Revista de Medicina Desportiva (English) September 2018 | Page 20

Figure 1 – Meyerding classification (https://
radiopaedia.org/articles/spondylolisthesis-grading-
system)
resonance imaging (MRI), and com-
puted tomography (CT) scan respec-
tively. Scintigraphy and single-pho-
ton emission computed tomography
(SPECT) allow the identification of a
stress reaction or subacute lesion of
the pars before the fracture is visible
on the plain radiograph and identify
the active lesions. 1,3,4
Treatment
Most cases of spondylolysis and
spondylolisthesis identified in chil-
dren and adolescents are low grade,
with few symptoms and a low risk
of progression. Despite this, they
should be diagnosed and treated
early. The treatment depends on age,
growth potential, symptoms, stage
and degree of listhesis. 1
Athletes with spondylolysis and
asymptomatic low-grade spon-
dylolisthesis generally do not require
treatment or activity modification.
In symptomatic cases the initial
treatment is usually conservative,
and it is especially challenging in
the athlete, since it implies the
modification of physical activ-
ity, kinesiological techniques and
the use of trunk orthosis until the
attainment of symptomatic control
and a functional recovery. 1-3,5,6
According to some retrospective
studies, conservative treatment has
good results, allowing 80 – 90% of
athletes to return to sporting activ-
ity between 3 and 6 months. The
studies differ in terms of inclusion
criteria and the conservative treat-
ment protocols themselves. 2,5,7,8
However, there is consensus
regarding some recommendations,
namely the restriction of physical /
sports activity with extension and
torsion forces in the pars inter-
artcularis. The literature advises
modification of the physical activity
for at least three months, allowing
for the subsequent return to sport
activity without negative functional
impact. 3,5,6 The ideal moment for
the return to sport activity is still
controversial. It is required, however
that the athlete be asymptomatic at
the time. 2
Kinesiological techniques should
promote the strengthening of the
core muscles and the stretching of
the hip flexors and hamstrings. 2
There is no consensus regarding
the most effective trunk orthosis
or duration of its use. However, the
clinical evolution seems to depend
particularly on adherence to its use
and not on the type of orthosis used. 7
The use of lumbosacral orthoses,
according to Sairyo et al., can reduce
lumbar pain in up to 80% of cases
of spondylolysis and spondylolis-
thesis grade I. The same group of
investigators showed on the CT that
the use of rigid orthosis had higher
consolidation rates at three months
compared to semi-rigid orthosis. 9,10
The duration of treatment with
orthosis varies in the different
studies between 6 to 12 weeks up
to 6 months. However, there are no
statistically significant differences
in clinical and radiological outcomes
between groups treated with and
without orthosis. 2,5-8
To detect the possible progression
of listhesis, follow-up of patients
should be done every 6-12 months
until bone maturity is reached (Ris-
ser 4-5). 1,3
The literature suggests that unilat-
eral and acute spondylolysis lesions
present higher rates of consolidation
than bilateral or progressive lesions.
Thus, the identification of the injury
at an initial stage by CT or hypersignal
at the adjacent T2-weighted pedicle in
MRI are predictors of bone consolida-
tion of the spondylolysis. 6,10,11
High grade and symptomatic
spondylolisthesis respond irregu-
larly to conservative treatment, and
low-grade spondylolisthesis – when
dysplastic – has an increased risk
of progression and development of
neurological deficits. 1,4
Surgical treatment is indicated in
children or adolescents with symp-
tomatic spondylolisthesis with more
than 50% of displacement, with
neurological deficits, and persistence
of pain or worsening of the listhe-
sis despite conservative treatment.
Youngsters with bone immaturity and
symptomatic grade II spondylolisthe-
sis may have a surgical indication,
which is also considered in sympto-
matic spondylolysis after conserva-
tive treatment for six months. 1,3,13
The evaluation of the efficacy of
the treatment is related to the reso-
lution of the symptoms, recovery of
global sagittal balance, consolida-
tion, and return to physical activity.
Figure 2 – Percentage of displacement of the inferior aspect of
the vertebral body to the underlying vertebral body. Figure 23 – Scotty dog collar. (http://www.orthoconsult.com/
(http://www.luzimarteixeira.com.br/wp-content/uploads/2010/07/espondilolistese.pdf) pars-defects-spondylolysis-spondylolisthesis/)
18 september 2018 www.revdesportiva.pt