26,28]. ...
Introduction Diagnosis and treatment of vertebrogenic pain syndrome caused by multilevel lumbar spondylolysis is crucial for patients of different age
groups. Objective To report a clinical case of diagnosis and treatment of a two-level lumbar spondylolysis in a 16-year-old male patient, and review
the relevant literature. Material and methods We had an experience of treatment and follow-up of a 16-year-old athlete who presented with low back
pain and was diagnosed with spondylolysis of the pars interarticularis at the L3 and L5 levels. Diagnostic workup included patient history, physical
examination, diagnostic imaging (plain radiograph, computed tomography). Scientific publications from modern medical databases were used for literature
review. A total of 32 relevant articles brought out between 1975 and 2019 were reviewed. Results The 16-year-old athlete was diagnosed with multilevel
spondylolysis of lumbar spine based on patient history, physical examination data and diagnostic imaging of lumbar spine. No pathognomonic clinical
findings were revealed. The diagnosis was confirmed with computed tomography. Conservative treatment was initiated for the patient and a long-termfollow-
up was available. Literature review included epidemiologic data characterizing multilevel lumbar spondylolysis: the indicence, patients' gender and
age. Major etiological factors, common localization of the pathology, the incidence of spondylolysis and spondylolisthesis, treatment strategy including
surgical procedures are described. Discussion There is a small number of scientific publications describing different aspects of multilevel spondylolysis of
the lumbar spine in the current medical literature. The diagnosis is often delayed for the reason. The natural history of pain in adolescent athletes sustaining
the load placed on them in both training and competition can be helpful for timely diagnosis. Conclusion The implications of this clinical case report can
be practical for accentuation of multilevel spondylolysis of the lumbar spine among Russian specialists, contribute to medical knowledge and extend to
both early diagnosis and efficient management.
... The risk factors for non-union in the patients with lumbar spondylolysis are multifactorial. Sakai et al. [25] reported that patients with L5 spondylolysis and spina bifida occulta have predisposing factors in the development of terminal-stage spondylolysis. In order to analyze the detail of the correlation between the CR and bone union, we need to conduct studies on a larger sample in the future. ...
Study design:
Prospective cohort study.
Purpose:
To quantitatively evaluate bone marrow edema (BME) in the pedicle on magnetic resonance imaging (MRI) for adolescent athlete patients with spondylolysis.
Overview of literature:
Spondylolysis, a stress fracture of the pars interarticularis, is a common occurrence in adolescent athletes with low back pain. T2-weighed fat-saturated MRI is reportedly useful for the detection of BME in the pedicle in the early stage of spondylolysis; however, to our knowledge, the quantitative assessment of BME in spondylolysis has not been reported.
Methods:
Adolescent athletes with spondylolysis, including those with symptoms of low back pain, were enrolled. The sporting activity of the patients was restricted, and a hard brace was attached to the spine. The BME range of interest was taken on T2-weighed fat-saturated MRI, and the signal intensity (SI) of the BME (SIedema) was measured. The contrast ratio (CR) between the SI of the BME and SI of the spinal cord (SIcord) was calculated per the following formulae: CRedema=(SIedema-SIcord)/(SIedema+SIcord). The CR of the normal pedicle was measured as a control per the following formulae: CRcontrol=(SIcontrol-SIcord)/(SIcontrol+SIcord).
Results:
The study enrolled 32 men and one woman; the mean patient age was 15.2 years (range, 12-18 years). The average CR of the edema and normal pedicle at the first visit was 0.506 (range, 0.097-0.804) and 0.137 (range, -0.741 to 0.572), respectively. The CR of the edema was significantly higher as compared to that of the normal pedicle (p<0.01). MRI that was performed 1 month after the first visit showed that the CR of the edema had decreased to 0.204 (range, -0.152 to 0.517). The CR of the edema 1 month thereafter was significantly lower than that at the first visit (p<0.01).
Conclusions:
Quantitative assessment of BME using CR on MRI is useful in the evaluation of the healing process of spondylolysis.
... Spina bifida occulta (SBO) is a common malformation of the lamina of the spine, most commonly occurring in the sacrum or lower lumbar spine [1,2]. Spondylolysis is a common etiology of back pain in children and adolescents. ...
... SBO is caused by failure of fusion between posterior vertebral elements without affecting the spinal cord or meninges. It is usually observed at L5 and/or at the upper one or lower two sacral vertebrae [1,2]. Goto et al. reported a case of SBO at the thoracolumbar junction and estimated the incidence as <5% within all SBO patients [6,7]. ...
Several reports have described the coexistence of spina bifida occulta (SBO) and spondylolysis, but the majority of defects occur at L5. No report has described the coexistence of SBO and spondylolysis at the thoracolumbar junction. We report a case of SBO with spondylolysis at L1, presenting cauda equine syndrome. A 37-year-old man presented with a gait disorder as a result of bilateral motor weakness of the lower extremities. A plain radiograph showed local kyphosis at L1-2 as a result of severe degenerative change and wedging of the vertebral body at L1. Magnetic resonance imaging (MRI) revealed degenerative disc changes and severe canal stenosis at L1-2. Computed tomography (CT) revealed SBO and spondylolysis at L1. He was diagnosed with cauda equina syndrome related to SBO and spondylolysis at L1. Posterior interbody fusion and decompression at L1-2 were performed. After surgery, his muscle power recovered to normal strength. The possible mechanisms in this case are the strain on anterior elements as a result of disruption of the posterior elements due to SBO and spondylolysis. The coexistence of SBO and spondylolysis at the thoracolumbar junction might induce at-risk status of increased strain to the anterior elements that may cause cauda equina syndrome.
... The most common fractures of the vertebrae and sacrum are due to repeated physical stress, indirect trauma, or preexisting disease. A very distinctive vertebral fracture for which there may be a genetic predisposition (Sakai et al. 2016) is the traumatic separation of the neural arch from the vertebral body known as spon dylolysis. Spondylolysis may be unilateral or bilateral in expression, but predominates in the lumbosacral region, particularly L5 and, to a lesser degree, L4 (Merbs 1996). ...
Trauma is one of the most commonly observed pathological conditions in human skeletal remains. The objectives of trauma analysis include the identification and description of lesions, interpreting the body's physiological response to trauma, recognizing temporal and geographic patterning of trauma, exploring the relationship of trauma to age and sex, and the identifying the potential social, cultural, or environmental causes of trauma. Hence, evidence of trauma provides information about an organism's or population's interaction with its physical and sociocultural environment and provides essential data in the reconstruction of past lifeways of humans and other organisms.
... Lumbosacral defects have been reported in prehistoric and historic skeletal series throughout the world, except Asia [13,[18][19][20][21][22]. Existing reports of lumbosacral defects in Asia are limited to discussions of clinical epidemiology that focus on patient symptoms and complicated analyses of medical images [15,[23][24][25][26][27]. ...
Paleopathological evidence for congenital and degenerative disorders of the lumbosacral vertebrae is informative about ancient individual lifeways and physical conditions. However, very few studies have focused on the paleopathology of the lumbosacral vertebrae in ancient skeletal series from East Asia. One reason for the lack of studies is that skeletal samples from East Asia are typically insufficient in size to represent populations for comparative studies within the continent. Here, we present the first comprehensive analysis of lumbosacral defects in an East Asian human skeletal sample, examining occurrences of spina bifida occulta (SBO), lumbosacral transitional vertebrae (LSTV), and spondylolysis in remains from Joseon tombs dating to the 16–18th centuries in Korea. In this study, we present an alternative methodology for understanding activities of daily life among ancient Koreans through paleopathological analysis.
... The most common fractures of the vertebrae and sacrum are due to repeated physical stress, indirect trauma, or preexisting disease. A very distinctive vertebral fracture for which there may be a genetic predisposition (Sakai et al. 2016) is the traumatic separation of the neural arch from the vertebral body known as spon dylolysis. Spondylolysis may be unilateral or bilateral in expression, but predominates in the lumbosacral region, particularly L5 and, to a lesser degree, L4 (Merbs 1996). ...
This paper reviews the mechanisms of injury and the types of fractures that most commonly affect the human skeleton, presents descriptive protocols for cranial and postcranial fractures adapted from clinical and forensic medicine, and summarizes anatomically the injuries most likely to be found in archaeological skeletons along with their most common causes and complications. Mechanisms of injury are categorized as direct and indirect trauma, stress, and fracture that occurs secondary to pathology. These are considered to be the proximate, or most direct, causes of injury and they are influenced by intrinsic biological factors such as age and sex, and extrinsic environmental factors, both physical and sociocultural, that may be thought of as the ultimate, or remote, causes of injury. Interpersonal conflict may be one of those causes but the skeletal evidence itself is rarely conclusive and must therefore be evaluated in its individual, populational, sociocultural, and physical context. A cautionary tale regarding parry fractures is presented as an illustration.
Aims: Pars interarticularis defect (PID) is a common problem in society and may be accompanied with low back pain and radiculopathy. Magnetic resonance imaging (MRI) can detect it with high sensitivity. If left untreated, it may progress to spondylolisthesis. In this study, we wanted to emphasize the importance of the pelvic incidence (PI) angle in terms of following the development of spondylolisthesis after PID by examining the relationship between PID and spondylolisthesis and PI. Methods: 118 patients who applied to Şanlıurfa Training and Research Hospital between 2021-2022 and underwent lumbar MRI were included in the study. The criteria for inclusion of patients in the study were the detection of a pars interarticularis defect on MRI, the ability to be evaluated by direct radiography or CT, and the ability to monitor the femoral head and sacrum in a way that PI could be measured. PI angle measurement was performed, confirmed by CT. The relationship between PID, spondylolisthesis and PI was examined. Results: Of the 118 patients participating in the study, 77 (65.3%) were women and 41 (34.7%) were men. Pars defect was most commonly seen at the L5 level (67.8%). The average pelvic incidence angle is 64.2±8.6. Half of the patients were calculated as Meyerding grade 0 and 95.8% were treated medically. The median pelvic incidence angle value of patients without spondylolisthesis was found to be 58.0, the median pelvic incidence angle value of patients with a Meyerding grading of one was found to be 68.0, and the median value of the pelvic incidence angle of patients with a Meyerding grading of one was found to be 78.0 (p
Background:
Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture.
Objectives:
To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture).
Search methods:
We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022.
Selection criteria:
We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests.
Data collection and analysis:
Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool.
Main results:
This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96).
Authors' conclusions:
The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.
Background: The effect of spina bifida occulta (SBO) on bone union in lumbar spondylolysis is controversial. The study aim was to assess the effect of SBO on bone union after conservative treatment of L5 spondylolysis, the most common level.
Methods: The study included 191 lesions in 145 patients (mean age, 14.0 years) with conservatively treated L5 spondylolysis. We examined the relationships between bone union after conservative treatment and the number of SBOs, levels, and single or multilevel status. Fisher's exact probability test, chi-square test, and Welch's T test were performed.
Results: The SBO incidence was 53%, with at least one SBO at any vertebral level. SBO at S1 (p = 0.034) or S2 (p = 0.0003), two SBOs (p = 0.0018), and three SBOs (p = 0.011) were associated with a lower bone union rate. The bone union rate was significantly lower for lesions with SBOs at both S1 and S2 than without (42% vs. 79%; p < 0.0001).
Conclusions: The SBO incidence in L5 spondylolysis was 53%. SBO at S1 or S2 and a higher number of SBOs were associated with lower bone union rates. In particular, the bone union rate of lesions with SBOs at both S1 and S2 was <50%.
Introduction
Lumbar spondylolysis typically arises during adolescence, whereas its onset in adulthood is rare. Several studies have reported incidentally identified terminal-stage spondylolysis in adults, but only one case series has investigated acute lumbar spondylolysis lesions with bone marrow edema in adults.
Methods
We retrospectively investigated lumbar spondylolysis in patients aged 18 years or older. Age at diagnosis, sex, competitive sporting level, and competitive sporting discipline were investigated in each patient. The level of the affected vertebra, pathological stage, bone union, and treatment period were analyzed for each lesion.
Results
The study included nine patients (eight males and one female), aged 18–22 years old, with 14 acute lumbar spondylolysis lesions. Four patients were soccer players (two professionals, and two amateurs), four were amateur track and field athletes, and one was an amateur basketball player. The affected vertebral levels were L3 in two lesions, L4 in seven lesions, and L5 in five lesions. The pathological stage was pre-lysis stage in two lesions, early stage in eight lesions, and progressive stage in four lesions. Ten lesions achieved bone union with conservative therapy. The average treatment period was 84.7 days.
Conclusions
The adult-onset lumbar spondylolysis patients were young, up to their early 20s, and generally professional sportspeople performing at an elite level. Most of them were performing a sport that has been reported to have a high risk of causing lumbar spondylolysis. L4 was the most affected vertebral level in contrast to L5, which has been reported in adolescent lumbar spondylolysis. Bone union was achieved for most lesions with conservative therapy.
