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
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