Dear Dr. Theriot,
I have an 8 year old son who is very active in sports and karate. He has had severe back pain and was diagnosed as having spondylolysis. The doctors have had him take anti-inflammatory drugs and rest, but he still is having pain. They say that rest is the best thing for him, and that he should stay out of many of the activities that he really enjoys. They say that it may advance to the point where he will need spine surgery. Please help me understand what spondylolysis is, and is there anything more I can do for him?
To understand spondylolysis and spondylolisthesis, let us first look at the normal anatomy. We have all seen pictures of the spine, a column of vertebrae that are stacked one on top of the other. From top to bottom, there are the cervical vertebrae, the thoracic vertebrae (chest), and the lumbar vertebrae (low back). The lumbar vertebrae sit on top of the sacrum which forms part of the pelvis.
Spondylolysis usually occurs at the junction of the last lumbar vertebra (L-5) and the sacrum. It can occur higher up, but this is much less common. Spondylolysis is a defect, usually a fatigue or stress fracture, of L-5. This defect is felt to be the result of repeated bending and extending of the spine. Over time, "micro-fractures" occur and this is what causes the back pain. With rest and inactivity, the body tries to heal the area, and the pain will abate. Once the activity is resumed, the process tends to progress...and in time can lead to an actual fracture. Spondylolysis is the fracture of the "pars interarticularis" of L-5 which is where it articulates with the sacrum.
When spondylolysis is present on one side of the vertebra, it can result in undue stress, or an overloading, of the opposite side of the vertebra. This can result in a spondylolysis of both sides. When this happens, the space between L-5 and the sacrum has un-opposing shear forces which can progress to spondylolisthesis...a forward slippage of L-5 on the sacrum.
Spondylolysis occurs in around 5% of the general population. It is uncommon before the age of five years, but steadily increases in frequency until the age of twenty. Genetics probably plays an important role in spondylolysis as it occurs in about 27% of first order relatives. In one tribe of Alaskan Eskimos, spondylolysis is present in 54% of the entire population. Spondylolysis is quite prevalent in athletes who participate in sports that require hyper-flexion and extension of the back. These include gymnastics, weight-lifting, tennis and football. One author reported the incidence of spondylolysis in female American gymnasts to be 11%.
In spondylolysis, pain typically does not occur until adolescence (11-15 years of age) when there is rapid growth. The most common complaint is low back pain which can radiate down to the knee. Associated findings are tight hamstrings muscles, abnormal posture and an abnormal gait.
Early in the course of sponsylolysis, the symptoms are decreased by rest and limited activity...unfortunately the relief is temporary. Other modalities such as non-steroidal anti-inflammatories and ice-heat are helpful as well. But spondylolysis tends to be a progressive disorder.
More serious objective findings can occur, and these are more common in adults with spondylolisthesis. These include weakness, defects in sensation and abnormal reflexes. They are the result of the forward slippage L-5 and the pressure placed on the nerves.
The diagnosis can usually be made by x-rays of the spine. This can be best seen with a special oblique view, however it does not always show up on x-ray. More sensitive tests may be needed to cinch the diagnosis. These include a bone scan, CT scan or MRI.
Most experts agree that the main goal in treating a child with spondylolysis is to minimize the symptoms, and prevent the progression to spondylolisthesis. This usually requires rest, limiting the activity, and the use of non-steroidal anti-inflammatory agents.
Immobilization by non-surgical means such as a brace or cast may be beneficial in certain cases. This has been somewhat successful when the onset of spondylolysis is recent, and there is no evidence of spondylolisthesis.
Surgery is the final option and is performed only when it is absolutely necessary. In selected cases of spondylolysis, repair of the defect at the pars interarticularis has been successful. In spondylolisthesis, the surgery of choice is a spinal fusion. Surgery is a major undertaking and the benefits must outweigh the risks. This requires much discussion between the patient, the parents and the surgeon.
In children, surgery is indicated if:
This is an overview of spondylolysis and spondylolisthesis. I hope it is helpful to you. It is important for you to discuss your son's progress with the doctors on a regular basis. I am sure that they will welcome any questions you might have. I wish your son the best of luck.