Recurrent Back Pain in a 15-year-old Female Athlete

History

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.

Examination

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.

Prior Treatment

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.

Pre-treatment Images

Figure 1:  Sagittal MRI

 Figure 2:  Sagittal MRI
  

Figure 3: Sagittal MRI.

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

Figure 4:  Sagittal CT scans showing fracture at L4

Diagnosis

The patient was diagnosed with isthmic spondylolisthesis at L4.

Selected Treatment

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. 

Intraoperative Images

 Figure 5:  Intraoperative photo showing surgical set-up
 

Figure 6

Figure 7

Figure 8

 

Figure 9

Immediate Post-treatment Images

Figure 10:  Immediate post-operative sagittal x-ray showing pedicle screw placement

Figure 11:  Immediate post-operative x-ray

Outcome

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.

Case Discussion

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.

Case Discussion

Dr. Dekutoski presents the case of a 15-year-old female athlete with recurring episodes of low back pain secondary to an L4 spondylolysis.  Her exam findings are significant for hamstring tightness but no neurologic complaints or neurologic deficit.  Not surprisingly, she reports pain that is increased with extension activities and mechanical loading.  She has been through fairly extensive conservative treatment including non-steroidal anti-inflammatories, physical therapy, chiropractic treatment, and activity modification.

The imaging studies demonstrate the bilateral pars defect at L4 without an evident spondylolisthesis.  The MRI demonstrates healthy appearing discs throughout the lumbar spine.

As opposed to the more common L5 spondylolysis, which often responds favorably to non-surgical treatment, L4 spondylolysis is often problematic and more frequently recalcitrant to non-surgical measures.  While further non-surgical treatment options such as pars injection, electrical stimulation or bracing are all reasonable considerations, they would be unlikely to afford an expeditious return to sports and would carry a significant risk for ultimate failure.  One potential advantage of pars injection would be diagnostic confirmation of the pain generator, although it seems pretty clear based upon the patient's clinical history and existing radiographic studies.

Assuming a decision to proceed with surgical treatment, the choice between pars repair and L4-L5 fusion is based upon the patient's age, the presence of listhesis, and the extent of associated disc degeneration.  In this instance, all of these factors favor the selection of pars repair over lumbar fusion. 

Pars repair can be difficult in adults, particularly smokers, because the pars is a relatively avascular zone.  In children and adolescents, however, healing rates have been very acceptable with direct repair.  Dr. Dekutoski selected a minimally invasive approach with percutaneous placement of pars screws, decortication and the use of allograft with biologic supplementation.  An alternative surgical technique might have been placement of bilateral pedicle screws and wiring of the lamina to compress the area of pars defect.  Dr. Dekutoski's technique offers several potential advantages including more rigid fixation and possibly less devascularization related to the minimally invasive approach.  It is important to note that successful healing is critical, suggesting the need for either iliac crest bone graft or biologic supplementation.  Even in children, decortication alone or bone bank bone alone is probably insufficient. 

Consistent with the outcome in this case, pars repair has been demonstrated to return adolescents to a high level of function, including participation in sports.