Thoracic Spondylolysis


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Definition

Spondylosis = various forms of spinal degeneration that accompany the natural aging process.

Spondylolysis is a unilateral or bilateral bony defect in the pars interarticularis or isthmus of the vertebra. It represents a weakness or stress fracture in one of the bony bridges that connect the upper with the lower facet joints of the vertebra.

It has been confirmed several times in literature that the thoracic spondylolysis is not as common as cervical or lumbar spondylolysis. The vast majority of spondylolitic defects are seen at level L5 (85-95%),(15 LOE: 4) with level L4 being the second most likely to be affected. The higher levels of the lumbar spine are rarely affected. (15 LOE: 4)

The term spondylolysis is derived from the Greek words spondylos (vertebra) and lysis (defect). [1][2] It can cause a slipping of the vertebra, in which case the term spondylolytic spondylolysthesis is used.

“Spondylolysis” is also known as a blanket term used by physicians to describe general deterioration of the spine. This defect can be asymptomatic or associated with significant back pain (7: level of evidence 2A)

Clinically Relevant Anatomy

The most important structures which are involved in a thoracic spondylolysis are: the thoracic vertebrae (T1-T12), the intervertebral disc of the thoracic vertebrae (These act like shock absorbers for the spine as it moves.), 12 pairs of spinal nerve roots, posterior rami (innervate the regional muscles of the back) and ventral rami (innervate the skin and muscles of the chest and abdominal area). (10) (level of evidence 3B)
The functions of the spine are:


• Stability; The costovertebral joints and rib cage are very important when it comes to stabilizing the thoracic spine. (11) (level of evidence 2B)
• housing of neurological structures and control.


The spine is supported by ligaments and muscles (1). When there’s a gap between the vertebral arches, a vertebra slipping or sliding can arise. In this condition are the nerves and spinal cord in danger (3).


Thoracic spondylolysis.png

Epidemiology/Etiology

The etiology of spondylolysis is considered to be a stress fracture at the pars interarticularis (12). (Level of evidence; 3B)
The reason that they call it a stress facture and not a congenital disorder is that they have never found a spondylolysis in neonates (newborns). Also spondylolysis don’t occurs in non-ambulatory patients. The last reason that this is a stress fracture is that the time line from spondylolysis to pseudoarthritis looks like the timeline from the long bone. (20; LOE: 1A)
This fracture can be the result of genetic predispositions (16 LOE: 4) including weak crossectional areas of the cortical bone area of the pars intervertebralis and relative cortical bone density (4,6) (4 LOE: 4) (6 LOE:1A). There is a possible genetic tendency for people with lower cortical bone density at the pars interarticularis.
Spondylolysis this is not spondylosis affects 3-6% of the population(17)(18)( 17: loe: 4) ( 18: loe: 1A), but the incidence of spondylolysis within the young athletic population is seen to be increased (47%) . (24 LOE: 2B) It is the most common cause in low back pain in pediatric patients. (22) ( loe: 2A) This condition appears in the first or second decade of life; the frequency of spondylolysis increases with age until 20 years. There is, however, no change in prevalence with increasing age from 20 to 80 years old. (19)(20)
Other risks are:
• structure of the pars interarticularis and the spine
• sport and activities that require repetitive flexion-extension movements, such as football, dance, gymnastics, wrestling, swimming (2,3,6,12).
• Excessive hyperextension forces is often associated with hypermobility.
• Muscle weakness
• long periods of static posture in extension and rotation (13) ( LOE: 2A)
• Men are affected twice as often as women (16)(17) ( 17 LOE: 4)
• Spondylolysis occurs more frequently in the young athletic population. There is an increased risk in gymnasts, football players, cricketers, swimmers, divers, weight lifters and wrestlers. (16) (18) ( 16 LOE: 4) ( (18 LOE: 1A)


These factors affect the efficiency in which the neural arch absorbs forces (5 LOE: 1B).
The terms spondylolysis and spondylolithesis are often switched with one another. Spondylolythesis is actually a health problem that follows on a spondylolysis.

Another condition, called spondylolisthesis, can occur when there is a complete bilateral fracture of the pars interarticularis. This fracture results in the translation (in the anterior/posterior or anterior-caudal) direction of one vertebral body over the adjacent caudal vertebra, which could lead to neurologic problems (because of compression of the nerves and spinal cord between the bony structures). (6,9, 20,21) (level of evidence 1A)

Characteristics/Clinical Presentation

• The onset of pain can start immediately after an acute injury or be gradual. Mild symptoms can last for a while and a particular event can cause acute worsening (2). (LOE 2A)
• Focal back pain (2, 8). ( LOE 2A)
• Symptoms increase during activities involving spinal extension and rotation which restrict the ADL activities(2). ( LOE 2A)
• acute or gradual pain after an intense activity (8). (LOE 2A)
• When the fracture is not recent: pain can be felt deep within the lower back and radiate to the buttock and thigh on the affected side (8). (LOE 2A)
• Pain throughout the full range of lumbar motion (9) (LOE 2A)
• rest usually relies the symptoms (12) (LOE 3B)
• symptoms become aggraved after a stressful activity (8) (LOE 2A)
• there can be an recent or old local trauma (8) ( LOE 2A)
Spondylolysis can be classified into three stages;
• early
• progressive
• terminal
The early stage, which follows the stress fracture, is shows as a hairline on CT scans.
If the spondylolysis can be found in the early stage. It can heal in osseously in about 90% of the cases within 3 months. This rate decreases in the progressive stage.
At the begin of the progressive stage, the gap at the defect site is clearly visible. The terminal stage is similar to pseudoarthrosis, showing sclerosis at the fracture site. Even using CT scan, the early stage is sometimes very difficult to diagnose.
Magnetic resonance imaging (MRI) is less invasive than computed tomography or plain radiography, and more recently, we have shown that a high signal at the pedicle in an axial slice of T2-weighted MR images can be used effectively for detecting the early stage of the disorder. (14,21) ( 14: level of evidence: 2B) ( 21 : level of evidence : 1A)


Differential Diagnosis

• Disc Injuries: Disc Herniation

A displacement of disc material beyond the intervertebral disc space.

→ Straight Leg Raise (29: level of evidence 2b), Slump Test (30: level of evidence 3b)

• Spondylolisthesis

→ RX, CT, MRI (31: level of evidence 1a)

• Lumbosacral Discogenic Pain Syndrome

Lumbar pain caused by degeneration of the intervertebral disc.

→ Clinical tests

• Facet Joint Syndrome

An articular disorder related to the facet joints and their innervations, producing local and radiating pain.

→ MRI, CT, RX (30: level of evidence 2a)

• Acute Bony Injuries

→ RX, CT

• Sprain/Strain Injuries

• Myofascial Pain in Athletes

→ Palpation


• Spondylolisthesis

Diagnostic procedure

Until now, no optimal tool for diagnosing spondylolysis has been identified. The most reliable method to use is a combination of various methods. However early diagnosis has been found to increase the likelihood of healing (25, 26: level of evidence 4).

There are a variety of imaging tools that can be used to establish a spondylolysis. CT scans (computed tomography) , SPECT scans and [/www.physio-pedia.com/MRI%20Scans MRI] have all been found to be sensitive diagnostic tools for diagnosing spondylolysis (8, 27: level of evidence 2A).

Amongst the literature however there is a big controversy as to which imaging method is preferential for diagnosing spondylolysis. Many papers suggest bone scintigraphy using SPECT to be the gold standard, followed by a CT scan (26, 28: level of evidence 4).

Masci et al found MRI to be inferior to bone scintigraphy (with SPECT) or CT. This study acknowledges the conclusion of Standaert et al. that bone scintigraphy (with SPECT) should remain the first-line investigation, followed by limited computed tomography if bone scintigraphy is positive (27: level of evidence 3B).

CT scans are able to distinguish between an acute or chronic spondylolysis and the type of fracture, which provides us with important information with regards to making a treatment plan. MRI is commonly used and often favoured because this imaging does not use ionising radiation. However, there is little evidence that supports its sensitivity in diagnosing spondylolysis.

Outcome measures

- level of impairments:(damage)
- VAS
- Fear-avoidance beliefs questionnaire ( FABQ)

- level of disabilities
- Roland Morris Disability Questionnaire (RMDQ)
- Patiënt Specifieke Klachten (PSK) KNGF

- level of participation (work)
- Oswestry Low Back Pain Disability Questionnaire (OLBPDQ)

- Oswestry disability index
- Quebec Back Pain Disability Scale (QBPDS)
- Quebec_Back_Pain_Disability_Scale

- level of personal aspects
- …The Hospital Anxiety and Depression

Examination

To demonstrate spondylolysis, plain radiographs of the thoracic back are used. (2). (LOE 2A)To visualize the suspected bony defect CT (computed tomography) scan can be helpful (image).This is one of the most valuable and sensitive method of identifying spondylolysis. SPECT (Single-Photon Emission Computed Tomography) and CAT scan (Computed Axial Tomography) are more sensitive to identify partial lesions (3,7). ( 3,7 LOE 2A)To define the status of the disc at and just above the level of slippage, MRI is the exam of choice can be used (7). ( level of evidence: 2A)


Physiopedia thoracic spondylolysis.png

Neurological examination is usually normal in most of the cases, except when the vertebrae slips. , This slippage of the vertebra can cause neurogenic symptoms can to arise (1).
• Pain when standing on the ipsilateral leg during the one legged hyperextension maneuver: the patient has to stand on one leg and lean backwards (2). ( LOE: 2A)
• Single leg raise test (link): the patient lifts one leg and places the trunk into hyperextension. This test is positive when there’s pain (unilateral or bilateral) determined in the sacroiliac area or lumbar spine, indicating shear forces on the pars interarticularis. (6). ( level of evidence 1A)
• Oswestry disability Index (hyperlink 2)
• Muscle strength testing
Thoracic_Examination



Medical examination

Treatment for spondylolysis has been studied using a variety of diagnostic standards, therapeutic interventions, and outcome measures. The lack of consensus on these issues and the lack of any large scale controlled clinical trials on the diagnosis and management of spondylolysis make it difficult to define an optimal treatment algorithm. (2: Level of Evidence 2A)

Conservative

It is highly recommended to apply conservative treatment methods to thoracic spondylolysis patients. Most symptomatic cases do well with conservative care. Many pars lesions may heal if managed conservatively, particularly those with early stage defects.

The use of bracing in the treatment of spondylolysis has been controversial. Many authors advocate the routine use of braces in the treatment of these patients, while others don’t. One argument for this is that braces may limit gross motion and hence overal physical activity (delaying or complicating the health process), rather than to limit intervertebral motion in an effort to achieve bony healing.

Steiner and Micheli assessed bony healing and clinical outcome in 67 patients with spondylolysis who were treated with an anti-lordotic modified Boston brace. Twelve of these patients showed evidence of bony healing and 78% had good to excellent clinical results including full return to activity and no brace use. (32: Level of Evidence 2A)

Pharmacological

Pharmacological intervention includes the application of pain relief medications. The nonsteroidal anti-inflammatory drugs (NSAIDs) should not be ordinarily used because they slow down the bone growth and healing. If the patient is osteoporotic or osteopenic, alendronate sodium is a pharmacological alternative (2: Level of Evidence 2A).

Physical applications

Once pain levels are controlled, pulsed ultrasound and therapeutic isometric contractions of surrounding musculature may be initiated to promote additional bloodflow. Through this way, the healing process is also facilitated. Moreover, the use of electrical bone stimulators seems to promote healing (8: level of evidence 2A).

Surgical

Surgical treatment is used only for symptomatic cases where all conservative methods failed to show any effect. Approximately 9-15% of cases of symptomatic spondylolysis undergo surgery. The main indications include:

- intractable pain

- progressive slip

- development of neurological deficits

- segmental spine instability

Surgical procedures typically attempt a direct repair of the pars which is sometimes accompanied by a fusion procedure. Specific surgical techniques such as translaminar screw fixation, cerclage wiring loop and pendiculolaminar hook screws preserve segmental motion by repairing the isthmic defect.

There are two main types of surgery:

1. Laminectomy: nerve compression can be caused by an excess of cartilage where the broken bones try to heal. The loose lamina is removed to take the pressure off the nerve (6: level of evidence : 1A).

2. Posterior spinal fusion: this is a technique which is recommended when a spinal segment is instable or loose. A spinal fusion results into one solid bone, because it allows that two or more bones grow together by means of small grafts in the problem area at het back of the spine. In some occasions the surgeon applies screws and metal plates to put two vertebrae together to avoid movement (6,9).(6: level of evidence A1) ( 9: level of evidence : 2A )

After the surgery the patients are recommended to use a supporting belt or a brace and they have to be careful with resuming activities in the first weeks (9).

Although treating spondylolysis may seem complicated, an uneventful outcome may be experienced. Rehabilitation programmes are strongly recommended for symptomatic and post-surgical patients. It is imperative these programmes to be guided by patients’ pain and tolerance and their objectives to be the promotion of bone healing, the relief of pain and the optimization of physical function. (32: level of evidence 2A)

Physical Therapy Management

In the early stage of the treatment, pain provoking activities should be avoided and relative rest is designated. El Rassi et al concluded that cessation of sporting activities for at least 3 months resulted in the most improved outcomes for symptomatic athletes with lumbar spondylolysis.(33: Level of Evidence 1B)The primary goal is minimisation of the biomechanical forces responsible for the propagation of the stress reaction in the pars.

The conservative treatment, aiming to increase blood flow to the affected area, promote physical activity and healing and control pain in symptomatic spondylolysis, includes:

• Physical therapy

• Electrical stimulation

• Ultrasound

• Heat and ice (2: Level of Evidence: A2) ,(6: Level of Evidence: A1).

• Bracing (see ‘Medical management- conservative)

-The first step is improving the healing and blood flow by therapeutic isometric contractions of the surrounding musculature and pulsed ultrasound.

An electrical bone stimulator (internally or external) may also be used to promote the healing (7: Level of Evidence: A2).

-Patients with symptomatic spondylolysis and postsurgical patients may benefit from rehabilitation to regain mobility to that particular region of the spine, as well to decrease the pain (5: Level of Evidence: 1A).

-It is important to do daily aerobic physical activity during the rehabilitation. The main goals of rehabilitation program are :

  • Active relieve of associated pain and promotion of bony healing
  • Control pain and inflammation
  • Optimize physical function
  • Regular participation in exercise programs

-daily stabilization, strength, flexibility, and functional movement are the four stages in which the rehabilitation program should progress.

To take stress off the area of lesion :

-It can be necessary during the conservative phase to take extreme care to avoid rotational shearing motions and extensions, because they cause stress on the structures of the lamina (15: Level of Evidence: A1). The maintenance of pelvic tilt is used during strength and flexibility activities to avoid this stress. Functional activities and more aggressive strengthening are added after the acute symptoms subside and when a certain base of stability establishes.

-The main goals of this exercise program are :

• to increase functional abilities

• promote the patient’s well being and functional capacity

• improve spinal range of motion and maintain pain alleviation

-This program focuses on :

• flexibility of the spinal cord

• stabilization of the whole back

• coordination of agonist and antagonist muscles

• strengthening of the trunk (5: Level of Evidence: A1).

-Core stabilization must be added to the therapy and include exercises to increase the strength and stability of the M. Erector Spinae, M. Quadratus Lumborum, Mm. Internal/External Oblique Abdominis and M. Serratus Anterior. (9: Level of Evidence: A2).

Exercises to strengthen the abdominal and back muscles and stretching exercises of the hamstrings and hip extensors showed good results in combination with a thoracolumbosacral orthotic brace (34: level of evidence 1B)

-Activities of daily living and postural awareness has to be added to the program. Patients with acute symptoms should be instructed in comfortable positions and postures (during sleeping, sitting, lying, standing, walking and picking up objects) that are safe for the spinal structures and introduced to gentle trunk exercises (2: Level of Evidence: A2).

-To control the spondylolysis area, neuromuscular stabilization techniques, including activation of the M. Transversus Abdominis and other core stabilizer muscles must be emphasized (6: Level of Evidence: A1), (9: Level of Evidence: A2).

-To reduce pressure on the pars interarticularis, it is important to teach the patient to stand in a neutral spine position, therefore, controlling pelvic tilts is an appointed exercise.

-To enhance control range of sensitivity and to gain strength, limited ranges of motion and isometric holds in various positions are recommended.

-To prepare the patient for future functional activities, strength, flexibility and endurance training must be progressed, as the inflammation and pain subside.

1. Primarily:

coordination, balance and coordination exercises are added as plyometric and proprioceptive parts.

2. Secondarily:

functional exercises are incorporated to allow the natural execution of functional daily activities, these are through home exercises supported using various equipment (hand weights, stability balls, foam rolers,..) (: Level of Evidence: 1A). The individuals have to be encourage to resume activities as tolerated (2: Level of Evidence: 2A).

3. Furthermore:

the patient is recommend in a home exercise program for daily practice and continue independently after the completion of rehabilitation. In some cases the use of bracing is recommended momentarily in the early stage to control the pain and mobility (6: Level of Evidence: 1A). It’s very important that the patient’s work place undergoes an ergonomic evaluation and that he/she is educated in proper body mechanics. These changes are meant to assist the employee’s return to work (2: Level of Evidence: 2A).

Key Research

Resources

• cochranelibrary
https://www.physiotherapyexercises.com/
http://www.pedro.org.au/
http://scireproject.com/
http://www.scipt.org/

Clinical Bottom Line

In order to provide the injured patient with the best care, physiotherapists should have elaborate knowledge of anatomy and functioning of the thoracic spine.The keystone to proper care of a spondylolysis is to start from the correct diagnosis within the first weeks of injury. This should also include the detection and diagnosis of associated injuries.[58] Treatment for the injury and the return to daily normal life depends completely upon the grade and associated injuries


References

1. David A., et al. Macnab’s Backache. P. 96- 102. (book with primary sources)

Level of evidence: 4 5

2. Standaert C.J. and Herring S.A Herring. Spondylolysis: a critical review. Br J Sports Med. 2000;34:415-422.

Level of evidence: 2A.

3. Robert Gunzburg and Marek Szpalski. Spondylolysis, spondylolisthesis, and degenerative spondylolisthesis. 2005. P.2-35. (book with primary sources)Level of evidence: 4 5

4. MacAuley D., Best T., Evidence-based Sports Medicine, Blackwell Publishing, 2007, p. 282.

Level of evidence: 4 4

5. Morita T. et al. Lumbar Spondylolysis in children and adolescents. J. Bone Joint Surg. 1995;77-B-620-625.Level of evidence: 1B.

6. Peer K. S. and Fascione J. M. Spondylolysis – A Review and Treatment Approach. Orthopaedic Nursing. 2007,26: 104-111.

Level of evidence: 1A.

7. Ruiz-Cotorro A. et al. Spondylolysis in young tennis players: Review. Br J. Sports Med. 2006;40:441-446.

Level of evidence: 2A

8. Syrmou E. et al. Spondylolysis: A review and reappraisal. Hippokratia. 2010;14:1:1721.

Level of evidence: 2A

9. Freeman B. J. C. and Debnath U. K. The management of Spondylolysis and Spondylolisthesis. Surgery for Low Back Pain. 2010:4:137-145.

Level of evidence: 2A

10. Ryan C. O’Connor et al., Physical &amp ; Medical Rehabilatation clinics of North America, Thoracic diseases, 2002

Level of evidence; 3 B

11. Oda et al, Biomechanical role of posterieur elements, costovertebral joints, and rib cage in the stability of the thoracic spine, 1996, Spine

Level of evidence; 2C

12. Robert Gunzburg., Marek Szpalski., spondylolysis, spondylolisthesis ande degenerative spondylosisthesis., Philadelphia : Lippincott Williams & Willkins, 2006

Level of evidence; 3B

13. Seitsalo S, Antila H, Karrinaho T, et al. Spondylolysis in ballet dancers. J Dance Med Sci 1997;1:51-54

Level of evidence: 2B

14. Sairyo K, Katoh S, Takata Y, et al. MRI signal changes of the pedicle as an indicator for early diagnosis of spondylolysis in children and adolescents: a clinical and biomechanical study. The 31st Annual meeting of ISSLS, Porto, Portugal, May 31-June 5, 2004.

Level of evidence: 2B

15. Standaert C.J., Herring S.A., Cole A.J., and Stratton S.A. (2003). The lumbar spine and sports. The low back pain handbook, 385-404

Level of ecidence: 4

16. MacAuley D., Best T., Evidence-based Sports Medicine second edition, Blackwell Publishing, 2007, p. 282.

Level of evidence: 4

17. Depalma M.J., iSpine: Evidence-based interventional spine care, Demos Medical Publishing, 2011, p. 156-157.

Level of evidence: 4

18. Haun D.W., Kettner N.W., Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management, J Chiropr Med 2005;4:206–217

Level of evidence: 1A

19. Aufderheide A.C., Rodriguez-Martin C., The Cambridge Encyclopedia Of Human Paleopathology, Cambridge University Press, 1998, p. 63.

Level of evidence: 5

20. Fast A., Goldsher D., Navigating The Adult Spine, Demos Medical Publishing, 2007, p. 55. Level of evidence: D

21. Koichi Sairyo, A review of the pathomechanism of forward slippage in pediatric spondylolysis: The Tokushima theory of growth plate slippage, Tokushima university, 2015 february

Level of evindence: 1A

22. Micheli LJ and Wood R., Back pain in young athletes. Significant differences from adults in causes and patterns, Department of Orthopaedic Surgery, Harvard Medical School, 1995 (level of evidence 1A)

23. Tebet, M.A. (2014). Currents concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Revista Brasileira de Ortopedia, 49 (1), 3-12. (Level of evidence 1A)

24. Micheli, L. J. and Wood, R. (1995). Back pain in young athletes: significant differences from adults in causes and patterns. Archives of pediatrics & adolescent medicine. 149(1): 15-18. (Level of evidence 2B)

25. Sundell, CG., Jonsson, H., Adin, L. and Larsen, KH. (2013) Clinical Examination, Spondylolysis and Adolescent Athletes International Journal of Sports Medicine 34(3): 263-267 (Level of evidence 4)

26. Standaert, CJ and Herring SA. (2007) Expert Opinion and Controversies in Sports and Musculoskeletal Medicine: A Diagnosis and Treatment of Spondylolysis in Adolescent Athletes Archives of Physical Medicine and Rehabilitation 88(4): 537-540 (Level of evidence 5)

27. Masci, L., e.a. (2006) Use of one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis British Journal of Sports Medicine 40(11): 940-946 (Level of evidence 3B)

28. Campbell, RSD., e.a. (2005) Juvenile spondylolysis: a comparative analysis of CT, SPECT and MRI Skeletal Radiology 34(2): 63-73 (level of evidence (level of evidence 4)

29. Tabesh, Homayoun, et al. "The effect of age on result of straight leg raising test in patients

suffering lumbar disc herniation and sciatica." Journal of research in medical sciences: the

official journal of Isfahan University of Medical Sciences 20.2 (2015): 150.

(Level of evidence: 2b)

30. Jackson RP. The facet syndrome. Myth or reality? Clin Orthop Relat Res. 1992;279:110–21. (level of evidence: 2b)

31. Tsirikos AI et al, Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br. 2010 Jun;92(6):751-9. doi: 10.1302/0301-620X.92B6.23014 (Level of evidence 1A)

32. Standaert, Christopher J., and Stanley A. Herring. "How should you treat spondylolysis in the athlete?." Evidence-Based Sports Medicine (2008): 281. (Level of Evidence 2A)

33. El Rassi G, Takemitsu M, Glutting J, Shah SA. “[/www-thieme-connect-com.ezproxy.vub.ac.be%3A2443/products/ejournals/linkout/10.1055/s-0036-1586743/id/JR1600057-33 Effect of sports modification on clinical outcome in children and adolescent athletes with symptomatic lumbar spondylolysis].” Am J Phys Med Rehabil 2013; 92 (12) 1070-1074 (Level of Evidence 1B)

34. Leonidou, Andreas, et al. "Treatment for spondylolysis and spondylolisthesis in children." Journal of Orthopaedic Surgery 23.3 (2015): 379-382. (Level of Evidence 1B)