Symptomatic Spondylolysis Research Articles

Correlation of Radiographic Healing on Advanced Imaging in Young Adults and Adolescents With Symptomatic Spondylolysis Before and After Treatment: A Retrospective Study.

Retrospective chart review. To determine the effect of conservative measures on radiographic outcomes in those with isolated spondylolysis. Spondylolysis is a common cause of low back pain in pediatric patients, affecting between 4.4% and 4.7% of all pediatric patients. This rate is even higher in high-level athletes, with recent studies suggesting a rate of 47% in this population. Conservative measures are recommended for treating symptomatic spondylolysis and are effective in controlling symptoms, but there is little evidence regarding their effect on radiographic outcomes. A retrospective review was conducted of patients diagnosed with spondylolysis who were treated at a single academic institution between January 1, 2012, and January 1, 2022. Data collected included demographics, presentation characteristics, pretreatment and post-treatment radiologic findings, types of treatments employed, and final symptomatic status at follow-up. The Student t test and the Wilcoxon rank sum test were used to compare continuous variables. The χ 2 test was used to compare categorical variables. A total of 119 patients were included in the study. There was an 81.5% rate of healing on advanced imaging for those treated with conservative measures. When comparing those with healing on advanced imaging to those without, those with healing were more likely to have an acute fracture ( P= 0.04), have symptomatic improvement ( P <0.01), and return-to-play ( P= 0.02) compared with those without. Those with healing also had an odds ratio of 6.9 ( P <0.01) and 4.5 ( P =0.02) to achieve symptomatic improvement and return to their sport, respectively, compared with those who did not. Our study found those with isolated spondylolysis who were treated with conservative measures had a high healing rate on advanced imaging and those with healing had significantly higher odds of having symptomatic improvement and returning to play compared with those without. 4.

Factors associated with non-fusion after direct pars repair of lumbar spondylolysis with pedicle screw and lamina hook: a clinical and CT-assessed study

BackgroundPedicle screw and lamina hook (PSLH) technique is an effective and popular method for direct pars repair of lumbar spondylolysis. There is a lack of studies to explore factors that may influence the healing of spondylolysis after direct pars repair surgery. The present study aimed to investigate the factors associated with non-fusion after direct pars repair of lumbar spondylolysis with PSLH technique.MethodsA total of 55 subjects (average age 21.1 ± 6.3 years, a total of 120 pars defects) diagnosed with symptomatic spondylolysis and underwent pars repair surgery with PSLH were followed up and their clinical data were analyzed. Subjects were divided into a non-fusion group and fusion group according to whether the pars defect had bony fusion at last follow-up assessed by CT. Radiographic data, data related to spondylolysis and clinical outcomes were collected and compared between groups.ResultsThe mean follow-up time of the 55 patients was 24.8 ± 12.0 (12–64) months. Among the 120 pars defects, 101 defects were successfully fused and 19 were not fused according to CT. The fusion rate was 84.2%. Multivariable logistic regression analysis showed the factors correlated with non-fusion after pars repair surgery: whether the spondylolysis segment was associated with spina bifida occulta (SBO) (P = 0.001), stage of the defect (P = 0.047), width of the defect (P = 0.002), and disc degeneration (P = 0.014).ConclusionDirect pars repair by PSHL is a reliable treatment for lumbar spondylolysis with a fusion rate of 84.2%. Association with SBO of the spondylolysis segment, a terminal stage of the defect, a wider defect gap, and grade III disc degeneration may be factors associated with non-fusion after direct pars repair of lumbar spondylolysis with PLSH. Non-fusion patients after pars repair appear to have worse clinical results compared to fusion patients.

Spondylolysis.

Spondylolysis is a bony defect of the pars interarticularis and most often results from repetitive stress. Although spondylolysis is usually asymptomatic, symptomatic spondylolysis is the most common cause of identifiable back pain in children and adolescent athletes. A thorough history and physical exam, as well as appropriate imaging studies are helpful in diagnosis. General first-ine therapy for spondylolysis is conservative and consists of rest from sports, core strengthening, as well as spinal bracing. Patients who have failed conservative therapy may consider surgical repair. This article aims to review the epidemiology, pathophysiology, presentation, and treatment options of spondylolysis.

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 athletics OUTCOME 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.

Repair of symptomatic bilateral L5 spondylolysis with autogenous iliac crest graft and temporary intersegmental pedicle screw fixation in youth

BackgroundWhen symptomatic spondylolysis fail to respond to nonoperative treatment, surgical management may be required. A number of techniques have been described for repair by intrasegmental fixation with good results; however, there are still some problems. We reported a repair technique with temporary intersegmental pedicle screw fixation and autogenous iliac crest graft. The aim of present study is to assess the clinical outcomes of L5 symptomatic spondylolysis with this technique.MethodsA retrospective analysis of 128 patients with L5 spondylolysis treated with this method was performed. According to CT scan, the spondylolysis were classified into 3 categories: line, intermediate, and sclerosis type. The diagnostic block test of L5 bilateral pars defect was done in all patients preoperatively. The sagittal and axial CT images were used to determine the bone union. The healing time, complications, number of spina bifida occulta, Japanese Orthopedic Association (JOA) score, and VAS for back pain were recorded. After fixation removal, the rate of ROM preservation at L5S1 was calculated.ResultsThere were 97 patients (194 pars) followed with mean follow-up of 23 months (range, 12–36 months). The union rate of pars was 82.0% at 12 months and 94.3% at 24 months postoperatively. Low back pain VAS significantly (P < 0.05) improved from preoperative mean value of 7.2 to 1.3 at the final follow-up postoperatively (P < 0.05). JOA score increased significantly postoperatively (P < 0.05) with average improvement rate of 79.3%. The rates of L5S1 ROM preservation were 79.8% and 64.0% after fixation removal at 1 and 2 years postoperatively. There were 3 patients of delayed incision healing without other complications.ConclusionsAlthough sacrificing L5S1 segment motion temporarily, more stability was obtained with intersegmental fixation. This technique is reliable for spondylolysis repair which has satisfactory symptom relief, high healing rate, low incidence of complications, and preserve a large part of ROM for fixed segment.

Minimally Invasive Approach Toward Percutaneous Direct Pars Repair: An Observational Study

Spondylolysis refers to a defect of the vertebral pars interarticularis. Percutaneous direct pars repair using a minimally invasive technique was performed in a group of young patients to maintain their spinal segment movement and to restore their normal anatomy. The aim of this study was to present the clinical, functional, and radiologic outcomes of pars defects that were repaired percutaneously via the minimally invasive technique. This was a single-center, nonrandomized, prospective study of the demographic, clinical, functional, and radiographic outcomes of 18 patients (age range, 18-32 years). The visual analog scale for back pain and the Oswestry Disability Index were used to evaluate the functional outcomes. The Macnab criteria were applied to evaluate patient satisfaction after surgery. All patients were admitted with bilateral pars fracture at the level of L4 (n= 4) or L5 (n= 14). The average duration of clinical follow-up was 16.04 months (range, 12-28 months). With reference to the Macnab criteria, 17 patients (94%) showed perfect or good outcomes. Fusion or bridging of bones was observed on computed tomography in 14 patients (77%) at the last radiological examination. Minimally invasive surgery to treat symptomatic spondylolysis is a safe option that minimizes muscle and soft tissue dissection. In this study, good clinical and functional outcomes were achieved in young patients with low complications and high fusion rates using completely percutaneous treatment.

CONSIDERATION OF SPORT DEMANDS FOR AN 18-YEAR-OLD LACROSSE PLAYER WITH RECALCITRANT SYMPTOMATIC SPONDYLOLYSIS: A CASE REPORT.

Spondylolysis is an anatomical defect or fracture of the pars interarticularis and encompasses almost half of all cases of low back pain in adolescent athletes. Most athletes return to sport with conservative treatment, but it is possible that consideration of sport demands may further improve rate of successful return. When surgery is performed, complication rate is high, so all conservative measures should be explored before considering surgical intervention. The purpose of this case report is to present a program where demands of sport were considered and allowed successful return to sport for a subject with recalcitrant symptomatic spondylolysis that had failed to respond to prior treatment. An 18-year-old lacrosse player with a history of recalcitrant symptomatic spondylolysis that failed three courses of conservative treatment and had been unsuccessful in returning to sport. A multi-phase program with a focus on multi-planar and full kinetic chain activities that addressed the nature of the sport demands is described, along with improvements in pain level, strength, range of motion, and subjective outcome scores. The subject was able to successfully return to sport after 10 weeks of physical therapy and complete the remaining few months of his lacrosse season without reinjury. Range of motion and strength testing was markedly improved upon discharge. The subject's Modified Oswestry Disability Index improved from 16% to 0% and his pain level did not rise above 2/10 with any sport activity upon return. Although return to sport rates following spondylolysis in young athletes is high, this case report demonstrates that a consideration of sport demands may increase return to sport rates in athletes that do not respond to standard care and prevent surgical intervention. Level 4, single case report.

Comparison of symptomatic spondylolysis in young soccer and baseball players

BackgroundSpondylolysis is the main cause of low back pain (LBP) in young athletes. There are few studies analyzing the difference of spondylolysis among young athletes with different sports activities. The purpose of this study was to compare the clinical factors and distribution of the lesions of spondylolysis on magnetic resonance imaging (MRI) scans in young soccer and baseball players with symptomatic spondylolysis.MethodsThe medical records of 267 young athletes aged 7 to 18 years old who underwent MRI to evaluate the cause of LBP between 2017 and 2020 were retrospectively reviewed to identify patients with spondylolysis. Of the young athletes with symptomatic spondylolysis, clinical factors and MRI findings in soccer and baseball players were retrospectively evaluated. The clinical factors were age, sex, interval from onset of LBP to MRI, and side of the dominant leg in the sports field. MRI findings included number, lumbar level, and side of the lesions.ResultsA total of 33 soccer players (mean age, 15.4 ± 1.4 years) and 49 baseball players (mean age, 15.4 ± 1.6 years) with symptomatic spondylolysis were enrolled. All patients were male. No significant differences were noted in age and the interval from onset of LBP to MRI between the groups. Soccer players had greater numbers of multiple (p < 0.001) and bilateral (p < 0.001) lesions than baseball players. The dominant side of the hand for pitching or batting was correlated with the contralateral-side lesions in baseball players (p = 0.001).ConclusionsThe distribution of the lesions of spondylolysis differed in young soccer and baseball players. Pitching or batting with the dominant-side hand would be associated with contralateral-side lesions in baseball players. Sports-specific movements and the side of the dominant leg should be considered when treating young athletes with symptomatic spondylolysis.

Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis

Background: Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players. Purpose: To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population. Study Design: Descriptive epidemiology study. Methods: A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance. Results: During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode. Conclusion: Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.

Percutaneous endoscopic-assisted direct repair of pars defect without general anesthesia could be a satisfying treatment alternative for young patient with symptomatic lumbar spondylolysis: a technique note with case series

BackgroundMultiple surgical procedures are applied in young patients with symptomatic lumbar spondylolysis when conservative treatments fail. Although the optimal surgical procedure option is controversial, the treatment paradigm has shifted from open surgery to minimally invasive spine surgery. To date, a limited number of studies on the feasibility of percutaneous endoscopic-assisted direct repair of pars defect have been carried out. Herein, for the first time, we retrospectively explore the outcomes of pars defect via percutaneous endoscopy.MethodsWe retrospectively examined young patients with spondylolysis treated using the percutaneous endoscopic-assisted direct repair of pars defect supplemented with autograft as well as percutaneous pedicle screw fixation between September 2014 and December 2018. Six patients with a mean age of 18.8 years were enrolled in the study. We used preoperatively computed tomographic (CT) scans to evaluate the size of pars defect, and graded disc degeneration using Pfirrmann’s classification through magnetic resonance images (MRI). We assessed the clinical outcomes using the Oswestry Disability Index (ODI), 36-Item Short-Form Health Survey (SF-36) as well as Visual Analogue Scale for back pain (VAS-B).ResultsOur findings revealed that pain intensity and function outcomes, including VAS-B, ODI, and SF-36 (PCS and MCS) scores, were markedly improved after surgery and at the final follow-up visit. The change in the gap distance of the pars defect was remarkably significant after surgery and during the follow-up period. Only one of the 12 pars repaired was reported as a non-union at the final follow-up visit. Moreover, no surgery-related complications were reported in any of the cases.ConclusionPercutaneous endoscopic-assisted direct repair of pars defect without general anesthesia, a minimally invasive treatment option, supplemented with autograft and percutaneous pedicle screw fixation, could be a satisfying treatment alternative for young patients with symptomatic lumbar spondylolysis.

Performance-Based Outcomes Following Symptomatic Pars Injuries in American Professional Baseball Players

Objectives:Previous studies in the evidence-based literature suggest that lumbar spine injuries can lead to a significant decrease in athletic performance. This phenomenon is particularly evident in sports that require repetitive truncal rotation, such as baseball. Although we have previously characterized the natural history of symptomatic spondylolysis and spondylolisthesis in professional baseball players, no prior study has investigated the impact of pars injuries on player performance in this patient population. The purpose of this study was to report performance-based outcomes following symptomatic pars injuries in elite-level baseball athletes.Methods:A retrospective cohort study was conducted among all professional baseball players who presented with a symptomatic pars defect between 2011 and 2016. Both Major League and Minor League players were enrolled using a de-identified injury surveillance database maintained by the MLB. Lumbar spine imaging reports were reviewed to confirm the radiologic diagnosis of spondylolysis or spondylolisthesis. Players were stratified according to baseball position (pitcher vs. position player). Primary outcome measures for pitchers were earned run average (ERA) and walks plus hits per inning pitched (WHIP), while primary outcomes for position players were batting average (AVG) and on-base plus slugging (OPS). Paired t tests were used to compare pre-injury statistical performance to post-injury performance, with p < 0.05 treated as statistically significant.Results:During the defined study period, 75 players presented with low-back pain in the setting of a pars defect. 47 players were diagnosed with spondylolysis (62.7%), while 28 were diagnosed with spondylolisthesis (37.3%). Of those individuals, 19 players were excluded due to incomplete statistical data in the MLB injury surveillance system. Pre-injury vs. post-injury statistical comparisons are presented in Table 1. Pitching performance after the pars injury did not significantly differ with regard to the primary outcome measures, ERA (3.45 vs. 4.73; p = 0.25) and WHIP (1.28 vs. 1.47; p = 0.26). There was also no significant difference in any of the secondary outcomes - runs per 9 innings (R/9), hits per 9 innings (H/9), walks per 9 innings (BB/9), strikeouts per 9 innings (K/9), home runs per 9 innings (HR/9), and strikeout-to-walk ratio (K/BB). Similarly, batting performance among position players did not significantly differ from pre-injury to post-injury with regard to the primary outcomes, AVG (.261 vs. .256; p = 0.59) and OPS (.672 vs. .667; p = 0.87), or any of the secondary outcomes - on-base percentage (OBP), slugging percentage (SLG), runs per plate appearance (R/PA), hits per plate appearance (H/PA), runs batted in per plate appearance (RBI/PA), extra-base hits per plate appearance (XBH/PA), home runs per plate appearance (HR/PA), and walk-to-strikeout ratio (BB/K).Conclusion:This study represents the most comprehensive analysis of the impact of symptomatic pars injuries on MLB player performance. While previous studies suggest that lumbar injuries lead to shorter careers in both pitchers and position players, our current data demonstrate that pars defects do not cause a significant decrease in performance when MLB athletes return to play following these injury episodes. Given the limitations of our study design, larger prospective investigations are needed to validate these conclusions.Table 1.Pre-Injury and Post-Injury StatisticsPre-Injury (mean)Post-Injury (mean)P ValuePitchers ERA3.454.730.25 WHIP1.271.470.26 R/93.985.500.22 H/98.698.550.86 BB/92.794.680.26 K/97.288.570.07 HR/91.150.840.57 K/BB2.883.000.69Position Players AVG.261.2560.59 OPS.672.6670.87 OBP.266.2590.27 SLG.406.4090.90 R/PA0.120.120.86 H/PA0.240.230.31 RBI/PA0.110.110.56 XBH/PA0.080.080.93 HR/PA0.020.020.74 BB/K0.450.430.70

Outcome of Conservative Management in the Treatment of Symptomatic Spondylolysis and Grade I Spondylolisthesis

Bracing (thoraco-lumbar-sacral orthosis) has been accepted as mainstay of treatment for symptomatic spondylolysis (SP) and grade I spondylolisthesis (SPL1). However, increasing costs and patient noncompliance can make bracing prohibitive and difficult to manage. The purpose of this study was to determine if SP and SPL1 can be effectively treated using physical therapy and other non-bracing conservative management techniques in order to relieve pain and restore physical function.We performed a cross-sectional study in which patients who presented from June 1, 2004, to May 1, 2015, with symptomatic SP and SPL1 who were treated with nonbracing conservative management, entailing a universal 6-week physical therapy program and restriction of offending activity, were considered for the study. Physical therapy included core strengthening activities, hamstrings stretching, and spine range of motion exercises. Patients meeting inclusion criteria were contacted via phone interview and asked to complete an Oswestry Disability Questionnaire (ODQ) in order to generate a disability score to assess their current pain and daily function. Patients were then stratified into groups based on their level of disability as denoted by their disability score; minimal disability = disability score of 0% to 19.9%, moderate disability = 20% to 39.9%, severe disability = 40% to 59.9%, crippled = 60% to 79.9%, and bed bound or exaggerating = 80% to 100%.Fourty-six patients were identified as meeting inclusion criteria (28 with SP and 18 with SPL1). Twenty-three of 46 were successfully contacted and agreed to complete the ODQ (10/23 with SP and 13/23 with SPL1). Twenty-two of 23 (96%) patients had a minimal disability score (0% to 19.9%), One of 23 (4%) patients had a moderate disability score (20% to 39.9%), and 18/23 (78%) patients had a disability score of zero, denoting no pain or limitation of function.The results of this study suggest that, in patients with symptomatic spondylolysis and grade I spondylolisthesis, pain relief and restoration of function can be achieved using conservative management techniques without use of a brace.

Outcome of Conservative Management in the Treatment of Symptomatic Spondylolysis and Grade I Spondylolisthesis

Purpose: Bracing, thoraco-lumbar-sacral orthosis (TLSO), has been accepted as mainstay of treatment for symptomatic spondylolysis (SP) and grade I spondylolisthesis (SPL1). However increasing costs and patient noncompliance can make bracing prohibitive and difficult to manage. The purpose of our study was to determine if SP and SPL1 can be effectively treated using physical therapy and other non-bracing conservative management techniques in order to relieve pain and restore physical function. Methods: We performed a …

Diagnosis of Spondylolysis and Spondylolisthesis Is Delayed Six Months After Seeing Nonorthopedic Providers*

Study DesignRetrospective single center. ObjectiveOur purpose was to quantify the time to diagnosis of spondylolysis/spondylolisthesis in symptomatic patients after first seeking medical care. Summary of Background DataSeveral studies have found a high prevalence of pars defects in adolescent athletes with back pain, up to 47%. A review by the Scoliosis Research Society Evidence-Based Medicine Committee reports that both nonsurgical and surgical treatment of symptomatic spondylolysis effectively relieves pain and allows most patients to return to activities. Nonoperative treatment outcomes improve with early diagnosis. MethodsA retrospective chart review was conducted of patients presenting at our institution between 2005 and 2015 with symptomatic spondylolysis or spondylolisthesis with radiographic confirmation. Medical records were reviewed for demographics, date of symptom onset, date of initial presentation to a health care provider, type of provider, and date of diagnosis. ResultsForty-six patients met the inclusion criteria. Average patient age was 14 years (range: 6–19 years). Forty-one percent (19/46) of patients had spondylolysis, and 59% (27/46) of patients had spondylolisthesis. Of those with spondylolisthesis, 20 had grade I, 4 had grade II, 2 had grade III, and 1 had grade IV slips. The average time between onset of symptoms and initial presentation was 24 weeks (orthopedic: 21 weeks, nonorthopedic: 29 weeks, unknown: 18 weeks; p = .26). The average delay between initial presentation to a health care provider and diagnosis was 15 weeks. Time from initial presentation to diagnosis was 1 week for orthopedic surgeons, 25 weeks for nonorthopedic providers, and 10 weeks for unknown providers; this difference was significant (p = .02). ConclusionDiagnosis of spondylolysis/spondylolisthesis was significantly longer after seeing a nonorthopedic versus an orthopedic provider. Education of primary care providers on this topic is warranted. Children suffering from back pain from spondylolysis/spondylolisthesis may benefit from early referral to an orthopedic surgeon. Level of EvidenceLevel II.

Efficacy and outcome predictors of fluoroscopy-guided facet joint injection for spondylolysis.

To assess the efficacy of fluoroscopy-guided facet joint injection for symptomatic spondylolysis and to analyze the outcome predictors. This study included 108 patients who underwent fluoroscopy-guided facet joint steroid injection for symptomatic spondylolysis with follow-up medical records from January 2013 to December 2016. Among them, 47 patients underwent concomitant epidural steroid injection. Response to injection was assessed at the initial follow-up. The symptom-free interval was analyzed using the Kaplan-Meier method. Outcome predictors were statistically analyzed using independent ttest and Chi-square test. The facet joint injection was effective in 52 of 108 (48.1%) patients at initial follow-up. Recurrence was reported in 21 of these 52 (40.4%) patients. For the 52 patients in whom facet joint injection was effective, the median symptom-free interval was 298days (95% confidence interval, 29-567days). No significant difference was found in the response between the group with facet joint injection only (n=61) and the group with facet joint injection and additional ESI (n=47). Additionally, no significant outcome predictors were detected. Fluoroscopy-guided facet joint injection may potentially be an effective therapy for providing prolonged pain relief and avoiding unnecessary surgery for symptomatic spondylolysis without significant outcome predictors.

Minimally-Invasive versus Conventional Repair of Spondylolysis in Athletes: A Review of Outcomes and Return to Play.

Spondylolysis from pars fracture is a common injury among young athletes, which can limit activity and cause chronic back pain. While current literature has examined the relative benefits of surgical and conservative management of these injuries, no study has yet compared outcomes between conventional direct repair of pars defects and modern minimally invasive procedures. The goals of surgery are pain resolution, return to play at previous levels of activity, and a shorter course of recovery. In this review, the authors have attempted to quantify any differences in outcome between patients treated with conventional or minimally invasive techniques. A literature search was performed of the PubMed database for relevant articles, excluding articles describing conservative management, traumatic injury, or high-grade spondylolisthesis. Articles included for review involved young athletes treated for symptomatic spondylolysis with either conventional or minimally invasive surgery. Two independent reviewers conducted the literature search and judged articles for inclusion. All studies were classified according to the North American Spine Society standards. Of the 116 results of our initial search, 16 articles were included with a total of 150 patients. Due to a paucity of operative details in older studies and inconsistencies in both clinical methods and reporting among most articles, little quantitative analysis was possible. However, patients in the minimally invasive group did have significantly higher rates of pain resolution (p<0.001). Short recovery times were also noted in this group. Both groups experienced low complication rates, and the majority of patients returned to previous levels of activity. Surgical repair of spondylolysis in young athletes is a safe and practical therapy. Current literature suggests that while conventional repair remains effective, minimally invasive procedures better clinical outcomes. We await further data to conduct a more thorough quantitative analysis of these techniques.

The Relationship Between Sacral Slope and Symptomatic Isthmic Spondylolysis in a Cohort of High School Athletes: A Retrospective Analysis

BackgroundSpondylolysis with and without anterolisthesis is the most common cause of structural back pain in children and adolescents, but few predictive factors have been confirmed. An association between abnormal sacropelvic orientation and both spondylolysis and spondylolisthesis has been supported in the literature. Sacral slope and other sacropelvic measurements are easily accessible variables that could aid clinicians in assessing active adolescents with low back pain, particularly when the diagnosis of spondylolysis is suspected. ObjectiveTo examine the relationship between sacral slope and symptomatic spondylolysis in a cohort of active adolescents. DesignCase-control retrospective study. SettingAcademic outpatient physiatry practice. PatientsSeventy-four patients of primarily adolescent age (between 12 and 22 years old) with a chief complaint of low back pain and presence of lateral radiographs of the lumbar spine were enrolled. Cases (n = 37) were defined as subjects with evidence of spondylolysis on both radiograph and magnetic resonance imaging of the lumbar spine. Controls (n = 37) were defined as subjects without spondylolysis. MethodsUsing a single sagittal radiograph, taken with the patient standing, a fellowship-trained interventional spine physiatrist measured the sacral slope of each subject (angle between the superior plate of S1 and a horizontal reference on sagittal imaging of the lumbosacral spine). Ages and genders were collected from medical records. Main Outcome MeasurementsThe primary outcome was mean sacral slope. Mean sacral slope of cases was compared with mean sacral slope of controls with the Student t-test. ResultsAges ranged from 12 to 22 for both groups, with no significant differences in age between the groups (cases: 16.8 ± 2.3 years; controls: 17.7 ± 2.7 years). The patients with spondylolysis (cases) consisted of 29 male and 8 female patients, whereas those without spondylolysis (controls) consisted of 15 male and 21 female patients (gender details for 1 patient were not available). The mean sacral slope among cases was 42.4°, whereas the mean sacral slope among controls was 37.4°. The difference achieved significance (P = .014). ConclusionsThe interdependence of positional parameters, such as sacral slope, with anatomic parameters, such as pelvic incidence, can affect lumbar lordosis and therefore upright positioning and loading of the spine. Sacral slope may be an important variable for clinicians to consider when caring for young athletes with low back pain, particularly when the index of suspicion for spondylolysis is high. Level of EvidenceIV

P.095 Soft tissue preserving direct multilevel pars repair using the ‘Smiley Face’ technique with 3D optical imaging based intraoperative spinal navigation

Background: Two broad categories for the surgical management of symptomatic spondylolysis exist: decompression, or direct reduction and fixation. Direct fixation can maintain mobility and leads to improved outcomes over spinal fusion. The ‘smiley face’ technique is a direct fixation method of pars defect repair that uses one bent rod to reduce the number of linkage points and simplify the construct. Methods: Bilateral pars defects at L3 and L5 were repaired using the ‘smiley face’ technique. Patient reported outcomes, including the Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for back and leg pain were assessed preoperatively and again at 6 weeks postoperatively. Results: The patient underwent a soft tissue preserving multi-level bilateral L3 and L5 pars defect repair using the smiley face technique while utilizing radiation-free 3D optical imaging to capture multiple points for registration despite minimal laminar exposure. The patient’s ODI and lower back VAS scores decreased from 25 to 8 and 7.5 to 4 respectively, after surgery, correlating to an excellent outcome on ODI. Conclusions: The smiley face technique can be used with soft tissue preserving techniques to achieve adequate bony reduction while maintaining intersegmental mobility in patients with multi-level pars defects. 3D imaging allows soft tissue preservation with increased registration points for intraoperative navigation.

P191 - Return to Play in Adolescent Athletes with Symptomatic Spondylolysis without Listhesis: a Meta-Analysis

P191 - Return to Play in Adolescent Athletes with Symptomatic Spondylolysis without Listhesis: a Meta-Analysis

Comparison of Direct Pars Repair Techniques of Spondylolysis in Pediatric and Adolescent Patients

Retrospective clinical cohort study. To compare the clinical and radiographic outcomes of patients who were treated with intrasegmental pars fixation by either laminar compression screw (LS) or a pedicle screw, rod, and laminar hook (PSRH) construct. Spondylolysis is a nonunion defect of the pars interarticularis. In symptomatic spondylolysis, direct repair of the pars interarticularis defect can preserve motion and prevent abnormal stresses at the adjacent levels. Sixteen patients who failed nonoperative treatment and underwent direct pars repair by using LS (n=9) or PSRH (n=7) constructs were included in the study. Clinical outcome was assessed by using the MacNab criteria. Radiologic fusion and complications were evaluated using plain radiographs or computed tomography images and patient charts. The healing rate was 100% after 6 months. The healing time was similar in both the groups: LS, 6.5 months; PSRH, 6.2 months. Patients with PSRH (5.9 mo) were more likely to return to sports earlier relative to patients with LS (7.7 mo). There were no complications in the LS group; in the PSRH group, 1 patient had mild sensory deficit and 2 had superficial wound infections. The MacNab criteria for pain assessment showed an excellent or good outcome in 8 of 9 patients in LS group and 6 of 7 patients in PSRH group. Relative to LS patients, there was a significant increase in surgical time and estimated blood loss among PSRH patients. Either of the mentioned 2 techniques appears to produce acceptable results. Biplanar fluoroscopy and navigation systems could minimize the risk of screw misplacement with LS construct. Familiarity with the various fixation techniques will allow the surgeon to select the most appropriate surgical technique.