Pars Defect

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Pars Defect also known as Spondylolysis. This is a small fracture in the pars L5/S1 Vertebrae. There is a small chance that with rest the fracture will heal with rest. 3-6 months. The fractures are measured in grades eg Grade 1 to grade 111. MRI scans should be used to measure any increase (or decrease) in the fracture.

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Bilateral or Lateral

Bilateral is when both "wings" of the vertebrae are fractured/cracked. Lateral is when just one side is damaged. The pars interarticularis is the part that gets damaged (the wings)

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Surgical Options

Lumbar Fusion

The goal of a lumbar fusion is to stop the pain at a painful motion segment in the lower back. Most commonly, this type of surgery is performed for pain and disability caused by lumbar degenerative disc disease or a spondylolisthesis. A spinal fusion surgery involves using a bone graft to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint. Spine surgery instrumentation (medical devices), bone graft procedures, and a bone stimulator are sometimes used along with spinal fusion.

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Spondylolysis may lead to Spondylolisthesis.

Spondylolisthesis is a slipping forward of the L5 vertebrae. Many people cope quite well with spondylolisthesis, with nothing more than a slight statistical increase in lower back pain. But, in severe cases, the forward migration can be significant and the segment may even become unstable. Surgical fusion is sometimes recommended in these cases.

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Taking part in Sport

Non-contact sport such as Swimming are strongly advised to keep the spine flexible and the back and stomach muscles strong. Contact sports such as Rugby, boxing and football (at a competitive level) are Not advised. Five a side may be OK

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Cause

The presumed cause is repeated hyperextension, or backward bending, of the lumbar spine. Pars defects often affect athletes whose spines are frequently stressed in this manner, such as gymnasts, divers and American football linemen.

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Prognosis of a spondylolysis

Rehabilitation following a spondylolysis usually occurs over weeks to months with direction from a physiotherapist and will vary depending on the severity of injury. With appropriate treatment, most minor stress fractures should be able to achieve bony union in 6 to12 weeks. Once this is achieved and the patient is symptom free, a gradual and progressive return to activity is indicated under guidance from a physiotherapist. This usually occurs over a subsequent period of approximately 4 to 6 weeks.

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More severe fractures may require an extended period of rehabilitation of approximately 6 to 12 months.

In some cases, a stress fracture may result in non-union of the bone and ongoing problems (especially if they are managed inappropriately). Accurate diagnosis, treatment and management in the early stage is therefore vital.

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Initial Exercises

Transversus Abdominus Retraining.

Slowly pull your belly button in "away from your belt line" and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis. Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it is pain free. Repeat 3 times daily.

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Rotation in Lying

Begin this exercise lying on your back as demonstrated. Slowly take your knees from side to side as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch. Repeat 10 times to each side provided the exercise is pain free.

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Knees to Chest

Begin lying on your back with your knees bent. Slowly take both knees towards your chest using your hands to assist as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch. Repeat 5 - 10 times provided the exercise is pain free.

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Terms used.

symptomatic spondylolysis - still causing pain?

Active or Inactive Spondylolysis - active causing pain, inactive not the cause of pain?

Lordosis - refers to the abnormal inward curvature of the lumbar and cervical regions of the spine.

Unilateral active spondylolysis - one broken par causing pain?

single-photon emission computed tomography (SPECT) - MRI type machine?

Bony union - when it knits/heals

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Spondylolysis or Isthmic Spondylolisthesis Activity Restrictions

In the past, patients have often been advised to limit their activities (especially participation in sports and active exercise) to avoid causing advancement of the spondylolysis. However, new information developed from modern imaging tests and recent research indicates that reduced activity and/or rest to protect the spondylolysis from slipping may not always be necessary. Rest is only necessary if the patient becomes symptomatic. Rest can help eliminate the pain, and when the pain resolves the patient can resume his or her normal activities.

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Often adolescents are pulled from their sports participation because of fears that their spondylolysis will lead to spondylolisthesis (slippage of the affected vertebra) and that the slippage will become so severe as to cause permanent damage or paralysis. Adults with spondylolysis are also often counseled to avoid rigorous exercise and/or physically demanding jobs. However, in published medical literature, there are no instances of a patient in a work, industrial, or sports-related environment that has experienced trauma causing spondylolisthesis to slip further and produce neurological deficit or paralysis.

Sophisticated imaging modalities such as single-photon emission computed tomography (SPECT) bone scans and magnetic resonance imaging (MRI) scans of the spine now provide the ability to evaluate the physiological changes that are associated with spondylolysis.

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This information allows for the important distinction between active and inactive spondylolysis.

* Active spondylolysis. On the SPECT scan an active spondylolysis shows uptake, and an MRI scan shows bone marrow edema adjacent to the pars defect. These findings indicate that there is activity/movement associated with the pars defect, which is likely to produce symptoms of low back pain.
* Inactive spondylolysis. If there are no indications of activity with the pars defect, then the spondylolysis is considered inactive and any low back pain the patient is experiencing is probably incidental (meaning that there is probably another cause of the patient's lower back pain, such as a muscle strain).

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Even though activity restriction is not always necessary, careful management of spondylolysis is always advisable. Acute (active) spondylolysis requires more intensive management, while symptoms from spondylolysis that has moved into a chronic (inactive) phase can be managed conservatively.1

References:

1. Bergmann TF, Hyde TE, Yochum TR. Active or Inactive Spondylolysis and/or Spondylolisthesis: What's the Real Cause of Back Pain? Journal of the Neuromusculoskeletal System. 2002:10:70-78.

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Profile and Diagnosis of Spondylolysis

Spondylolysis develops most commonly in adolescents, most typically in 10 to 15 year olds. The majority of adolescents with spondylolysis do not have symptoms, or their symptoms are mild and are often overlooked. If the spondylolysis is not correctly identified and managed, there is a chance that the affected area may heal incorrectly, resulting in the possibility of continued stress that can lead to the slippage ofspondylolisthesis and recurrent low back pain.

Spondylolysis is seen more often in athletes than in people who do not actively participate in sports, although studies differ as to just how much more. Approximately 3% to 7% of the general population is thought to have spondylolysis. It is suspected that spondylolysis occurs most frequently in young athletes who are involved in sports that require repeated hyperextension of the lower back.

* One study found that spondylolysis occurred most frequently in young athletes involved in throwing, bobsledding, artistic gymnastics, rowing, and boxing
* Another study found the highest incidence of the condition in diving, wrestling, weightlifting, modern pentathlon and triathlon, and track and field (e.g. from javelin throwing, high jump, and other activities involving hyperextension of the spine)

Of course, most athletes involved in the above and other sports do not develop spondylolysis, and at this time it is not known what causes the condition to develop in some people and not in others.

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Older adults can also develop spondylolysis because of degeneration in the disc and the facet joints (degenerative spondylolisthesis), which can allow slippage even without a fracture. While it is not known exactly what causes this condition, it is theorized that it probably involves overloading the back part of the facet joints, which can eventually lead to stress fractures.

Spondylolysis diagnosis
Whenever an athlete (especially a young athlete in the 10 to 15 year old age group) experiences low back pain following a traumatic event, spondylolysis must be considered as a potential cause of the pain. Typically, symptomatic spondylolysis involves a complaint of focal low back pain, although the pain can also extend into the buttock or legs.

One orthopedic test that is useful (although not totally conclusive) in diagnosing spondylolysis is the one-legged hyperextension maneuver (also known as the unilateral extension test or Michelis' test). The patient stands on one leg in a position that hyperextends the lumbar spine; he or she then repeats the move on the opposite side. If the test produces pain, this can indicate active spondylolysis.

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Clinical studies have found varying degrees of healing using conservative (non-surgical) treatments (such as bracing) ranging from 73% healing of early-stage spondylolisthesis versus 38% healing in those with progressive disease. One study of adolescent athletes found that 37% of them showed signs of healing at the pars defects after 2 to 6 months of bracing.1

Treatments for Active Spondylolysis

The recommended treatment program for active spondylolysis is usually a combination of the following:

* Bracing to immobilize the spine for a short period (e.g. four months) to allow the pars defect to heal
* Pain medications and/or anti-inflammatory medication, as needed
* Stretching, beginning with gentle hamstring stretching and progressing with additional stretches over time
* Exercise that is controlled and builds gradually over time.

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On rare occasions, spondylolysis that is not healing or may have neurological components can require surgery to provide internal fixation and stability to the area. Usually, two procedures are performed as part of the same surgery:

* A decompressive laminectomy, which reduces irritation and inflammation in the area (but increases spinal instability)
* A spinal fusion to provide stabilization of the affected area.

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Treatments for Inactive Spondylolysis

For inactive spondylolysis, bracing is usually not necessary. In many cases, however, the spondylolysis will be discovered long after the pars defect has already healed. This condition is often referred to as chronic inactive spondylolysis and may produce symptoms of chronic or recurring lower back pain or discomfort.

Medical literature indicates that once the lesion has healed and becomes inactive, the likelihood of significant progression is minimal, and only rarely does the slippage require surgical intervention.

For discomfort or pain associated with chronic inactive spondylolysis, there are several treatment options available, including pain medications, chiropractic or osteopathic manipulation, physical therapy and exercise.

For patients seeking chiropractic or osteopathic manipulation for this condition, it is important to note that there is no evidence in the medical literature that manipulation can reduce slippage or cause an active site to heal. But there are some case studies to show that manipulation will often provide temporary pain relief for the patient. This is because appropriate manipulation treatment can relieve many of the side effects of spondylolysis, such as lower back pain caused by stresses on various spinal structures, including the facet joints.

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In general, most people with chronic inactive spondylolysis can find sufficient pain relief through a combination of conservative treatments, such as manual therapy, exercise, and lifestyle changes.

However, it is important to note that any therapeutic approach must take into account that spondylolysis means that there is a potentially unstable area of the spine, so caution and the skill of the treating spine specialist are very important considerations.

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Abstract

The purpose of this study was to evaluate the healing capacity of fatigue fractures of the pars interarticularis in young elite athletes. Between 1991 and 2000, a fatigue fracture of the pars interarticularis was diagnosed in 34 highly competitive athletes. The study group included 28 athletes with a mean age of 17.2 years at diagnosis (range 12-27 years). The average time per week dedicated to sports was 10.9 h. Diagnosis was made with both planar and single-photon-emission computed tomographic (SPECT) bone scintigraphy and computed tomographic (CT) scan. Lesions were classified into three groups according to their distribution on the scintigram: unilateral, bilateral, or "pseudo-bilateral" (asymmetrical tracer uptake). The study was limited to athletes with subtle fractures, which means that they had normal radiographs and positive bone scans. All subjects were braced for a mean time of 15.9 weeks (range 12-32 weeks). We looked at healing of the fracture, subjective outcome, and sports resumption in the three groups.

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The athletes were reviewed after an average of 13.2 months (range 3-51 months), and a second CT scan was performed to evaluate osseous healing. Healing of the fracture was noted in all 11 athletes with a unilateral lesion, in five out of nine athletes with a bilateral lesion and in none of the eight athletes with a pseudo-bilateral lesion. Twenty-three athletes (82.2%) rated the outcome as excellent, three athletes (10.7%) as good, and two (7.1%) as fair. Twenty-five athletes (89.3%) managed to return to their same level of competitive activity within an average of 5.5 months after the onset of treatment. There was no difference in outcome or in sports resumption between the three groups. Our data suggest that osseous healing is most likely to occur in unilateral active spondylolysis. Chances of bony healing diminish when the fracture is bilateral, and diminish even further when it is pseudo-bilateral. Non-union does not seem to compromise the overall outcome or sports resumption in the short term.

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Questions
1. Will it heal with rest
2. Do they (pars) ever heal
3. Will a brace aid healing/pain
4. Is it Active or Inactive, which is worse
5. Is it lateral of bilateral
6. Does Spondylolysis always lead to Spondylolisthesis
7. What about surgery, pin and screw/bone graft in the future
8. Is Spect better than MRI to see change
9. Chiropractic to ease pain, yes or no
10. Is there any possibility of a full recovery
11. At the moment he is pain free and quite active. Can he step it up to see if the pain returns as a one off test
12. In your opinion, will he ever make a near full recovery and return to all sporting activities

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13. How old is the fracture

14. Is it possible that the the pain is due to something other than the fracture

15. What about pars injections where corticosteroid and local anaesthetic is injected into the broken Pars

16. Pars defects can be subdivided into early, progressive and terminal stages, which is this

17. The MRI image seems to show a big gap, is this Grade 1, 11 or 111