Tratamiento y vuelta a la práctica deportiva en jóvenes con diagnóstico de espondilólisis. Revisión sistemática / Tratamento e retorno à prática esportiva em jovens com diagnóstico de espondilólise. Revisão sistemática / Treatment and return to sports practice in young people diagnosed of spondylolysis. Systematic review

Objetivo: Analizar los tratamientos aplicados en pacientes menores de edad con espondilólisis y ver su relación con la vuelta al deporte.Método: Se revisaron los artículos en inglés, español o portugués publicados entre 2015 y 2020 publicados en PubMed, Medline, Cinahl, Scopus, Sport Discuss y Web Of Science, seleccionando aquellos que reflejasen el tratamiento de espondilólisis en menores de 18 años y su vuelta al deporte. Se seleccionaron 10 artículos que cumplieron con los criterios de inclusión y exclusión y fueron analizados.Conclusión: El tratamiento conservador es la primera opción para todos los pacientes con espondilólisis, pero parece ser efectivo en las etapas tempranas y progresivas, siendo la opción ideal para las espondilólisis terminales una intervención mínimamente invasiva. Ambos tratamientos deben constar de un periodo de reposo de la actividad deportiva y una rehabilitación física progresiva antes de retomarla. (AU)

Objective: To analyze the treatments applied in minor patients with spondylolysis and to see its relationship with the return to sport.Method: Articles in English, Spanish or Portuguese published between 2015 and 2020 published in PubMed, Medline, Cinahl, Scopus, Sport Discuss and Web Of Science were reviewed, selecting those that reflect the spondylolysis treatment in children under 18 years and their return to sport. 10 articles that met the inclusion and exclusion criteria were selected and analyzed.Conclusion: Conservative treatment is the first option for all patients with spondylolysis, but it seems to be effective in the early and progressive stages, being the ideal option for terminal spondylolysis a minimally invasive intervention. Both treatments must be consistent with a period of rest from sports activity and progressive physical rehabilitation before resuming it. (AU)

Objetivo: Analisar os tratamentos aplicados em pacientes menores com espondilólise e verificar sua relação com o retorno ao esporte.Método: Se revisaram os artigos em inglês, espanhol ou português publicados entre 2015 e 2020 publicados no PubMed, Medline, Cinahl, Scopus, Sport Discute e Web Of Science, selecionando aqueles que refletem o tratamento da espondilólise em menores de 18 anos e seu retorno a esporte. Foram selecionados e analisados ​​10 artigos que atenderam aos critérios de inclusão e exclusão.Conclusão: O tratamento conservador é a primeira opção para todos os pacientes com espondilólise, mas parece ser eficaz nos estágios inicial e progressivo, sendo a opção ideal para a espondilólise terminal uma intervenção minimamente invasiva. Ambos os tratamentos devem consistir em um período de descanso da atividade esportiva e da reabilitação física progressiva antes de retomar. (AU)

Physical features of pediatric patients with lumbar spondylolysis and effectiveness of rehabilitation.

The purpose of this study was to evaluate the physical features of pediatric patients with lumbar spondylolysis (LS), factors that increase the load during compensatory movements at the lumbar spine, and the outcomes of rehabilitation. Twenty patients were included. Fifteen items were used:fingertip-to-floor distance (FFD), straight leg raising (SLR), heel-to-buttock distance (HBD), tightness of the rectus femoris, the lateral and medial rotator muscles, iliopsoas, tensor fascia lata, adductor muscles, soleus muscle, and latissimus dorsi, and trunk rotation, sit-ups and endurance of the abdominal and back muscles. Initial findings were judged as positive or negative using previously reported cut-off values and were re-evaluated 2 or 3 months later. Positive tests were found for HBD and tightness of the rectus femoris in 85% of the patients, for endurance of the abdominal muscles in 75%, SLR and sit-ups in 70%, and FFD and tightness of the external rotator muscles in 60%. The physical features varied according to the type of sport played, and some patients were refractory to rehabilitation. Only 17.6%, 33.3%, and 40.0% of patients with initially positive findings for HBD, tightness of the external rotator muscles, and endurance of the abdominal muscles, respectively, achieved improvements after rehabilitation. J. Med. Invest. 65:177-183, August, 2018.

High defect stage, contralateral defects, and poor flexibility are negative predictive factors of bone union in pediatric and adolescent athletes with spondylolysis.

PURPOSE: To identify predisposition to spondylolysis and physical characteristics associated with "bone union" following conservative spondylolysis treatment among pediatric and adolescent athletes. METHODS: We retrospectively analyzed pediatric and adolescent athletes with spondylolysis who underwent conservative treatment and rehabilitation for three or more consecutive months following sports activity cessation. Patients with terminal spondylolysis or who did not discontinue sports activities were excluded. We compared physical fitness factors in the union and nonunion groups and examined the association between bone union and spondylolysis severity by logistic regression analysis. RESULTS: Of 183 patients with spondylolysis who underwent rehabilitation over a four-year period, 127 patients with 227 defects were included in the final analysis. Bone union was achieved in 66.5% (151/227) of the pars interarticularis defects and 70.1% (89/127) of the patients. On multivariate analysis, stage of pars interarticularis defect (odds ratio [OR], 0.26;p = 0.0027), stage of contralateral pars interarticularis defect (OR, 0.51;p = 0.00026), and straight leg-raising test (OR, 1.06;p = 0.028) were significantly associated with bone union. CONCLUSIONS: High defect stage, stage of the contralateral pars interarticularis defect, and poor flexibility were negative prognostic factors of bone healing in athletes with spondylolysis. J. Med. Invest. 65:126-130, February, 2018.

A minimal soft tissue damage approach of spondylolysis repair in athletes: preliminary report.

PURPOSE AND HYPOTHESIS: Both spondylolysis and spondylolisthesis come in second place in the causes of pain among athletes. Treatment options include both conservative management and different operative methods. Athletes and adolescents are groups where the priority is to protect tissues from perioperative damage. OBJECTIVE: We present our modification of the Buck's, direct pars repair method, which we believe offers maximum protection of tissues. We used the modified surgical method in young, competitive athletes, in whom non-surgical treatment was not effective. METHOD: Eight pars defects in five patients were treated using suggested method. All of them were young males (aged between 13 and 18 years), who practice soccer professionally. We use modified method of direct repair pars through the cannulated screw fixation, first proposed by Buck. Preoperative preparation consists of proper analysis of computer tomography images in multiplanar reconstruction mode: measuring screw length, measurement of inclination angle of the optimal screw trajectory in the frontal and sagittal plane. During the operation, the wire proper direction is performed by usage of the predetermined angles. Starting point for guide wire was also changed to the lower end of the facet. The fusion takes place with a screw of 3 mm diameter. After the operation patient need to use thoracolumbar spinal orthosis as a primary immobilization for 6 weeks and appropriate rehabilitation for another 6 weeks. We used these methods in eight pars fixations. RESULTS: All of the patients were painless in first week after surgery. All of them underwent total rehabilitation programme and returned to sport. CONCLUSIONS: Direct pars repair using Buck's method with proposed modification, including adequate radiographic preparation, the use of a thin cannulated screw and changing the point of screw entry, allows precise and safe screw placement, regardless of the size of the bone at the defect site.

Active stretching for lower extremity muscle tightness in pediatric patients with lumbar spondylolysis.

BACKGROUND: It was reported that hamstring muscle tightness may increase mechanical loading on the lumbar spine. Therefore, we attempt to decrease tightness in the leg muscles in pediatric patients. METHODS: Forty-six pediatric patients with spondylolysis underwent rehabilitation. We applied active stretching to the hamstrings, quadriceps, and triceps surae. Tightness in each muscle was graded as good, fair, or poor. We educated each patient on how to perform active stretching at home. They were re-evaluated for muscle tightness 2 months later. RESULTS: Tightness at baseline and after 2 months was as follows: for the hamstrings, good in 3 patients, fair in 9, and poor in 34 and significant improved after 2 months (p<0.05), with improvement by least 1 grade seen in 86% of patients with fair or poor at baseline; for the quadriceps, 7, 3, and 30 patients had good, fair and poor, with significant improvements in 72% (p<0.05). For the triceps surae, 6, 3 and 10 patients had good, fair and poor, which improved significantly (p<0.05). CONCLUSION: Home-based active stretching was effective for relieving muscle tightness in the leg in a pediatric population. Adolescent athletes should perform such exercise to maintain flexibility and prevent lumbar disorders. J. Med. Invest. 64: 136-139, February, 2017.

Timing of Physical Therapy Referral in Adolescent Athletes With Acute Spondylolysis: A Retrospective Chart Review.

OBJECTIVES: The purposes of this study were (1) to determine whether the duration of rest before referral to physical therapy (PT) affects the time to make a full return to activity for patients with an acute spondylolysis, (2) to assess the safety of an early referral to PT in patients with an acute spondylolysis. STUDY DESIGN: Retrospective chart review. SETTING: Hospital-based sports medicine clinic. PATIENTS: The medical charts of 196 adolescent athletes (mean age = 14.3 ± 1.8 years) with an acute spondylolytic injury met the inclusion criteria and were reviewed. INDEPENDENT VARIABLE: Patients were subgrouped based on physician referral to PT. PATTERNS: An aggressive referral group (<10 weeks) and a conservative referral group (>10 weeks). MAIN OUTCOME MEASURES: Duration of rest before clearance to a full return to activity and the frequency of adverse reactions during the course of treatment. Safety was assessed by calculating the risk of experiencing an adverse reaction in each group. RESULTS: Median days to a full return to activity for aggressive referral group (115.5 days, interquartile range 98-150 days) and conservative referral group (140.0 days, interquartile range 114.5-168 days) were significantly different (P = 0.002). Eleven patients had adverse reactions during the course of treatment. The risk of adverse reaction was not statistically significant between groups (P = 0.509). CONCLUSIONS: Patients with acute spondylolysis in the aggressive referral group were able to make a full return activity almost 25 days sooner. No differences in the risk of adverse reactions were noted between aggressive and conservative referral groups.

Reabilitação baseada em movimento para melhora de dor e atividade em indivíduos com espondilólise ou espondilolistese: revisão sistemática / Movement-based rehabilitation to reduce pain and improve activity in people with spondylolysis and spondylolisthesis: a systematic review

Introdução: Alterações em estrutura e função decorrentes de espondilólise/espondilolistese podem incluir dor lombar e/ou irradiada para membros inferiores com limitações de atividade. Objetivo: avaliar a eficácia de programas de reabilitação baseados em movimento para redução da dor e melhora de atividade em indivíduos com diagnóstico de espondilólise/espondilolistese. Método: Revisão sistemática de ensaios clínicos aleatorizados, cuja intervenção foi programa de reabilitação baseado em exercício. As medidas de desfecho foram dor e atividade. Resultados: Cinco estudos foram incluídos. Dois estudos investigaram a eficácia da intervenção experimental comparada a placebo/não-intervenção, encontrando resultados inconclusivos. Três estudos investigaram a eficácia da intervenção experimental em comparação ao tratamento cirúrgico, reportando superioridade do tratamento cirúrgico. Conclusão: Os resultados são inconclusivos em relação à eficácia da reabilitação baseada em movimento, e sugerem que é menos eficaz do que tratamentos cirúrgicos na redução da intensidade de dor e melhora de atividade de indivíduos com diagnóstico de espondilólise/espondilolistese.

Introduction: Body structure and function impairments due to spondylolysis/spondylolisthesis may include low back pain and/or radiating pain, leading to activity limitations. Objective: To investigate the efficacy of movement-based rehabilitation programs to reduce pain and improve activity in people with spondylolysis/spondylolisthesis. Method: Systematic review of randomised clinical trials. Experimental intervention was movement-based rehabilitation program and outcome measures were pain and activity. Result: Five trials were included. Two trials examined the efficacy of the experimental intervention compared with placebo/no-intervention, and found inconclusive results. Three trials examined the efficacy of the experimental intervention compared with a surgical treatment, and reported superiority in favour of the surgical treatments. Conclusion: The results are inconclusive regarding the efficacy of movement-based rehabilitation, and suggested that it is less effective than surgical treatments.

Effect of sports modification on clinical outcome in children and adolescent athletes with symptomatic lumbar spondylolysis.

OBJECTIVE: This cohort study aimed to report the compliance of young athletes with nonoperative treatment and to clarify the role of sports modification on clinical outcome of symptomatic spondylolysis. DESIGN: This study included patients with a chief complaint of low back pain participating in regular sports activity, having spondylolysis, and being treated and followed up between 1990 and 2002 in the authors' hospital. RESULTS: One hundred thirty-two athletes were included in this study: 78 males and 54 females. The mean age of the patients was 13 yrs (range, 7-18 yrs). Only 56 patients (42.4%) were compliant to nonoperative treatment. Eighty-six patients (65%) stopped all sports activities for at least 3 mos, and 46 patients (35%) stopped exercising for a variable period of less than 3 mos. The grading of clinical outcome after nonoperative treatment was as follows: excellent in 48 patients (36.4%), good in 74 patients (56.1), fair in 6 patients (4.5%), and poor in 4 patients (3%). The patients who stopped sports for at least 3 mos were 16.39 times more likely to have an excellent result than those who did not stop sports. Bony healing on radiographs did not correlate with clinical outcome. CONCLUSIONS: Timely cessation of sports activity for 3 mos is considered an effective method of nonoperative treatment for young athletes with symptomatic lumbar spondylolysis.

Acute lumbar spondylolysis in intercollegiate athletes.

STUDY DESIGN: A retrospective case series. OBJECTIVE: The purpose of this study was to describe a unique group of intercollegiate athletes who are skeletally mature and who developed symptomatic acute lumbar spondylolysis and to study long-term return to play outcome of nonoperative and surgical repair of L3 and L4 spondylolysis in skeletally mature athletes. BACKGROUND: Traditionally, symptomatic acute lumbar spondylolysis is a defect found in skeletally immature athletes, most commonly in the pars interarticularis of L5, less commonly in the L3/L4 region, and even less commonly in skeletally mature athletes as described in this group. METHODS: Eight intercollegiate athletes (2 women and 6 men, ages ranging from 19 to 21 y) with acute lumbar spondylolysis were diagnosed by means of computed tomography (CT) and single photon emission-CT bone scan. L3 lesions were present in 5 patients, and L4 lesions were present in 3 patients. All patients were treated initially nonoperatively with a protocol of bracing and activity modification. The healing progress was assessed through repeat CT scan. Patients who failed to respond to nonoperative procedures underwent direct repair of their pars defect through variable angle pedicle screw and sublaminar hook. Outcomes were measured by completion of the Oswestry Low Back Pain Disability Questionnaire (mean follow-up 6.5 y) and return to athletic participation. RESULTS: All patients successfully returned to full athletic competition. Two patients showed radiographic healing and resolution of pain following 3 months of nonoperative treatment. Five patients required surgical repair of the pars defect. All of these patients eventually returned to unrestricted participation in athletics. CONCLUSIONS: This study shows that this subgroup will generally respond well to surgical correction of the pars defect and return to uninhibited competition following conservative treatment and/or surgical repair.

Conservative treatment of lumbar spondylolysis in young soccer players.

PURPOSE: The purpose of this study was to report the functional outcomes of young active soccer players with lumbar spondylolysis undergoing conservative treatment. METHODS: Between 2002 and 2004, all soccer players diagnosed with spondylolysis with a minimum 2-year follow-up were retrospectively reviewed. All patients were treated nonoperatively with cessation of sports activity and rehabilitation for 3 months. The rehabilitation protocol was identical for all patients and emphasized strengthening of abdominal muscles, stretching of the hamstrings, "core" stability exercises, and trunk rotational movements in a pain-free basis. Those patients with pain at rest and with daily life activities were also treated with a thoracolumbar orthosis. Symptomatic patients or those with positive SPECT were not allowed to return to sports and continued the rehabilitation protocol for 3 more months. RESULTS: The mean time of cessation of sports activity was 3.9 months (SD 0.8) and 5.2 months (SD 2.1) for a complete return to sports. At the 2-year follow-up, 28 patients (82%) obtained excellent results, 4 (12%) good results, 1 patient (3%) a fair result, and 1 patient (3%) a poor result. CONCLUSIONS: Conservative treatment of spondylolysis in young soccer players with cessation of sports and rehabilitation, with or without thoracolumbar orthosis, was associated with excellent functional results in terms of return to sports and level of achievable physical activity.

Elite male adolescent gymnast who achieved union of a persistent bilateral pars defect.

An adolescent 15-yr-old male competitive gymnast presented to a university-based multidisciplinary spine institute with a persistent low-back pain for 18 mos. Although the results of x-rays were negative, his pain rendered him unable to compete in his sport any longer. A computed tomography scan was performed, which showed a bilateral pars fracture at L5, without spondylolisthesis. A nuclear medicine bone scan revealed negative findings, confirming chronic nonunion. The patient completed a 4-wk course of physical therapy 6 mos before our intervention, without any relief of pain or radiologic evidence of healing. The patient was treated with a bone stimulator for 4 hrs/day and was recommended to wear a warm-and-form-type brace. Isometric core trunk exercises were also initiated. Only after 6 wks of treatment, the subject showed clinical improvement at the follow-up visit. Computed tomography scan performed 12 wks after the initial scan showed complete union of the fracture correlating with clinical improvement. Two years later, the athlete remains completely pain-free, is training regularly, and is able to compete on a national and, possibly, international level.

Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes.

Although spondylolysis is relatively common in adolescent athletes, there are substantial disagreements in the literature concerning the best methods for diagnosing and treating the condition. Controversy particularly arises regarding the optimal use of available imaging modalities in the diagnosis of athletes with suspected pars defects and the extent of activity restriction or brace use required for appropriate treatment. Because there have been no controlled trials on the treatment of spondylolysis and only a very limited number of studies addressing potential imaging strategies, it is difficult to develop true evidence-based guidelines for this condition. Given the current state of the literature, it is our impression that nuclear imaging with single photon emission computed tomography followed by computed tomography, with a limited role for plain radiography, remains the standard for appropriately diagnosing a symptomatic pars lesion. Treatment hinges on activity restriction for an amount of time adequate to allow for symptom resolution and, when possible, potential bony healing followed by a progressive sport-specific rehabilitation program. The biomechanic effects of brace use in this population are not well understood, but there may be some detrimental effects to the use of a brace and there currently is no evidence that the routine use of a rigid brace results in any significant improvement in radiographic or functional outcome.

Spondylolysis: a review and treatment approach.

Low back pain, specifically "spondylo" conditions, has traditionally been misunderstood and often times ill-treated. A thorough understanding of the function of pars interarticularis and its relationship to the entire vertebral unit and low back health are essential for successful treatment and rehabilitation outcomes. Lifestyle awareness and controlled progression through the inflammation, stabilization, strength, and functional rehabilitation phases provide primary guidance for patients. In addition, a broad spectrum of pharmacological, psychological, therapeutic modality, and newer surgical techniques must be considered in the overall treatment plan. Having a strong understanding of the anatomy, biomechanics, treatment, and rehabilitation of this condition, will help the allied healthcare provider better meet the individualized needs of spondylolysis patients.

Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment.

The purpose of this study was to clarify the efficacy of conservative treatment in athletes with severe low back pain and spondylolysis, especially focusing on returning to original sporting activities. One hundred and four athletes (96 males and eight females), who consulted our sports medicine clinic during the 11-year period between September 1991 and October 2002 because of low back pain with an apparent defect of the pars interarticularis on plain radiographs, were subjected to conservative treatment. The mean age of the patients was 20.7 years. Of all the patients, 40 (38.5%) discontinued sporting activities due to severe low back pain, and were conservatively treated with activity restriction and antilordotic lumbosacral bracing, aimed at relieving low back pain by achieving stability of the fracture partly associated with fibrous union. After their low back pain was markedly reduced, the brace was removed and then individual training to return to the original sporting activities was started. Thirty-five patients (87.5%) could return to their original sporting activities in an average of 5.4 months (range: 1.0-11.5 months) after the onset of treatment, and could continue the activities for at least 6 months despite non-bony union. These results suggest that the outcome of conservative treatment with activity restriction and bracing appears to be satisfactory in controlling symptoms and returning to original sporting activities. Randomized controlled trials or comparative follow-up studies are needed to confirm our results.

A systematic review of physiotherapy for spondylolysis and spondylolisthesis.

The purpose of this systematic review was to assess the evidence concerning the effectiveness of physiotherapy intervention in the treatment of low back pain related to spondylolysis and spondylolisthesis. A literature search of published and unpublished articles resulted in the retrieval of 71 potential studies on the subject area. Fifty-two of the 71 articles were studies, and these studies were reviewed using preset relevance criteria. Given the inclusion and exclusion criteria chosen for this systematic review, there were very few acceptable studies and only two studies met the relevance criteria for the critical appraisal. Both studies provide evidence to suggest that specific exercise interventions, alone or in combination with other treatments, have a positive effect on low-back pain due to spondylolysis and spondylolisthesis; however, the type of exercise used was different in the two studies. In this review, very few prospective studies were found that examined the efficacy of physiotherapy on the topic area; therefore, few conclusions can be made, and further research is warranted.

Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes.

We studied prospectively 22 young athletes who had undergone surgical treatment for lumbar spondylolysis. There were 15 men and seven women with a mean age of 20.2 years (15 to 34). Of these, 13 were professional footballers, four professional cricketers, three hockey players, one a tennis player and one a golfer. Preoperative assessment included plain radiography, single positron-emission CT, planar bone scanning and reverse-gantry CT. In all patients the Oswestry disability index (ODI) and in 19 the Short-Form 36 (SF-36) scores were determined preoperatively, and both were measured again after two years in all patients. Three patients had a Scott's fusion and 19 a Buck's fusion. The mean duration of back pain before surgery was 9.4 months (6 to 36). The mean size of the defect as determined by CT was 3.5 mm (1 to 8) and the mean preoperative and postoperative ODIs were 39.5 (SD 8.7) and 10.7 (SD 12.9), respectively. The mean scores for the physical component of the SF-36 improved from 27.1 (SD 5.1) to 47.8 (SD 7.7). The mean scores for the mental health component of the SF-36 improved from 39.0 (SD 3.9) to 55.4 (SD 6.3) with p < 0.001. After rehabilitation for a mean of seven months (4 to 10) 18 patients (82%) returned to their previous sporting activity.