GRAND ROUNDS Active or Inactive Spondylolysis and/or Spondylolisthesis: What’s the Real Cause of Back Pain?

This 16-year-old male patient presented to a chiropractor with low back pain. He related that he hurt his back while playing baseball. His physical examination, including vital signs, was considered normal. His weight was 142 lbs. The patient complained of sharp lumbosacral pain, which was worsened with rotation and extension of the trunk. Extension, left lateral flexion, and left rotation were mildly restricted. He was neurologically intact. Routine orthopedic tests performed on his lower back were initiated. There was no significant pain except for Kemp’s test in hyperextension. He received 4 weeks of chiropractic care (eight sessions) that included chiropractic spinal manipulation, electrical muscle stimulation, ultrasound, and passive stretching. Very little relief was obtained from these treatments, and the chiropractor decided that x-rays were indicated. Conventional radiographs demonstrated a left-sided pars defect and a questionable right-sided pars defect at L5 without slippage (Fig. 1). To visualize more adequately the pars interarticularis, a computed tomogram of the lumbar spine was performed (Fig. 2), which showed a complete defect on the left and a partial pars defect on the right at L5. In an attempt to determine whether these defects were clinically active, a single photon emission computed tomography (SPECT) bone scan was obtained (Fig. 3). The nuclear medicine scan showed marked activity in both pars at the L5 level, consistent with active spondylolysis that was the most likely cause of the patient’s localized pain. The patient was then referred to an orthotist who custom fit him with a Boston overlap (antilordotic) brace. While in this brace, the patient performed aquatic exercises three times per week for 8 weeks. After this 8-week period of time, the patient was asymptomatic. Follow-up computed tomography (CT) scan (Fig. 4) showed both the right and left pars defects at L5 to have completely healed with bony union. The patient was released to a home exercise program. Two years later, he was still asymptomatic and had returned to normal physical and sports-related activities.