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