Bilateral L2 Spondylolysis: Nonsurgical or Surgical Treatment?
The patient is a 29-year-old male pharmaceutical representative and former collegiate American football player. He presented with sharp stabbing pain in the upper lumbar spine for 3 years. Although he recalls no injury to the spine, he did incur multiple lumbar strains and contusions while playing football. His daily pain is severe, constant, and increases with any activity, especially during extension and while running. Pain is relieved by medication, change of position, including leaning forward. He has no radiating pain, paresthesias, or other red flags.
A previous work-up included lumbar MRIs and bone scan with SPECT. Both were normal except T11-T12 and T12-L1 where Schmorl's nodes and mild disc changes were noted. Leg length films were normal.
The patient presented as a pleasant, healthy individual in no distress. His cardiopulmonary and neurological exams were normal.
The lumbar examination included full range-of-motion. However, the patient experienced pain in extension with guarding at end-range and tenderness to palpation at L2-L3 in the midline. The straight leg raise was negative.
His past medical history includes knee arthroscopic menisectomy twice without any current problems. Family history includes a sister who experienced stress fractures while in college.
The patient tried, without success, multiple physical therapy treatments, conventional exercise, and chiropractic with a 'decompression machine'. He was taking oxycodone/APAP (10/325) and ibuprofen 600 mg 2-3 times daily.
Unenhanced CT scan of the lumbar spine showed, bilateral L2-L3 spondylolysis without spondylolisthesis. There was also a small posterior bulging disc at L2-L3 with very minimal bulging discs seen at more caudal levels. (Figures 1A, 1B)
Bilateral L2 spondylolysis.
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A CT-guided pars injection into the L2-L3 pars defect was performed with 20 mg of Kenalog, 0.5 mg of bupivacaine, and 0.5 mg of 1% lidocaine. (Figure 2) The injection provided immediate and complete pain relief for a 2-week period. A surgical consultation was obtained, but the patient declined operative intervention. One month later, he under went radiofrequency denervation of the L2 and L3 medial branch nerves at 80-degrees for 90 seconds. At a one-month follow-up, he reported 75% pain relief and no longer required analgesics. Pain relief continued for 3 months after which pain gradually returned to pre-injection levels.
Figure 2. CT-guided L2-L3 pars injection
The patients plans to repeat radiofrequency ablation and is contemplating surgical intervention. The surgical procedure offered to him is a L2-L3 pars fracture repair with bone graft, lamina hooks, and posterior instrumented fusion, followed in 6 months by hardware removal, if needed.
While spondylolysis of the lumbar spine is a relatively common condition in both the general public and athletes, it usually involves L4-L5 or L5-S1. That is what makes this case somewhat unusual and interesting.
There is generally less biomechanical stress on the pars interarticularis in the upper lumbar segments. Treatment of lumbar spondylolysis often depends on the patient's age and the likelihood of potential bony healing, although patients also do clinically and functionally quite well who do not achieve bony healing.
The potential for healing is great in the adolescent and very young athlete who has a spondylolysis noted only on bone scan imaging. The treatment is analgesics as needed, activity modification (e.g. avoiding extension and repetitive loading of the spine), core and glutei strengthening, and lumbar and lower extremity stretching for a period of up to 8-12 weeks. A return to sports and other activities is based on clinical symptoms and findings at physical examination. Once the patient/athlete has no pain with activities of daily living, full and pain-free range of motion, and has completed a course of physical therapy -- then a gradual return to sports activities is allowed.
Rigid bracing has been recommended by some authors; however, in the vast majority of patients, the literature does not support the necessity for these braces. The use of local injections for pain control has been described, but has not been fully validated.
We presented a similar case of bilateral upper lumbar spondylolysis in a young gymnast. Her examination included a full metabolic work-up for endocrine and underlying metabolic bone abnormality. Given the history of sudden pain experienced by the patient in this case, I fully agree with obtaining CT imaging, as we have also seen patients with what appeared to be a spondylolysis that turned out to be a pedicle and laminar fracture.
In general, I agree with the management of the case presented. In this relatively "older" patient, the treatment consists of analgesic pain control and possibly injections. The role of radiofrequency denervation (RF) again has been described, but has not been scientifically validated for spondylolysis pain. Therefore, its use would be based on the use of RF for chronic facet-mediated pain, which requires meticulous pre-procedural screening blocks. Surgery (usually fusion) is indicated in cases with severe refractory pain and generally in patients with greater than Grade 2 spondylolisthesis and neurologic findings (e.g. radiculopathy). This is generally uncommon.
My final comment would be regarding the "multiple physical therapy treatments" mentioned. This needs to be explored much more carefully, as often the therapy provided amounts to nothing more than passive modalities of electrical stimulation, ultrasound, etc. This form of treatment is unlikely to provide benefit and should not be prescribed. Rather, restoration of full segmental spinal motion, proper lower extremity flexibility and aggressive core and glutei strengthening is more likely to provide both short-term and long-term benefits, although the patient must be encouraged to be faithful to a home exercise program.
I agree entirely with Dr Malanga's discussion. I also think the case highlights the utility of CT scanning over MRI in the identification of this entity, which was not visible on the patient's MRI scans, even with retrospective review. If the patient decides not to undergo surgery, I plan to follow him yearly with repeated plain x-ray and MRI imaging to watch for evolving disc degeneration.