Figure 1. Anteroposterior radiograph of lumbar spine.
Figure 2. Lateral view shows spondylolisthesis at L4-L5.
An 18-year-old athlete with chronic low back pain presents with a new report of pain and weakness down the right leg that started a few months ago. He is currently playing high school lacrosse and reports that his right knee seems to be “giving out on him.” He denies any left-sided leg symptoms, numbness or tingling, and bowel or bladder issues. On physical examination, quadriceps and anterior tibialis testing on the right side is 4/5 and 5/5 on the left leg. Radiographs of the lumbar spine are ordered (Figures 1 and 2) and reveal an anterior spondylolisthesis at L4-L5 and hemisacralization of L5 (left side). A magnetic resonance imaging (MRI) shows a grade 1 chronic spondylolytic spondylolisthesis at L4-L5 with no bone marrow edema. The patient has mild foraminal narrowing on the left at L4-L5.
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Spondylolysis and spondylolisthesis are often diagnosed in children presenting with low back pain.1,2 The most common presenting symptoms are a history of activity-related low back pain and presence of painful spinal mobility and hamstring tightness without radiculopathy.1
Spondylolysis with low-grade spondylolisthesis (≤50% forward translation) generally responds well to conservative treatment including rest, activity modification, use of a corset brace to limit extremes of spine motion, and physical therapy to strengthen the core muscles.1 Patients and athletes can return to work and sports when the back is pain-free, they have full range of motion, and any hamstring spasm has subsided. Return to sports generally occurs after 6 to 12 weeks depending on the severity of the injury.1
Surgical treatment is indicated in patients who have failed conservative treatment for 6 to 12 months and have persistent pain or neurologic deficits.2 Treatment involves a spinal fusion at the affected level. In situ spinal fusion indirectly decompresses the nerve root and eliminates spinal motion that is contributing to nerve root irritation. Nerve root decompression with a laminectomy is not generally performed with fusions for spondylolysis.2
The patient in this case was educated on his condition and advised to avoid any sports that involve contact, bending, twisting, or lifting. Because of his lower extremity weakness and nerve impingement seen on MRI, in situ fusion was recommended. He was placed in a corset brace and physical therapy was prescribed until surgery could be performed in a nonurgent matter.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopaedics for Physician Assistants.
1. Cavalier R, Herman MJ, Cheung EV, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: I. diagnosis, natural history, and nonsurgical management. J Am Acad Orthop Surg. 2006;14(7):417-424. doi:10.5435/00124635-200607000-00004
2. Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: II. surgical management. J Am Acad Orthop Surg. 2006;14(8):488-498. doi:10.5435/00124635-200608000-00006