Recurrent Back Pain in a 15-year-old Female Athlete
A 15-year-old female athlete presented with recurrent back pain (>18 months). The original onset was in playing basketball, and when she stopped playing, it improved. She re-injured her back 3 months ago.
She is very active, and participates in dance, track (hurdles), baseball, and horseback riding.
The patient, who is 12 months post-menarchal, has hyperlordotic posture, a neutral pelvis, and hamstring tightness.
She notes that her pain is worse with extension, jumping, and bending.
Previously, the patient has tried non-steroidal anti-inflammatory medications (NSAIDs), physical therapy, and chiropractic. She has also tried activity modification. None of this has provided relief.
For more information on the use of MRI in sports injuries, see Gundry CR, Fritts HM. MR imaging of the spine in sports injuries. Magn Reson Imaging Clin N Am. 1999;7(1):85-103.
You can also refer to Gundry CR, Fritts HM. Magnetic resonance imaging of the musculoskeletal system. Part 8. The spine, section 2. Clin Orthop Relat Res. 1997 Oct;(343):260-71
The patient was diagnosed with isthmic spondylolisthesis at L4.
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The patient had a direct repair using percutaneous screw placement with intraoperative navigation. We decorticated through a tube and microscope the sclerotic margins of the pars defect back to bleeding bone. Then we placed the allograft scaffold and biologic.
For more information on direct repair in spondylolisthesis, please see: Wimbery RL, Lauerman WC. Spondylolisthesis in the athlete. Clin Sports Med. 2001;21(1):133-45.
Immediate Post-treatment Images
The patient is doing well and returned to sports at 16 weeks. She has pain free range of motion now, and a VAS of 0.
This patient had persistent pain with sports. She is young and wanted to continue her sports involvement. Treatment to relieve her pain is totally justifiable. I would suggest a period of conservative treatment of 8 weeks before I elect to go for surgery. I use full time, except sleeping and therapy time, lumbosacral canvas corset with rigid back, physical therapy 3 times weekly for 6-8 weeks, and NSAIDs for 4-6 weeks. My experience as well as literature showed that protocol will relieve the pain in more than 90% of the patients, regardless of whether the pars will heal or not.
If conservative treatment fails and pain persisted or reoccurs after returning to sports, then surgical treatment is indicated.
The patient is young, MRI shows normal discs in the lumbar area and no degenerative changes, therefore pars repair, rather than fusion, is the appropriate surgery.
The technique used in this case is completely appropriate and the MIS procedure will decease tissue dissection and will allow the patient early return to daily living activities. I would expect she will be limited from sports for 6-8 weeks to assure some healing of the pars.
The problem here is that this technique needs certain training and expertise, which probably is not available for mainstream surgeons. I personally prefer a limited open procedure where I use a technique which I described at the SRS 1988 Annual Meeting. I prepare the pars defect area and decorticate from the tip of transverse to the lamina with extreme care to protect the joints. I cover the area with adequate graft, and I use Mersilene 5 mm tape and inserted as a figure of 8 under the transverse processes and tightened around the spinous process. I had more than 35 cases, and I had to convert one only to fusion due to the lack of healing on CT scan.
I'd like to congratulate Dr Dekutoski on this appropriately decided and performed surgery and on his exceptional MIS technique.