OUCH MY BACK! Spondylolysis in the Pediatric Population

by Maya Spencer (’22)

Back pain is a symptom that occurs frequently in the adult population. However, in pediatrics it is not a complaint that is frequently encountered, and when it does there may be a degree of hesitancy when addressing the concern. While a significant portion of adolescents may have no identifiable or benign causes of pain, the athletic patient that presents with pain should heed caution. Spondylolysis/spondylolisthesis are an increasingly common cause of back pain in highly athletic adolescents and should be considered for further work up to avoid prolonged diagnosis.

Spondylolysis is a stress fracture that occurs within the vertebrae, typically at the pars interarticularis. When the fracture occurs bilaterally and completes all the way through the bone this can progress to spondylolisthesis, where the vertebrae slides anteriorly over the bone below it. As children are becoming more active in sports at an earlier age with a higher intensity of practice this is becoming an increasingly common condition in the pediatric population. It is estimated to be seen in 4 – 8% of the general pediatric population with back pain however, can be seen in up 50% of athletes with back pain.

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The injury occurs due to  repetitive stress from activities requiring excessive lumbar extension such as gymnastics, dance, baseball, and football to name a few. However, the number of sports that this is seen in is increasingly varied.

Patient will present with lower back particularly with extension. This is due to increased loading pressure on the posterior elements of the spine where the fracture has occurred.  Typically the injury occurs at the level of L4-L5 however, it has started to be seen higher up in the lumbar spine as well. A positive single leg hyperextension test (aka stork test) on physical exam should raise concern for spondylolysis. This test is performed by having the patient stand on one leg with the other leg flexed at the knee. The patient then extends backward at the waist. A positive test occurs when pain is produced either ipsilaterally or bilaterally. 

Next steps should include obtaining an x-ray spine (AP and lateral). X-rays will pick up the injury about 50-60% of the time. However, in classic presentations with negative X-ray, MRI is the most beneficial imaging. As the injury can progress within a matter of a few weeks with continued activity, it is beneficial to refer to a sports medicine specialist once ordering the imaging for further management as particular imaging/protocols are used when ordering MRIs.

Treatment includes activity modification to avoid extension, NSAIDS, and physical therapy for core strengthening and flexibility. Bracing is an adjunctive treatment that is also beneficial however, debated between specialists on it’s efficacy. Surgery is typically reserved only for advanced spondylolisthesis.

References:

  1. Lamb, M., & Brenner, J. S. (2020, November 1). Back pain in children and adolescents. American Academy of Pediatrics. Retrieved December 22, 2021, from https://publications.aap.org/pediatricsinreview/article/41/11/557/35355/Back-Pain-in-Children-and-Adolescents.
  2. Metzl, J. D., Metzl, J. D., & Bernhardt, D. T. (2018). Sports medicine in the pediatric office: A multimedia case-based text with video. American Academy of Pediatrics.

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