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Low back stress fracture, spondylolysis and the importance of diagnosis: a retrospective MRI/CT and clinical study of stress reactions in the spine of young athletes
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Sports medicine.ORCID iD: 0000-0001-8762-024
Bild och funktionsmedicin, Västerbotten.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Clinical Physiology.ORCID iD: 0000-0003-4578-1122
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Low back pain (LBP) is common in adolescence as well as in adulthood but the reason for LBP differs between the different age groups. Stress reaction is a reason for LBP in adolescence and there is a discussion about the progression from stress reactions to spondylolysis, which in turn can develop into spondylolisthesis.

Sixteen out of nineteen MRI identified subjects with spondylolysis agreed to take part in the whole investigation that included a questionnaire and reexamination of MRI scans performed at the time of diagnose and after the initial treatment (84,2%) with mean age of 15,5 years at diagnosis and mean age of 20.8 at the time of follow-up 1-12 years after diagnosing.

We found a mean time between first symptom of low back pain and time of diagnosis of 28 weeks (0-127 weeks) and a mean activity level of 8.9 hours a week at follow-up with the questionnaire. From the studied MRI investigations seventeen pedicels out of 31 had healed with rest from physical activity as treatment. Seven individuals that displayed spondylolysis on the final MRI had at follow-up (1-12 years after diagnosing) got relief of symptoms and had return to a high level of physical activity. The subject that developed spondylolysis with out healing could thus to a great extent still be physically active.

Keywords [en]
CT, MRI, Stress fracture
National Category
Physiotherapy
Research subject
Sports Medicine
Identifiers
URN: urn:nbn:se:umu:diva-155869OAI: oai:DiVA.org:umu-155869DiVA, id: diva2:1283923
Available from: 2019-01-30 Created: 2019-01-30 Last updated: 2019-01-31
In thesis
1. Low back pain in adolescent athletes
Open this publication in new window or tab >>Low back pain in adolescent athletes
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Globally Low back pain (LBP) is one of five leading causes of years lived with disability (YLD), and LBP is a common complaint among adults as well as adolescents and adolescence athletes. During adolescents, the LBP often is considered as non- specific without structural findings and thus not needed to be further diagnosed or treated specifically. However, LBP that begins in adolescence often continue through adulthood, and since adolescent athletes with high physical activity seems to have more LBP than less physically active adolescents, high physical loading during adolescence, might be a risk factor for LBP later in life.

Studies: Epidemiology: The Standardized Nordic Questionnaire adjusted for adolescence was used to investigate the prevalence of LBP during adolescence (16-19 years old individuals).

Retrospective study: A ten-year follow-up on symptomatic low back spondylolysis patients identified on MRI or CT. Sixteen out of nineteen identified patients agreed to answer a questionnaire and to have their case-history reviewed.

Case-control study: Twenty-five patients (13-19-year-old boys and girls) with LBP and 13 pain free individuals (controls, 14-19-year-old boys and girls) were investigated with physical examination and MRI. If the patients had findings on MRI a CT investigation was performed.

Clinical study: Twelve of 14 patients (a subgroup from the case-control study) with Spondylolysis on MRI and CT were evaluated with a modified Hollenberg classification (six levels). These patients were re-evaluated with MRI and CT after 3 months of treatment with complete rest from sports activity.

Differential diagnosis: Five adolescent patients with on-going LBP/thigh pain previously treated in other clinics, were reevaluated for a “second opinion”.

Results: Epidemiology study: The prevalence of LBP among adolescents was 46% (N= 2522) with an annual incidence of 42 %. Girls reported more LBP than boys (52 % versus 40 %). Individuals who were active in sports > 6 h/w had significantly more LBP compared with less physically active individuals. 

Retrospective study: Thirteen of the 16 individuals had a second MRI/CT investigation and thus 52 out of the initial 64 pars interarticularis where investigated a second time (mean 3 months after the first investigation). These patients had had different treatments, most commonly rest for 3 months. In total, 7 out of 16 individuals healed (44%).

Case control study: In 22/25 patients (88%) there were clinical findings and MRI findings such as spondylolysis, disc herniated discs, disc degeneration and injuries to the vertebral body. In 13/25 patients (52%) spondylolysis of different stages were found. No clinical test alone, or in combination, could reliably diagnose spondylolysis, and could thus not be used as a selection test for patients who need further diagnostics with MRI and CT.

Clinical study: Using a combination of MRI and CT examination the early signs of skeletal injury (oedema, incomplete fracture) to the pars interarticularis were detected. Patients diagnosed with these early stages healed significantly better than if diagnosed in later stages (complete fracture and pseudoarthrosis).

Differential diagnosis: The second opinion with careful physical examination and MRI examination diagnosed stress reactions in the pelvic ischial tuberosity in the patient seeking help for pain in the lower back/thigh. After guided rehabilitation, all these patients returned to previous sport activities.

Conclusions: LBP is common during adolescence, more common in girls and in highly active individuals. LBP must be taken seriously, especially in adolescent athletes who not seldom have fractures in pars interarticularis (Spondylolysis). If diagnosed early, there seems to be good potentials to heal the fracture with 3 months ́ of rest from loading (sport activity). Differential diagnoses such as stress reactions in the pelvic ischial tuberosity should be taken into consideration.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2019. p. 59
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2014
Keywords
Adolescence, Ischial Tuberosity, Low Back Pain, Oedema, Pars Interarticularis, Physical Activity, Pseudoarthrosis, Sport Activity, Stress fracture, Stress reaction
National Category
Physiotherapy
Research subject
Sports Medicine
Identifiers
urn:nbn:se:umu:diva-155848 (URN)978-91-7855-024-1 (ISBN)
Public defence
2019-02-22, Aulan, Vårdvetarhuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Funder
Swedish National Centre for Research in Sports, 330610018
Available from: 2019-02-01 Created: 2019-01-30 Last updated: 2019-01-31Bibliographically approved

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Sundell, Claes-GöranLarsén, Karin

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