Original ResearchVariables associated with active spondylolysis
Introduction
Spondylolysis in the lumbar spine is usually a result of a fatigue fracture of the pars interarticularis that tends to occur at two distinct periods of skeletal development (Micheli & Wood, 1995). In early childhood, as a child attempts to stand and walk, a structurally deficient pars may fracture as it fails to withstand the increase in mechanical loads that occur when first walking. This form of spondylolysis does not normally cause any pain or functional restriction in childhood and there does not seem to be any increase in long term disability or low back pain (LBP) when compared to the general population (Beutler et al., 2003). The second period in which spondylolysis may develop, is in early adolescence. In this instance the pars of the maturing spine fractures as it fails to withstand the increase in mechanical loads associated with increasing activity and sporting participation. The pathophysiological development of a pars stress fracture is called ‘active spondylolysis’ and, although the condition often remains asymptomatic, it can be responsible for significant pain and disability (Congeni, McCulloch, & Swanson, 1997).
More recently, spondylolysis has been recognised as a potential source of LBP in athletic adolescents with some authors suggesting it accounts for up to 50% of symptoms in this population (Micheli and Wood, 1995, Wiesel, 2002). Gender would also appear to have a factor in the prevalence of spondylolysis with some studies showing up to a two fold increase in the incidence of spondylolysis in males (Sys, Michielsen, Bracke, Martens, & Verstreken, 2001). Despite advances in the understanding of the development of the condition, considerable uncertainty exists in diagnosing the condition (Moeller & Rafit, 2004).
Low back pain is the most common symptom that is attributed to spondylolysis and is typically aggravated by upright postures such as standing and walking as well as active movement involving lumbar spine extension (Standaert & Herring, 2000). The Single Leg Hyperextension Test (SLHT) has been advocated as the most effective clinical test for confirming spondylolysis (Hresko & Micheli, 1989). This test requires the patient to stand on one leg and actively extend their lumbar spine, however the specificity and sensitivity of this test has recently been shown to be poor (Masci et al., 2006). It is recognised that the symptoms that are common in spondylolysis are often present in non specific LBP and there are limitations in making a diagnosis of spondylolysis based on patient characteristics, history and physical examination alone (Wiesel, 2002). The radiological visualisation of a pars lesion is therefore essential to confirm the diagnosis of spondylolysis (Lim, Yoon, & Green, 2004). The combination of Computerised Tomography (CT) and Single Photon Emission Computerised Tomography (SPECT) bone scanning remains the gold standard for diagnosing and classifying an active spondylolysis as there is a higher sensitivity to detect subtle fractures and an improved insight into the metabolic activity of a pars fracture when compared to alternate radiological investigations (Wiesel, 2002).
Clinically, it is often difficult to determine if a patient with LBP is presenting with symptoms that are directly associated with an active spondylolysis and further research is required to improve our understanding of the condition. This study is therefore an initial step in identifying variables that are associated with active spondylolysis. An improved understanding of the demographic, physical and symptomatic variables that are associated with a developing spondylolysis may assist clinicians in diagnosing the condition and initiating treatment more efficiently. Conversely, patients who present with characteristics that are not strongly associated with spondylolysis are less likely to require unnecessary radiological imaging to exclude the diagnosis.
Section snippets
Methods
A retrospective, non-experimental study was undertaken to determine if an association existed between specific patient characteristics and the outcome of radiological investigations for spondylolysis. The study was conducted within a large medical facility that included a sports medicine centre and radiology clinic. The study sample consisted of a group of patients with LBP that had been referred, over a two year period, for a SPECT bone scan to confirm an active spondylolysis. Six exploratory
Results
Eighty two subjects were included in the retrospective sample. Twenty six of the subjects had a positive SPECT scan indicating an active spondylolysis. The descriptive data for the six exploratory variables are shown in Table 1.
The results from the univariate regression analysis of the association between individual exploratory variables and the SPECT bone scan are shown in Table 2. There was a statistically significant association between bone scan outcome and age (p = 0.01) and gender (p = 0.01).
Discussion
The results of this study indicate that age and gender has a significant association with the diagnosis of active spondylolysis. The odds ratio (3.6) for gender shows that an individual with spondylolysis is three and a half times more likely to be male. The high proportion of males with active spondylolysis is similar to that found in previous studies and it would appear that males are more susceptible to developing pars stress fracture than females (Beutler et al., 2003, Miller et al., 2004,
Conclusion
Clinicians considering the likelihood of a patient having an active spondylolysis should consider the gender and age of the patient and not rely on the predictive ability of the Single Leg Hyperextension Test.
Conflict of interest statement
The authors of this submitted manuscript declare that there is no conflict of interest related to this research project and academic paper.
Ethical approval
Ethics approval for this study was granted from the Central Regional Ethics committee, a division of the National Ethics committee. The National Ethics Committee is a branch of the Health Research Council of New Zealand, representing the New Zealand Ministry of Health.
Acknowledgements
We are extremely grateful for the support of the clinical specialists in this study. In particular we wish to thank Dr Ruth Highet and Dr Jake Pearson, Wakefield SportsMed; Dr Steve Target and Dr Karen Bisley of Capital Sports Medicine; and Mr Chris Hoffman and Mr Peter Welsh of The Back Institute. We also wish to thank Prue Lamerton, the Nuclear Medicine Technician at Pacific Radiology, for her ongoing assistance with data collection.
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