Revista de Medicina Desportiva (English) September 2018 - Page 19

Rev. Med. Desp. informa, 2018; 9(5):17–19. A Conservative Approach to Spondylolysis and Spondylolisthesis in Athletes Dra. Inês Mendes Ribeiro 1 , Dra. Elsa Marques 2 1 Interna de Formação Específica MFR, Hospital Prof. Doutor Fernando Fonseca, EPE. 2 Assistente Hospitalar Graduada MFR, Centro Hospitalar Lisboa Central. ABSTRACT Spondylolysis and spondylolisthesis are common causes of low back pain in children and adoles- cents. The incidence increases in children participating in sporting activities with repetitive hyperex- tension of the lumbar spine. There is a lack of consensus regarding the best conservative treatment. According to some authors its efficiency is based on the symptomatic resolution, radiologic consoli- dation and/or return to sport activity. We present a review of literature of the current knowledge of spondylolisis and spondylolistesis in athletes. spondylolisthesis (dysplastic, isthmic, degenerative, traumatic, pathological) and the most common in children and adolescents are the dysplastic (type I) and isthmic (type II). In 1997 Marchetti and Bartolozzi proposed an alternative classification system that distinguishes acquired spondylolis- thesis and developmental spon- dylolisthesis. The latter includes the dysplastic and isthmic forms. These classifications consider the aetiology, but do not allow the establishement of a therapeutic algorithm. 1,4 The Meyerding classification system (Figures 1 and 2) is used to determine the degree of listhesis, describing the percentage of slip- page of the inferior aspect of the vertebral body to the underlying vertebral body (Figure 2). 3,4 KEYWORDS Spondylolysis, spondylolisthesis, brace, orthosis Clinical Presentation Introduction and Epidemiology Pathogenesis Spondylolysis (from the Greek spondylo = vertebra, lysis = separa- tion) refers to a uni or bilateral defect of pars interarticularis. In spondylolisthesis (olisthesis = slip) there is anterior translation of one vertebral segment over another, usually preceded by spondylolysis. 1,2 Spondylolysis is more prevalent in the male gender, although the progression to spondylolisthesis is more frequent in the female gender. The prevalence is higher in children and adolescents who practice sports involving repeated hyperextension of the lumbar spine, such as gym- nastics, weightlifting, diving, swim- ming and rowing. 1,3 The incidence of spondylolysis ranges from 11% in gymnasts to 43% in divers. 3 The incidence in the general population is difficult to determine, since only symptomatic cases are investigated. However, the literature suggests an incidence of spondyloly- sis of 4.4% in children under 6 years and 6% at 18 years, a percentage that remains stable in adulthood. 3 There is great ethnic variability, with an incidence of 40% in Inuit, 5-12% in Caucasians and 1-3% in the Black population. 1 The aetiology is multifactorial, with predisposing factors such as hereditary vertebral dysplasia and sacropelvic morphology, but also environmental factors, such as orthostatism, gait and repeated loads in the lumbosacral spine. The load associated with orthos- tatism plays an important role, with the incidence increasing from the onset of the gait until 18 years of age and tyhen remaining stable in adulthood. In children and adoles- cents, the posterior vertebral arch is not completely ossified, and the intervertebral disc is very elastic, contributing to the susceptibility of pars interarticularis to fatigue due to stress and shear forces, especially in those with modalities with repeated spinal hyperextension and axial rotation. 1,3,4 The degenerative spondylolisthesis most commonly affects L4-L5, com- pared to L5-S1, the most involved level in children and adolescents. 1 Classification The Wiltse-Newman classifica- tion is the most commonly used to classify the aetiology of spon- dylolisthesis. There are five types of Spondylolysis and low-grade spon- dylolisthesis are often asympto- matic. 1 The most characteristic symptomatology is mechanical lum- bar pain and usually has an insidi- ous onset. 1,4 Usually the symptoms that suggest radicular involvement and bowel or bladder dysfunction can occur in high grade spondylolis- thesis (Meyerding III or IV). 4 In high grade spondylolisthesis, pain is frequent with the hyper- extension of the lumbar spine. 3 In these athletes there may be an increase in the support base in orthostatism to compensate for the lumbosacral kyphosis produced by the listhesis, moving forward the centre of gravity. They present pelvic retroversion, extension of the hips, flexion of the knees, retraction of the hamstring muscles and limitations in the flexion of the trunk. 1,4 Diagnosis can be established by radiographs of the lumbosacral spine with antero-posterior, lateral and oblique incidences. The oblique incidence is particularly important to identify unilateral spondylolysis, in which there is a fracture on the isthmus – Scottie dog sign (Figure 3). The lateral radiographs are good to rule out any associated spondylolis- thesis. There may be a need to per- form exams to exclude other causes of low back pain or to better charac- terize bone morphology: magnetic Revista de Medicina Desportiva informa september 2018 · 17