by Mark W. McFarland, DO
As an Orthopaedic Spine Specialist, I often see patients who complain of low back pain, which may or may not radiate into the buttocks and legs. They can be adolescents or adults. Although most lower back pain is caused by muscle strain, some patients have a condition that most likely developed when they were young and was aggravated by sports or activities that required a lot of flexion and extension of the spine. This repetitive stress loading of the lumbar spine can cause stress fractures. It may bother them as youngsters, or for most, only cause pain much later in life. That is when they come to see me.
First, an anatomy lesson. The Pars interarticularis are bones within the lumbar (lower) vertebral column that assist in connecting the vertebrae to each other. The fracturing of one of these pars interarticularis is known as spondylolysis. Spondylolysis can be caused by inheriting weak vertebrae, or be repeatedly damaging the pars interarticularis in the lower back. Over time, this damage can lead to a stress fracture. Athletes participating in sports such as gymnastics, wrestling, football, or weight lifting are more likely to develop spondylolysis due to the pressure on the lower back during these activities. Some of these fractures may be genetic, but most are not.
Oftentimes this condition is left untreated, because young people often either do not feel any pain or very minimal pain. They just go about their business. However, the fracture of the pars interarticularis should be treated with bracing and restricted activity for several months to allow it to completely heal and prevent future problems.
If the fracture of the pars interarticularis is not treated, this fracture can worsen, eventually causing one of the vertebra to slide forward. This worsened condition is known as spondylolisthesis. Rarely, Spondylolisthesis can be caused without a patient previously having spondylolysis. A tumor, arthritis, or other spinal conditions can cause the moving forward of a vertebrae.
The severity of spondylolisthesis is determined by the amount the vertebra has shifted forward and is ranked thusly: Grade I – 0-24% shifted, all the way to Grade V – 100% shifted.
Symptoms of spondylolisthesis include low back pain, leg pain, and changes in posture or the way in which a person walks. The lower back pain will often worsen when participating in high-energy activities. The condition can worsen to cause a pinched nerve, a lack of feeling, numbness, tingling or pain in the legs.
One or more imaging scans may be required to diagnose either spondylolysis or spondylolisthesis. I can request X-rays, a computed tomography (CT) scan, magnetic resonance imaging (MRI), to determine the amount that the vertebrae has shifted as well as to assess the damage of the fractured bones.
Typical treatment for spondylolisthesis suggests refraining from high-energy activities, such as sports, until the patient’s pain has disappeared. Other treatments include icing or applying heat to the back, physical therapy, and pain reducing and anti-inflammatory medications.
If none of these treatments are effective, epidural steroid injections may be recommended to reduce the inflammation of the surrounding nerves, which often is effective in reducing pain and disability. These injections may totally or partially relieve pain and allow the patient to resume normal activities without surgery.
If the pain persists and all other treatment options have failed, fusing the vertebrate together is a surgical option, though uncommon unless the condition has progressed beyond Grade I. Cages, screws and rods may be used to provide stability for the vertebra once it has been restored to the proper position and spinal alignment is restored. I perform most lumbar fusions on an outpatient basis and the patient can recover in the comfort of their own home.
Recovery from lumbar fusion surgery is now much better than it was even 10 years ago, due to the minimally-invasive surgical techniques that I use. There is much less trauma, blood loss, muscle cutting and a much smaller incision. Patients will need typically need a week or two off from work and will be required to wear a back brace while there fusion heals. Pain during recovery is easily managed with medications for pain relief and muscle relaxation. Ice packs can also be used to reduce pain and swelling. There will be restrictions on lifting, bending and twisting. I recommend that my patients walk and move as soon as possible and continue to build on this throughout recovery.
Complications may include infection, failure of the bone to fuse (non-union), bleeding, anesthesia-related complications or nerve damage. Sometimes, although the lumbar fusion was performed correctly, pain may persist.
To prevent spondylolysis and the development of spondylolisthesis, a person should use proper protective equipment when participating in a sport or high-intensity activity. It is also important to use correct form when weight lifting or lifting heavy loads to reduce the risk of injury by rotation, flexion, extension or loading of the spine.