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Stress Fractures in Sport: Spine

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Fractures in Sport

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Abstract

Stress reactions of the pars interarticularis is termed spondylolysis and plays a major role in debilitating back pain in the adolescent athlete. While many athletes will rest and ultimately improve, the adolescent who ignores their symptoms may experience persistence or worsening back pain and may ultimately develop other signs such as hamstring tightness or neurologic compromise. While imaging modalities have been scrutinized, recent algorithms have been published to guide evaluation. Surgical management is reserved for cases that do not respond to conservative treatment, or in those with neurologic compromise. Outcomes are generally favorable, though surgeons should be aware of the potential complications.

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA

    Arash J. Sayari, James D. Baker & Gregory D. Lopez

Authors
  1. Arash J. Sayari
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  2. James D. Baker
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  3. Gregory D. Lopez
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Editor information

Editors and Affiliations

  1. Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, UK

    Greg A. J. Robertson

  2. Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK

    Nicola Maffulli

Review

Review

1.1 Questions

Multiple Choice

  1. 1.

    Lumbar spondylolysis involves injury to which anatomical structure:

    1. A.

      The vertebral body

    2. B.

      The nucleus pulposus

    3. C.

      Spinous process

    4. D.

      Pars interarticularis

  2. 2.

    Classification of spondylolysis is important due to all the following EXCEPT for:

    1. A.

      Unilateral lesions can progress to become bilateral lesions if not identified

    2. B.

      Early, progressive, and terminal lesions may require different treatment approaches and have different clinical outcomes

    3. C.

      The upper levels of the lumbar spine are more commonly affected

    4. D.

      Factors such as a steeper L5-S1 pelvic tilt and higher degree of lumbar lordosis can result in worse responses to conservative management

  3. 3.

    All the following are clinical exam findings associated with lumbar spondylolysis EXCEPT for:

    1. A.

      Midline low back pain that may radiate to the buttock

    2. B.

      Radiculopathy

    3. C.

      Pain worsens with low back extension

    4. D.

      Hamstring and/or hip flexor tightness

  4. 4.

    Treatment of clay shoveler’s fracture may include all the following EXCEPT for:

    1. A.

      A brief period of cervical bracing

    2. B.

      Pain and symptom control

    3. C.

      Immediate surgical management

    4. D.

      A graduated return to sport

1.2 Answers

  1. 5.

    Briefly explain the pathogenesis of lumbar spondylolysis in athletes:

    ANSWER: Athletes, particularly those with underdeveloped paraspinal muscles and dysplastic facet joints, can place large amounts of strain on their low back when performing certain athletic movements. These movements include repeated extension and flexion of the low back that result in cyclic loading of the lower lumbar spine. In addition, a combination of compression and rotation in the low back can also place stress on the pars interarticularis. Eventually, repeated stress loading and paraspinal muscle fatigue may result in the formation of a stress fracture.

  2. 6.

    Describe the imaging workup of lumbar spondylolysis:

    ANSWER: The imaging workup begins with radiographs of the low back, and can include AP, lateral, and oblique views. If inconclusive, additional tests can be ordered based on the chronicity of the injury, If acute, MRI may be appropriate, as it may be able to diagnose stress fractures earlier than other modalities. Additionally, if the athlete presents with neurological signs, MRI may help identify nerve lesions. If chronic, CT can be used, as it offers better visualization of the bony anatomy. SPECT is also an option that can help diagnose early stress fractures, although it introduces radiation to the patient, and is generally reserved for patients whom MRI or CT is contraindicated.

  3. 7.

    What are the complications associated with surgical treatment of lumbar spondylolysis:

    ANSWER: The most common complication following surgical repair of lumbar spondylolysis is pseudarthrosis. However, non-union may not be necessary for a solid clinical outcome, and revision treatment should be decided on an individual basis. Other complications include progressive spondylolisthesis, neurological injury, and lumbar radiculopathy.

  4. 8.

    Why are C7 and T1 the most common sites for a clay shoveler’s fracture?

    ANSWER: The spinous processes of C7 and T1 are longer and more horizontally oriented than those at adjacent levels. Therefore, pulling from the upper spinal muscles exert a strong perpendicular force to these spinous processes that can result the avulsion fracture. In addition, the ligamentum nuchae, as well as the trapezius and rhomboid muscles, insert to the spine at these levels, resulting in stress during asymmetrical loading of the upper spine.

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Sayari, A.J., Baker, J.D., Lopez, G.D. (2021). Stress Fractures in Sport: Spine. In: Robertson, G.A.J., Maffulli, N. (eds) Fractures in Sport. Springer, Cham. https://doi.org/10.1007/978-3-030-72036-0_28

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