An increasing number of boys and girls are playing recreational and organized sports. As a result, there is a rise in the number of overuse injuries seen among children and adolescents. The majority of sports and overuse injuries are due to minor trauma involving soft tissue injuries--injuries that affect the bone, muscles, ligaments, and/or tendons. One such injury is Spondylolysis, or a pars defect, which is marked by back pain.
Brian Kelly, MD discusses the ways in which Spondylolysis is classified. He shares treatment and prevention advice and when it is important to refer to the specialists at St. Louis Children;s Hospital.
Spondylolysis in Children
Featured Speaker:
Learn more about Brian Kelly, MD
Brian Kelly, MD
Dr. Brian Kelly’s practice focuses on pediatric and adolescent disorders of the cervical, thoracic, and lumbar spine, as well as general pediatric orthopaedic surgery. He specializes in the non-operative and surgical treatment of pediatric spinal deformity (scoliosis, kyphosis and spondylolisthesis), including congenital, neuromuscular, and early-onset scoliosis, and surgical treatment of the growing spine. His interests also include conditions of the pediatric hip, lower extremity and foot, as well as pediatric trauma.Learn more about Brian Kelly, MD
Transcription:
Spondylolysis in Children
Melanie Cole (Host): An increasing numbers of boys and girls are playing recreational and organized sports. As a result, there’s a rise in the number of overuse injuries seen among children and adolescents. One such injury is spondylolysis or pars defect, which is marked by back pain. Here to tell us about that is Dr. Brian Kelly. He’s a Washington University Pediatric Orthopedic Surgeon at St. Louis Children’s Hospital. Dr. Kelly, tell us what is spondylolysis?
Dr. Brian Kelly (Guest): Thank you Melanie. So spondylolysis, just breaking it down comes from the Greek spondylo or spondylos, meaning vertebrae or spine and lysis being dissolution. So what this specifically refers to is a defect or a break in some of the posterior part or posterior elements of the spine that can occur as a result of repetitive cyclical loading of the spine.
Host: So tell us how that happens and what causes it and really what sports that you see it most often.
Dr. Kelly: So we know that spondylolysis, and specifically symptomatic spondylolysis, occurs more frequently in athletes whose sports require repetitive hyperextension of the lower back and lumbar spine. Specific activities that this is more common in are sports like gymnastics with competitive tumbling and flips, football down linemen who are always going from their three point stance and popping up with that hyperextension moment during that. Other sports like rowing, volleyball where you’re constantly reaching back and arching your back to get power for your serve or spiking, but it can be seen really in any sport and tends to be more symptomatic with activity.
Host: Is there both a hereditary and acquired risk factors because you talked about the sports where it might be most at risk, what about a hereditary factor?
Dr. Kelly: So there’s certainly a subset of spondylolysis that we could probably consider developmental or congenital. There was a large study done following a large group of kids over childhood and they obtained imaging of 500 4-year-old’s lumbar spines, and approximately 4% to 5% of those children already had evidence of spondylolysis, and that probably rose to somewhere between 8% and 10% by the time they reach the age of 18. So we know that this can develop either as more of a development or a congenital way, but there’s certainly a higher incidence of symptomatic spondylolysis as we discussed in those children who participate in those sports that require hyperextension.
Host: What are some of the hallmarks of it, and red flags that a pediatrician should be looking for and if it’s asymptomatic in a child, how would they know?
Dr. Kelly: So most spondylolysis is going to be asymptomatic and is often found incidentally when imaging for another condition or injury is obtained. There’s really no way to – other than that incidental imaging – pickup on those asymptomatic spondylolysis, that when a child is actually presenting with a symptomatic spondylolysis, they’re going to be complaining typically of lower back pain. It may be bilateral or only on one side, and it typically is exacerbated with their activity and with sports that often kids are not having pain in between activity with spondylolysis unless it’s a particularly severe. The real hallmark on examination is pain with extension of the spine. So having the child trying to lean backwards in a standing position should reproduce that severe pain, and we all have pain when we lean too far back, but real symptomatic spondylolysis with any extension of the spine can cause that severe pain. Typically we do not see nerve type symptoms with pure spondylosis, that those things are pretty rare, and would be more of a red flag of something else going on. Other red flags are constant pain or pain that is waking a child up from sleep in the middle of the night after they’ve fallen asleep, those sort of things don’t typically go along with spondylolysis.
Host: Once diagnosed, can you predict risk factors for progression of the slip to spondylolisthesis in these children?
Dr. Kelly: So a very small percentage of patients who have a spondylolysis, because of that disruption or disconnection of the posterior elements, can develop a spondylolisthesis, or relative slippage of the vertebrae relative to one another. It’s actually very uncommon for pure spondylolysis to progress into a spondylolisthesis. In long term studies, only a small percentage of patients actually progressed, and most of those don’t progress to any sort of significant spondylolisthesis or slippage.
Host: Is there any way to prevent it?
Dr. Kelly: In terms of specifically preventing the pars defect or the pars fracture, the spondylolysis itself, there’s not any specific things that can be done to help prevent it. What’s more important is trying to prevent back pain and symptoms and trying to maintain good aerobic fitness, strong core muscles, strong back muscles, whether you have spondylolysis or not, is really going to be our best defense from developing that musculoskeletal back pain and pain from spondylolysis as well.
Host: When do you feel a patient should be referred to a specialist doctor?
Dr. Kelly: So I think anytime there is concern for a spondylolysis, whether that is based on exam or imagining, it’s appropriate to refer that patient to someone who treats and manages spondylolysis regularly.
Host: Speak a little bit about treatment, what’s the first line of conservative management, and are there some long term effects or complications if it’s not found early on?
Dr. Kelly: So the main stay of treatment for spondylolysis fortunately is nonoperative, and a vast majority of patients, 80% to 90%, will get significant long term relief with just nonoperative treatment. So when I see a patient who I suspect will have a spondylolysis, I do my best to confirm that with imaging, starting with just plain radiographs, a lateral or spot lateral at the lumbar spine or lumbosacral junction being the most important study to help us diagnose spondylolysis because really the treatment pathways for low back pain with and without spondylolysis are very different. When we confirm a spondylolysis, the first thing that I do is remove a child from the activities that are exacerbating her pain, and that really means shutting the child down, taking them out of all sports and really avoiding all activities that they can reasonably avoid that are causing some of this back pain and typically with a period of activity restriction, that sometimes can last 2-3 months or more, most children will feel significant relief and feel much better. At that point, the next steps typically are to, in my practice to start physical therapy, which tends to focus on core and back strengthening and really getting the child back into the sports that they want to participate in. In terms of long term effects, what we know about spondylolysis is that it does not need to heal, even though we think of these things as stress fractures or fractures – it does not need to heal for a child to be pain free and participate in all the activities that they want, and we know that people with spondylolysis as adults have the same incidents of back pain as people without spondylolysis, so symptomatic spondylolysis typically is present really in childhood and adolescence, and if you can get most kids through this period where they’re having difficulty playing their sports and having pain with these nonoperative means, typically they’re going to go on to do very well, participate in the things they want to, and then have the same symptoms with their back that the general population has as adults.
Host: Isn’t that so interesting, Dr. Kelly, what else can a pediatrician expect from the ortho team at Children’s after referring a patient, and what would you like referring physicians to know about spondylolysis?
Dr. Kelly: So I think that’s, what I just mentioned is a very important part of it, and something I stress to all of my patients, that the goal is not healing of this fracture. The goal is return to pain free activity and return to activity that the child wants to participate in, and like I said that often involves a long period out of sports, which is often very difficult for our adolescent patients but really does tend to be effective. I tend not to use a brace. Our best evidence on brace use for this condition doesn’t support it having any long term benefit, and the surgical treatment of spondylolysis is really reserved for those rare, rare cases where children have continued pain and symptoms despite all of these nonoperative means over a period of at least 3 to 6 months and are unable to return to the sports that they want to participate in and it is unacceptable for them to give up those sports or modify their activity around their back pain.
Host: That’s great information, Dr. Kelly, thank you so much for coming on today and sharing your expertise for other providers on what to look for, for spondylolysis and what treatment options might be available. Thank you again. To consult with a specialist, a physician can refer a patient by calling the Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds wit St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you could go to stlouischildrens.org, that’s stlouischildrens.org. This is Melanie Cole, thanks so much for listening.
Spondylolysis in Children
Melanie Cole (Host): An increasing numbers of boys and girls are playing recreational and organized sports. As a result, there’s a rise in the number of overuse injuries seen among children and adolescents. One such injury is spondylolysis or pars defect, which is marked by back pain. Here to tell us about that is Dr. Brian Kelly. He’s a Washington University Pediatric Orthopedic Surgeon at St. Louis Children’s Hospital. Dr. Kelly, tell us what is spondylolysis?
Dr. Brian Kelly (Guest): Thank you Melanie. So spondylolysis, just breaking it down comes from the Greek spondylo or spondylos, meaning vertebrae or spine and lysis being dissolution. So what this specifically refers to is a defect or a break in some of the posterior part or posterior elements of the spine that can occur as a result of repetitive cyclical loading of the spine.
Host: So tell us how that happens and what causes it and really what sports that you see it most often.
Dr. Kelly: So we know that spondylolysis, and specifically symptomatic spondylolysis, occurs more frequently in athletes whose sports require repetitive hyperextension of the lower back and lumbar spine. Specific activities that this is more common in are sports like gymnastics with competitive tumbling and flips, football down linemen who are always going from their three point stance and popping up with that hyperextension moment during that. Other sports like rowing, volleyball where you’re constantly reaching back and arching your back to get power for your serve or spiking, but it can be seen really in any sport and tends to be more symptomatic with activity.
Host: Is there both a hereditary and acquired risk factors because you talked about the sports where it might be most at risk, what about a hereditary factor?
Dr. Kelly: So there’s certainly a subset of spondylolysis that we could probably consider developmental or congenital. There was a large study done following a large group of kids over childhood and they obtained imaging of 500 4-year-old’s lumbar spines, and approximately 4% to 5% of those children already had evidence of spondylolysis, and that probably rose to somewhere between 8% and 10% by the time they reach the age of 18. So we know that this can develop either as more of a development or a congenital way, but there’s certainly a higher incidence of symptomatic spondylolysis as we discussed in those children who participate in those sports that require hyperextension.
Host: What are some of the hallmarks of it, and red flags that a pediatrician should be looking for and if it’s asymptomatic in a child, how would they know?
Dr. Kelly: So most spondylolysis is going to be asymptomatic and is often found incidentally when imaging for another condition or injury is obtained. There’s really no way to – other than that incidental imaging – pickup on those asymptomatic spondylolysis, that when a child is actually presenting with a symptomatic spondylolysis, they’re going to be complaining typically of lower back pain. It may be bilateral or only on one side, and it typically is exacerbated with their activity and with sports that often kids are not having pain in between activity with spondylolysis unless it’s a particularly severe. The real hallmark on examination is pain with extension of the spine. So having the child trying to lean backwards in a standing position should reproduce that severe pain, and we all have pain when we lean too far back, but real symptomatic spondylolysis with any extension of the spine can cause that severe pain. Typically we do not see nerve type symptoms with pure spondylosis, that those things are pretty rare, and would be more of a red flag of something else going on. Other red flags are constant pain or pain that is waking a child up from sleep in the middle of the night after they’ve fallen asleep, those sort of things don’t typically go along with spondylolysis.
Host: Once diagnosed, can you predict risk factors for progression of the slip to spondylolisthesis in these children?
Dr. Kelly: So a very small percentage of patients who have a spondylolysis, because of that disruption or disconnection of the posterior elements, can develop a spondylolisthesis, or relative slippage of the vertebrae relative to one another. It’s actually very uncommon for pure spondylolysis to progress into a spondylolisthesis. In long term studies, only a small percentage of patients actually progressed, and most of those don’t progress to any sort of significant spondylolisthesis or slippage.
Host: Is there any way to prevent it?
Dr. Kelly: In terms of specifically preventing the pars defect or the pars fracture, the spondylolysis itself, there’s not any specific things that can be done to help prevent it. What’s more important is trying to prevent back pain and symptoms and trying to maintain good aerobic fitness, strong core muscles, strong back muscles, whether you have spondylolysis or not, is really going to be our best defense from developing that musculoskeletal back pain and pain from spondylolysis as well.
Host: When do you feel a patient should be referred to a specialist doctor?
Dr. Kelly: So I think anytime there is concern for a spondylolysis, whether that is based on exam or imagining, it’s appropriate to refer that patient to someone who treats and manages spondylolysis regularly.
Host: Speak a little bit about treatment, what’s the first line of conservative management, and are there some long term effects or complications if it’s not found early on?
Dr. Kelly: So the main stay of treatment for spondylolysis fortunately is nonoperative, and a vast majority of patients, 80% to 90%, will get significant long term relief with just nonoperative treatment. So when I see a patient who I suspect will have a spondylolysis, I do my best to confirm that with imaging, starting with just plain radiographs, a lateral or spot lateral at the lumbar spine or lumbosacral junction being the most important study to help us diagnose spondylolysis because really the treatment pathways for low back pain with and without spondylolysis are very different. When we confirm a spondylolysis, the first thing that I do is remove a child from the activities that are exacerbating her pain, and that really means shutting the child down, taking them out of all sports and really avoiding all activities that they can reasonably avoid that are causing some of this back pain and typically with a period of activity restriction, that sometimes can last 2-3 months or more, most children will feel significant relief and feel much better. At that point, the next steps typically are to, in my practice to start physical therapy, which tends to focus on core and back strengthening and really getting the child back into the sports that they want to participate in. In terms of long term effects, what we know about spondylolysis is that it does not need to heal, even though we think of these things as stress fractures or fractures – it does not need to heal for a child to be pain free and participate in all the activities that they want, and we know that people with spondylolysis as adults have the same incidents of back pain as people without spondylolysis, so symptomatic spondylolysis typically is present really in childhood and adolescence, and if you can get most kids through this period where they’re having difficulty playing their sports and having pain with these nonoperative means, typically they’re going to go on to do very well, participate in the things they want to, and then have the same symptoms with their back that the general population has as adults.
Host: Isn’t that so interesting, Dr. Kelly, what else can a pediatrician expect from the ortho team at Children’s after referring a patient, and what would you like referring physicians to know about spondylolysis?
Dr. Kelly: So I think that’s, what I just mentioned is a very important part of it, and something I stress to all of my patients, that the goal is not healing of this fracture. The goal is return to pain free activity and return to activity that the child wants to participate in, and like I said that often involves a long period out of sports, which is often very difficult for our adolescent patients but really does tend to be effective. I tend not to use a brace. Our best evidence on brace use for this condition doesn’t support it having any long term benefit, and the surgical treatment of spondylolysis is really reserved for those rare, rare cases where children have continued pain and symptoms despite all of these nonoperative means over a period of at least 3 to 6 months and are unable to return to the sports that they want to participate in and it is unacceptable for them to give up those sports or modify their activity around their back pain.
Host: That’s great information, Dr. Kelly, thank you so much for coming on today and sharing your expertise for other providers on what to look for, for spondylolysis and what treatment options might be available. Thank you again. To consult with a specialist, a physician can refer a patient by calling the Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds wit St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you could go to stlouischildrens.org, that’s stlouischildrens.org. This is Melanie Cole, thanks so much for listening.