Lumbar Spondylolysis

Where is it painful for a client with Lumbar Spondylolysis?

Classical patient features for Lumbar Spondylolysis

Age: Younger athletes participating in high-risk activities (accounts for up to 47% of athletes presenting with back pain)

Gender: males more prevalent than females 2:1. However high prevalence in female athletes with poor bone health (special questions for menstrual disturbance or relative energy deficiency in sport)

sport: cricket, tennis, ballet, divers, gymnastics, soccer, volleyball

Area of symptoms for Lumbar Spondylolysis

- Localised unilateral back pain

- Can refer in the buttock and leg but uncommon

- If crosses the midline consider other differentials

- if persistent pain and bilateral may provide evidence for Spondylysthesis

Characteristics of symptoms of a client with Lumbar Spondylolysis

- Sharp, catching pain with an extension activity

- dull aching with sustained positions of aggravation

- intermittent pain but persistently bought on by aggravating activities

Typical activity capability/restriction for Lumbar Spondylolysis

- Insidious: patient often still high activity and often have not changed their participation in sport

- Acute: ie fracture pain will be intense enough for the participant to be removed from the activity

- will progressively reduce sporting performance as symptoms are provoked due to the worsening nature

- stress response at the bone will accumulate over time or throughout a season

Behaviour of symptoms for Lumbar Spondylolysis

Ease: rest and avoidance or alterations to aggravating activities (can be in the form of activity modification or general factors such as technique changes ie fast bowler)

Agg: lumbar extension, combined movements, repeated movements, fast movements especially if at the end of rance

24-hour pattern: activity dependant

Typical history for a client with Lumbar Spondylolysis

- Participation in activities with bending forces that have a unilateral bias (rotation or side-flexion)

- can have hyperextension incident with acute onset (more likely fracture)

- can have insidious onset (more likely in the earlier stages of a bone stress injury)

- will get worse with activity (no warm-up effect)

- can be brought on by an increase in load (training or gameplay secondary to demographic)

Pathobiological mechanisms underlying Lumbar Spondylolysis

- Nociceptive with acute presentations.

- The longer the symptoms have been evident, especially if long term rehabilitation is required, the patient may have an increase in nociplastic pain

Proposed pathology for Lumbar Spondylolysis

- Most commonly affects the pars interarticularis in the region of the posterior vertebral arch

- The term includes a range of bony lesions that occur at this site of injury

- Imaging has shown that the injury commonly involves the adjoining pedicle and lamina

Physical impairments & associated structure/tissue sources (ie P/E findings)

Local

- pain with lumbar extension

- increased pain with lumbar combine movements (extension + unilateral bias)

- pain with unilateral lumbar PAIVM

- increased lumbar lordosis // if adaptive might have a reduced lordosis

- reduced motor control // assess with normal activities and at end of the range

- reduced lumbar body schema // worse if the pain has been around for a long period of time, evidence for nociplastic influences

- hip flexor and hamstring tightness

- abdominal and glute weakness

- hypermobility in the Lx

Remote

- reduced extension range in thoracic spine and/or hips

- reduced independent control into extension in spine and hips

General

- poor dynamic control at the end of range

- excessive extension moments

- bracing

Typical contributing factors for Lumbar Spondylolysis

- participation in high-risk activities

- Weight

- Genetics

- hypermobility in the lumbar spine

- REDS

- menstrual disturbance

- malnutrition

Relevant precautions/ contraindications to P/E and treatment

- with acute onset could have a fracture with nonunion // if suspect this need to send to hospital for imagining ASAP

- if the patient has neuro symptoms // referral straight away

- if the patient has a suspected stress fracture// imaging is required and referral to a sports physician for medical management to align with rehabilitation

Relevant diagnostic imaging for Lumbar Spondylolysis

X-ray: may pick up a larger defect however little diagnostic accuracy and can not rule out the presence of pathology, therefore not recommended

CT: will identify stress fracture however is likely to provide sufficient detail to identify a stress response in the early stages

MRI: Gold standard, will alert to stress injuries in early stages as well as fractures

Note: may need scans throughout rehab period to determine healing response prior to progression // especially with contact sports

Typical prognosis for Lumbar Spondylolysis

- 92% return to sport with conservative management

- for boney stress and united stress fractures return to sport timeframe is between 3-6 months

- for complex stress fractures and when there is non-union, return to sport can take up to 12 months

Management/treatment selection for Lumbar Spondylolysis

Phases of rehabilitation

- stage 1: protection and fracture healing (~0=8 weeks)

- stage 2: reloading phase (~ 9-16 weeks)

- stage 3: return to full function and sport (~17 weeks onwards)

Note: the stage of pathology will determine the speed of rehabilitation

Relative load reduction (high-level evidence)

- period of rest from the aggravating activity indicated in pain dominant presentations // non-negotiable if fracture present

Immobilization

- low levels of evidence for both taping and bracing

- need to provide clear instructions to restrictions in spine loading in conjunction with other members of the medical team

Rehabilitation objectives:

Local (no evidence)

- mobility into flexion

- muscles control and performance safe to begin in the non-provocative inner range

- progress loading progressively with strengthening, especially at the end-stage when moving into extension

Remote

- Abdominal strengthening ( mid-level evidence for TA activation)

- (early stage) remove the extension from the lumbar spine (increase extension at thoracic and hips)

- (early stage) muscles control and performance safe to begin in the non-provocative inner range

General

- consider biomechanics and technique // are we able to redistribute the load somewhere else

- posture

- address contributing factors and cardiovascular fitness

Surgical

- with failed conservative treatment surgery is indicated in ~9% of cases

High evidence in the back pain world for ensuring the use a biopsychosocial approach when planning for optimal rehabilitation

Differential diagnosis for Lumbar Spondylolysis

Spondylolisthesis // bilateral pain, neurological symptoms

Disc pathology// flexion pattern and pain that crosses the midline

Spinal cord injuries // positive neurological or neurological symptoms

Cord equina // B&B, saddle anesthesia, bilateral symptoms

Muscle strains // dynamic assessment

Central canal stenosis // neurological symptoms, bilateral symptoms

Nerve root // positive neurological or neurodynamic findings

Cancer // subjective special questions

Ankylosing spondylitis // inflammatory special questions

References

Bahr R. The IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.

Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.

Garet, M., Reiman, M.P., Mathers, J. and Sylvain, J., 2013. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review. Sports health, 5(3), pp.225-232.

Leone, A., Cianfoni, A., Cerase, A., Magarelli, N. and Bonomo, L., 2011. Lumbar spondylolysis: a review. Skeletal radiology, 40(6), pp.683-700.

McNeely, M.L., Torrance, G. and Magee, D.J., 2003. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual therapy, 8(2), pp.80-91.

Peer, K.S. and Fascione, J.M., 2007. Spondylolysis: a review and treatment approach. Orthopaedic Nursing, 26(2), pp.104-111.

Standaert, C.J. and Herring, S.A., 2000. Spondylolysis: a critical review. British journal of sports medicine, 34(6), pp.415-422.

Lawrence, K.J., Elser, T. and Stromberg, R., 2016. Lumbar spondylolysis in the adolescent athlete. Physical Therapy in Sport, 20, pp.56-60.