Imaging guides treatment of lumbar spondylolysis fractures in contact sports

Spondylolysis is a common spinal stress fracture than can occur in athletes who carry out repetitive hyperextension activities. It is often seen in conjunction with over-training, particularly in one sport. Whether chronic or acute, the prognosis depends on several variables that spine surgeons should be aware of, according to an orthopedic surgeon who spent 14 years on the sidelines covering National Football League games.

In lumbar fractures in sports “obviously diagnosis, management and return to play is what we are interested in,” Andrew Dossett, MD, of the W.B. Carrell Clinic in Dallas, said.

These spine fractures occur during such contact sports as football, hockey and rodeo, as well as in baseball and gymnastics, he said, noting spondylolysis fractures can be insidious and cause significant pain when they are acute.

Dossett usually gets five radiographic views in these cases and omits oblique views to reduce the patient’s overall radiation exposure. Flexion and lateral views typically reveal whether any gapping of a chronic fracture exists.

“If it is a chronic fracture, [then] you are going to see it on the lateral,” he said.

Beyond the bone scan

When a patient presents with an acute fracture, such as an acute fracture and chronic pars fracture in combination, “you are not going to see it on an X-ray,” Dossett said about the acute fracture. Therefore, in patients suspected of having the type of injury that would lead to this kind of stress fracture, he gets both a bone scan and a single-photon emission computed tomography (SPECT) scan.

“You are probably going to miss 10% to 15% of your fractures without getting a SPECT scan. If it is positive, then I get a CT scan. If it is negative, then I get an MRI,” Dossett said. “The CT scan helps me delineate where they are in this fracture pattern” of being either acute or chronic.

Fracture characteristics, such as acuteness and chronicity, can be detected on the CT scan.

Managing acute vs. chronic fractures

The type and duration of immobilization and other aspects of treatment depend on whether the fracture is chronic or acute, according to Dossett, who immobilizes a patient with an acute fracture for 3 months.

“If it is L4-5 or L-5/S-1 I do not brace them. I just ask them to self-immobilize. If it is L3 and above, I brace them,” he said. “In my experience, only about 50% heal…but about 90% of them quit hurting within 6 weeks or up to a year.”

Patients whose symptoms are minimal at 6 weeks post-injury and have little or no pain on the Jackson’s test can begin rehabilitation with cardiovascular exercises and some light weight-lifting. Isometric core stability exercises can begin at 6 weeks and should include only minimal flexion/extension motion. At 3 months they can begin a full course of core-stability exercises, according to Dossett.

Dossett treats acute fractures that are contralateral to chronic injuries symptomatically because even if the patient remains inactive for 3 months these fractures usually do not heal, and if they do heal they have a very high likelihood of recurrence with resumption of the sport.

Surgery is optional

“There is surgery for this — direct pars repair utilizing several techniques,” said Dossett, who has, however, returned thousands of young athletes with these fractures to sport without surgery on the pars defect.

“I certainly know it works, but the recovery time is going to be 3 months to 6 months,” he said. “It is unlikely that you are going to improve the natural history of this.”

Pedicle fractures may present like spondylolysis, but they are significantly less common and can be more problematic, Dossett said. He has seen three such fractures in collegiate pitchers in the last 5 years, but sees about 200 cases of the more typical acute spine stress fractures each year. – by Susan M. Rapp

Reference:

Dossett A. Symposium: Spine injuries in contact sports — Sports-related lumbar fractures. Presented at: North American Spine Society Annual Meeting; Oct. 9-12, 2013; New Orleans.

For more information:

Andrew Dossett, MD, can be reached at W.B. Carrell Clinic, 9301 N Central Expressway, Suite 400, Dallas, TX 75231; email: docdrew@sbcglobal.net.
Disclosure: Dossett has no relevant financial disclosures.