Summaries
Rev . Medicina Desportiva informa , 2018 ; 9 ( 3 ): 22-26
XXVIII Rehabilitation and traumatology course of sport Coimbra , 27 January 2018
Organizers : Prof . Doctor J . Páscoa Pinheiro , Dr . Pedro Lemos Pereira
Summaries : Part 1
Dr . João Paulo Branco . Medicina Física e de Reabilitação . Coimbra
Spondylolysis and spondylolistheses
Introduction . Spondylolysis is a phenomenon occurring in the posterior vertebral pillar , often referred to as the dynamic element . Although of varying the topography , the vertebral isthmus , the pars interarticularis , is the region most affected at L5 ( fifth lumbar vertebra , with 85 % to 90 % of cases ) and L4 ( fourth lumbar vertebra with 5 % to 15 %). Spondylolysis may arise with listesis , spondylolistheses , the most common condition in symptomatic cases , where 25 % of spondylolysis occurs with vertebral instability . The etiology of spondylolysis isthmian remains unknown and the stress fracture caused by excessive load due to the repetition of the technical gesture seems to be at the origin of this pathology . The prevalence in the general population is estimated to be between 3 and 6 %, rarely in children under the age of 3 and frequent in adolescents , which have a higher rate of spondylolysis ( 47 %) than adults ( 5 %). Prevalence is not superior in young athletes compared to non-athletes . There is reference to family and ethnic predisposition . The participation of young athletes in sports involving repetitive hyperextension maneuvers and lumbar spine rotation ,
such as gymnastics , wrestling and diving , seem to be disproportionately associated with higher rates of spondylolysis . In the cases of back pain that lasts more than 3 months , more than 40 % present an abnormality at the level of the posterior arc . Clinically It is manifested with a mechanical pain , referred to the low lumbar region , and frequent gluteus suffering , more attributable to the muscular retraction than to the root path . It is aggravated by the hyperextension of the rachis and may not be worse by palpation . The inspection of the back can demonstrate excessive lumbar lordosis . The Laségue maneuver often reproduces the discomfort arising from the retraction of the hamstring muscles , more than from a radiculopathy , being of little use in the diagnosis of spondylolysis . The neurological exam most of the time is normal . The progression of pathology occurs more frequently in young athletes , associated with early return to sporting activity . Some cases of spondylolysis are radiological findings remaining permanently asymptomatic . Complementary diagnostic Exams . In athletes with more than six weeks of pain and suspected spondylolysis a simple lumbar-posterior , lateral and oblique radiological study should be performed . The oblique incidences should be obtained bilaterally , allow a clearer image of the posterior bone structures in relation to the lateral incidence , with the typical image of the collar around the Scotty dog , revealing a stabilized spondylolysis . Approximately 85 % of the injuries are displayed with this incidence . The spondylolisthesis or vertebral lysis is classified in the lateral X-ray according to the Meyerding system in : Grade I , indicating < 25 %; Grade II , 25 % to 50 %; Grade III , 50 % to 75 %; and grade IV , 75 % to 100 %. The spondylolistheses grade IV is rarely observed . Athletes with negative radiological study and with symptomatic persistence should be conducted to more specific examinations , such as nuclear magnetic resonance ( MRI ), thyroid and simple photon emission computed tomography , more known by the acronym SPECT ( Single Photon Emission Computed Tomography ) with technetium . The SPECT is pointed out as the most sensitive image examination to detect an injury from the pars interarticular when all the other exams are negative . The role of the MRI for the detection and / or classification of the spondylolysis continues to be clarified . The Treatment conservative and surgical . Most athletes with spondylolysis respond favorably to conservative treatment . After medical treatment , 80 % of athletes present symptomatic relief regardless of the existing radiological changes . The existence of spondylolistheses influences the prognosis , and it is observed that the absence of sliding has a more favorable evolution . Usually the conservative treatment includes a period of rest , with total reduction of sports activity , followed by physical rehabilitation . The maintenance of the symptoms for a period of more than three months implies the use of the orthosis . The utility of external immobilization , its form and time of application are situations that remain unclear and do not gather consensus before the authors . Generally , the competitive activity is resumed with the asymptomatic athlete , regardless of the evidence of radiographic consolidation . There are authors who consider that an unconsolidated defect does not prevent clinical success and return to sporting activity . The failure of conservative treatment after six months is in most situations indication for surgical treatment . The presence of neurological deficit related to spondylolistheses , progressive lysis and grade III in the Meyerding classification are indications for surgical treatment , irrespective of symptoms . The most commonly used surgical technique is laminectomy decompression associated with various fusion methods . Recently the arthrodesis for isthmian spondylolisthesis in adult patients has often been reported , but adolescent athletes are generally not candidates . The appropriate time to return to sports after surgical treatment is controversial and most authors agree that only the asymptomatic athlete , with functional levels ( strength , flexibility and endurance ) within the parameters of normality and with bone consolidation after imaging can return . The local injection into the pars interarticular that relieves
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