It cannot be emphasized enough that obtaining a proper diagnosis in the athlete presenting with low back pain is crucial. It is the key to initiating an appropriately aggressive diagnostic and therapeutic plan.5,6 Particularly in the adolescent and younger athlete, a high index of suspicion must be maintained to accurately diagnose conditions such as stress fractures and spondy-lotic defects.7 A great variety of pathologic conditions can be diagnosed on plain radiographs and their relationship to the athlete and his or her sport can be more specifically addressed.8 The bone scan is a vital part of the diagnostic armamentarium of the physician caring for lumbar spine problems in athletes. An adolescent athlete with significant back pain, persisting longer than 3 weeks should have radiographs and a bone scan. Findings can range from unusual conditions such as osteoid osteoma, infection, and stress fracture of the SI joint to the more routine spondylotic defects. The incidence of spondylotic defects seen on radiography is approximately 30% to 38% and 35% of young athletes presenting with significant lumbar pain have a positive bone scan.7,9
In diagnosing the exact cause of lumbar spine pain in athletes, age is an important factor. Younger athletes are certainly more likely to have stress fractures and to have congenital predispositions to stress fractures. Diseases that affect growing cartilage are more common in young athletes, such as Scheuermann's disease. In the mature athlete, often the radiographic assessment involves distinguishing between age-related, asymptomatic changes and symptomatic recent trauma. Is the L5-S1 disk degeneration the symptomatic level in a 30-year-old athlete or is it an asymptomatic finding? The diagnostic plan must use an organized system of diagnosing the most common conditions as well as retain the ability to diagnose the rare conditions such as a herniation of the inferior lumbar space10 or osteoid osteoma.
One of the most important diagnoses to make in the athlete with back and leg pain is that of peripheral nerve injury and peripheral nerve entrapment. There is a great variety of peripheral nerve problems ranging from a generalized peripheral neuropathy to carpal tunnel syndrome, pyriformis syndrome, peroneal nerve injury, femoral neuropathy, and interdigital neuroma. The chief reason for performing electromyography and a nerve conduction study of the lower extremities is to diagnose a peripheral nerve problem. The nerve conduction study combined with a careful physical examination can at least raise the distinct possibility of a peripheral nerve problem and heighten the diagnostician's skepticism concerning small, poten tially asymptomatic spinal lesions in the role of the patient's extremity nerve pain.
Age is important in the natural history of spondylolysis and spondylolisthesis. There is a 4.4% incidence at age 6, increasing to 6% by adulthood. It is unusual for children to present with spondylolysis before the age of 5, and unusual for young children to present with severe spondylolisthesis grade III or IV Most symptoms appear in adolescence, but fortunately the risk of progression after adolescence is low, being approximately 15%. Symptoms cannot be correlated with the degree of slip. A high degree of slip may present with deformity and very little pain. Many times, it is the pain of an injury that leads to the identification of spondylolisthesis that may not be originating in the spondylolisthetic segment.
Isthmic spondylolisthesis develops as a stress fracture. It is thought that there is a hereditary predisposition to developing the stress fracture, and there is certainly the predisposition in conditions in which the bone of the pars inarticularis is not sufficient to withstand normal stresses. Also, certain mechanical activities that expose the patient to repeated biomechanical challenge, increasing stress concentration on the pars interartic-ularis, have a higher incidence of spondylolisthesis. The concept of repeated microtrauma with concentration of these stresses in the pars has become increasingly recognized in adolescent athletes participating in certain sports such as gymnastics and weight lifting.
The most common site for spondylolysis and spondylolisthe-sis is L5-S1 (Fig. 43-1). The slippage in spondylolisthesis results from the lack of support of the posterior elements produced by the stress fracture of the pars (Fig. 43-2). The spectrum of neurologic involvement runs from rare to more common with higher degree slips. The majority of neurologic deficits are an L5 radiculopathy with an L5-S1 spondylolisthesis. Cauda equina symptoms are more likely in grade III or IV slips. Cauda equina neurologic loss is rare.
The diagnostic and therapeutic plan for spondylolisthesis begins with a high degree of diagnostic suspicion in the adolescent athlete with low back pain. As many as one third of adolescent athletes presenting with low back pain will have a
positive bone scan for a stress fracture. Certainly patients with low back pain that is not resolved within 3 weeks should have a bone scan. If the bone scan is positive, the patient should have a computed tomography scan to see whether there is a demonstrable stress fracture or whether the bone scan is positive due to impending fracture. If the bone scan is negative and the lum-bosacral pain persists, magnetic resonance imaging is indicated. A combination of magnetic resonance imaging, bone scans, and computed tomography used in this manner should diagnose most significant pathologies in the lumbar spine.
The treatment plan for spondylolisthesis is basically rest or restriction of enough activity to relieve the symptoms. This may vary from simply removing the athlete from the sport until the pain has significantly improved; to immobilization in a lumbosacral corset, Boston brace, or thoracolumbosacral orthosis; to bed rest; to casting.
In summary, stop the pain through whatever amount of inactivity it takes. We routinely, with a hot bone scan, brace the patient and restrict that activity for a minimum of 3 months. Repeat the bone scan, and if it is negative, sufficient healing has taken place to allow beginning a rehabilitation program. If the bone scan is still positive and the athlete asymptomatic, it can be a very difficult decision at times whether to start the athlete back onto a rehabilitation program or continue further restriction. We usually continue restrictions another 3 months. Unilateral hot bone scans with or without fracture demonstrated have a reasonably high incidence of healing, and adolescent athletes in general should be treated with the idea of healing the defect. Bilateral stress fractures are less likely to heal despite comprehensive nonoperative therapy.
If the bone scan is cold and there is a spondylitic defect present, we should treat these patients as we would any patient with mechanical low back pain. This usually involves a progressively vigorous trunk stability rehabilitation program. We put no permanent restrictions on athletes with spondylolysis or spondy-lolisthesis. It should be obvious that patients with grade III to IV spondylolisthesis are less likely to be able to participate in vigorous sports activities without pain and discomfort. They should probably avoid the heavy strength sports such as football and weight lifting.
There is a high incidence of spondylolysis and grade I and II spondylolisthesis in sports. As a long-term factor, this condition is not considered to be significant in an athlete's ability to play.
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