Brief Article
Copyright ©2010 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Orthop. Nov 18, 2010; 1(1): 26-30
Published online Nov 18, 2010. doi: 10.5312/wjo.v1.i1.26
Return to sports activity by athletes after treatment of spondylolysis
Jun Iwamoto, Yoshihiro Sato, Tsuyoshi Takeda, Hideo Matsumoto
Jun Iwamoto, Tsuyoshi Takeda, Hideo Matsumoto, Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
Yoshihiro Sato, Department of Neurology, Mitate Hospital, Fukuoka 826-0041, Japan
Author contributions: All authors contributed to this paper.
Correspondence to: Jun Iwamoto, MD, Institute for Integrated Sports Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. jiwamoto@sc.itc.keio.ac.jp
Telephone: +81-3-33531211 Fax: +81-3-33529467
Received: August 30, 2010
Revised: October 28, 2010
Accepted: November 3, 2010
Published online: November 18, 2010

Abstract

AIM: To clarify the efficacy of conservative and surgical treatment of spondylolysis in athletes.

METHODS: PubMed was used to perform a search of the literature for studies published during the period from 1990 to 2009 that reported data on the outcome of conservative or surgical treatment of spondylolysis in athletes. The articles were examined for data on the percentage of athletes who returned to sports activities and the interval between the start of treatment and their return.

RESULTS: Five studies were identified. Two studies were concerned with conservative treatment and the other three with surgical treatment (wire fixation or screw fixation with bone graft). The percentages of athletes who returned to sports activities ranged from 80.0% to 89.3% and from 81.9% to 100%, respectively, and the intervals until their return ranged from 5.4 to 5.5 mo and from 7 to 12 mo, respectively.

CONCLUSION: The percentages of athletes who returned to sports activities after conservative and surgical treatment appeared to be satisfactory, but the interval until their return to sports activities was longer after surgery than after conservative treatment.

Key Words: Spondylolysis, Athletes, Conservative treatment, Surgical treatment, Return to play, Literature review



INTRODUCTION

Spondylolysis is a common injury that causes low back pain in athletes. Sports in which participants are subjected to repetitive hyperextension and rotation across the lumbar spine pose a risk for such injury, and football linemen, oarsmen, dancers, gymnasts, and athletes in sports that involve throwing have a high incidence of this condition[1,2]. Two prospective studies have shown that the incidence of low back pain in athletes with spondylolysis was 72.5% in high school rugby players, 79.8% in high school football players, and 80.5% in college football players[3,4]. Low back pain associated with spondylolysis often prevents athletes from continuing sports activities, and management of spondylolysis in athletes is a challenge.

Enabling patients to return to sports activities is at the heart of sports medicine, and achieving that goal frequently presents significant challenges to the sports physician[5]. Nevertheless, a review of the literature on spinal injuries in athletes and their return to play suggests that there are differing opinions regarding the evaluation and treatment of spondylolysis, and that there is less disagreement with regard to return to play[6]. Thus, not only is there no agreement on the optimal strategy for the management of spondylolysis in athletes, but there is a lack of research-based evidence in the literature with regard to return to play in athletes with spondylolysis. However, because athletes with sports injuries usually desire an early return to sports activities, it is naturally important for sports physicians to inform them of the likely outcome of several treatment options and the estimated duration of each treatment.

The primary goal of treatment of athletes with spondylolysis is healing of the injury and prevention of progression to nonunion of the pars interarticularis. Most sports physicians agree that the treatment of spondylolysis should include a period of rest, with or without bracing, to allow healing, rehabilitation, and return to play when asymptomatic[7]. Actually, earlier studies published in the 1980s have shown that treatment that consists of avoiding aggravating activities and rest enabled athletes to return to pain-free competition after an average interval of 7.3 mo[8], and that after treatment with the modified Boston brace, 78% of athletes had either excellent or good results with no pain and returned to full activity[9]. Surgical treatment is indicated in athletes with persistent pain from non-healing of the pars after a minimum of 6 mo[10]. Wiring technique, direct repair with screw fixation, and pedicle screw-hook constructs across the pars interarticularis defect with bone grafting are effective options to achieve pars healing while preserving spinal motion[10].

However, despite the obvious theoretical desirability of healing the pars interarticularis, there has been little correlation between bony healing and outcome, and numerous studies have shown good short-term outcomes for return to play regardless of healing status[11]. Because there have been no controlled trials of treatment of spondylolysis, and only a few of studies have addressed potential strategies, it is difficult to develop true evidence-based guidelines for this condition[11]. There have been no high level evidence studies that have led to specific recommendations for bracing, rehabilitation, or surgery, and no head to head study has ever proven superiority of treatment methods. To date, the outcomes of conservative or surgical treatment of spondylolysis in athletes have been documented[12-16]. The purpose of the present study was to clarify the efficacy of conservative and surgical treatment of spondylolysis in athletes; especially in terms of their ability to return to sports activities, by reviewing the recent literature.

MATERIALS AND METHODS

PubMed was used to search the literature for studies published during the period from 1990 to 2009, which presented data on the outcomes of conservative or surgical treatment of spondylolysis in athletes; especially in terms of their ability to return to sports activities. The key words used in the search were “spondylolysis”, “sport”, “sports”, “athlete”, and/or “athletes”. Inclusion criteria were full-length English-language papers or abstracts, conservative treatment, surgical treatment, athlete’s outcomes, adequate information about the ability of athletes to return to sports activities, prospective studies, and retrospective studies. Exclusion criteria were non-English-language papers or abstracts, case reports, review papers, non-athlete’s outcomes, and inadequate information about the ability of athletes to return to sports activities.

The efficacy of conservative and surgical treatment of spondylolysis in athletes was clarified. The primary endpoint was the percentage of athletes who returned to sports activities. The secondary endpoint was the interval between the start of treatment and their return to sports activity. In addition, the outcomes of conservative and surgical treatment methods were compared by calculating the ratio (surgical/conservative) of the percentage of athletes who returned to sports activities and 95% confidence interval (CI). The statistical analysis was performed by using Excel Analysis 2008 Software (Social Survey Research Information Co., Ltd, Tokyo, Japan) on a personal computer. A significance level of P < 0.05 was used for all comparisons.

RESULTS
Studies in athletes

Five studies were identified[12-16]. All of them were case series studies. One was a prospective study, and four were retrospective. Two studies were concerned with conservative treatment, and the other three with surgical treatment (wire fixation or screw fixation with bone graft).

Outcomes of conservative and surgical treatment

Table 1 shows the outcomes of conservative and surgical treatment. The percentages of athletes who returned to sports activities ranged from 80.0% to 89.3% and from 81.9% to 100%, respectively, and the intervals until their return ranged from 5.4 to 5.5 mo and from 7 to 12 mo, respectively. The percentages of athletes who returned to sports activities after conservative and surgical treatment appeared to be satisfactory, but the interval until their return to sports activities was longer after surgery than after conservative treatment.

Table 1 Outcomes of five studies.
Investigator, yrStudy designNo. of casesMean age (yr)SubjectsTreatmentPercentage of athletes who returnedInterval until to return
Sys et al[12], 2001Retrospective2817.2Highly competitive athletesConservative (Boston Overlap Brace)89.35.5 mo
Iwamoto et al[13], 2004Retrospective4020.7Various levels of athletesConservative (rest and anti-lordotic brace)87.55.4 mo
Reitman et al[14], 2002Retrospective417.8High school and collegiate athletesSurgery (screw fixation with bone graft)100< 1 yr
Debnath et al[15], 2003Prospective2220.2Young athletesSurgeries (wire fixation or screw fixation with bone graft)81.97 mo
Nozawa et al[16], 2003Retrospective2023.7AthletesSurgery (segmental wire fixation)100No information
Outcomes of conservative versus surgical treatment

The combined results of the two studies of conservative treatment showed that 60 of the 68 athletes returned to sports activities. Overall, the percentage of athletes who returned to sports activities after conservative treatment was 88.2%. The combined results of the three studies of surgical treatment showed that 42 of the 46 athletes returned to sports activities, and overall, the percentage of athletes who returned to sports activities after surgical treatment was 91.3%.

The ratio of the percentage of athletes who returned to sports activities after surgical treatment to the percentage who returned after conservative treatment was 1.03 (95% CI: 0.60-1.78), and the results of the statistical analysis confirmed that the overall percentage of athletes who returned to sports activities after surgical treatment was not significantly different from the overall percentage of those who returned after conservative treatment (P = 0.506).

DISCUSSION

There is convincing evidence that athletes with early or progressive stage lesions of the pars interarticularis should be advised to rest for 3 mo, with the aim of achieving bony union because of the good potential for healing (especially if unilateral), whereas athletes with chronic lesion of the pars interarticularis should be advised to rest, with the aim of relieving low back pain because of the very little chance to achieve bony union[11]. Thus, conservative treatment with the aim of relieving low back pain, as well as surgical treatment with the aim of achieving bony union of the pars interarticularis is an acceptable means of treating athletes with chronic lesions to enable them to return to sports activities. The present study revealed that similar percentages of athletes returned to sports activities after surgical and conservative treatment (81.9%-100% vs 87.5%-89.3%), although the interval until their return to sports activities was longer after surgery than after conservative treatment (7-12 mo vs 5.4-5.5 mo).

The outcome of conservative treatment appears to be satisfactory in athletes, especially in terms of their return to sports activities. Iwamoto et al[13] were able to return 87.5% of athletes to sports activities by treating with rest and anti-lordotic bracing after an average interval of 5.4 mo. They stated that their goal was obtain stability by fibrous union of chronic lesions, and not necessarily bone union. Sys et al[12] have reported that 89.3% of athletes managed to return to their same level of competitive activities within an average of 5.5 mo after the start of non-operative treatment (Boston Overlap Brace). They also have stated that nonunion did not seem to compromise overall outcome or sports resumption in the short-term. These consistent results support the evidence that excellent clinical outcomes can be achieved even in the absence of bony healing[17]. However, there could be a criticism that, despite the satisfactory outcome of conservative treatment of spondylolysis, prolonged and failed conservative treatment could cause formation of communicating synovial pseudoarthrosis at the pars interarticularis, which might prevent healing.

d'Hemecourt et al[18] have reported that 80% of athletes with spondylolysis that were treated with the Boston Overlap Brace had a favorable clinical outcome. They have speculated that athletes with symptomatic spondylolysis treated with an anti-lordotic brace can expect improvement in their clinical course, and return to sports participation in 4-6 wk. However, this is not an evidence-based opinion, but only speculation. It might take longer (5-6 mo) for athletes to return to their same level of sports activities after conservative treatment, including athletic rehabilitation programs (4-6 wk).

As to the natural course of spondylolysis, Miller et al[19] have shown that most young athletes conservatively treated for early spondylolysis (radiography negative, nuclear scintigraphy positive) maintained good functional outcome for up to 11 years, and that unilateral defects underwent full bony healing, but took longer than 12 wk. However, bilateral defects underwent further degeneration and slip with time. Congeni et al[20] also have shown that, among athletes with subtle fractures of the pars interarticularis (normal radiographs and positive bone scans), 45% of athletes had chronic non-healing fractures, 40% developed acute fractures in various stages of healing, and 15% had no obvious fractures according to computed tomography scans. These results suggest the limitations of conservative treatment in athletes with bilateral defects, and that the risk of nonunion of the defect, degeneration and slip increases unless athletes with spondylolysis are treated properly. Computed tomography scans can play a very important role in diagnosis, assessment of the defect, short-term and long-term management decisions, and in determining prognosis.

A high percentage of athletes might be able to return to sports activities after surgery (wire fixation or screw fixation with bone graft). Nozawa et al[16] have reported that 100% of the athletes that they treated by segmental wire fixation returned to sports activities. Reitman et al[14] and Debnath et al[15] have reported that 100% and 81.9%, respectively, of the athletes treated by wire fixation or screw fixation with bone graft returned to sports activities in 1 year and after an average interval of 7 mo, respectively. The indication for surgery in both studies was failure to respond to conservative treatment, including rest, bracing, rehabilitation, and/or medication[14-16]. However, the interval until their return to sports activities was longer after surgical treatment than after conservative treatment.

One possibility for this result is that surgery inevitably involves invasion of the back muscles and it would take at least several months before bony union is achieved. Actually, the results of a survey of the membership of the Scoliosis Research Society[21] have shown that almost half of the surgeons who perform fusion to treat children and adolescents with spondylolysis and spondylolisthesis do not permit return to non-contact activities such as running or tennis before 6 mo, and that approximately one-third of the responders permit a return to collision sports such as football and hockey after 1 year.

Other possibilities are that the degree of the lesion might be more severe in those who undergo surgery, which could prolong any return to sports activities; athletes who have prolonged cessation of play might return later; concomitant rehabilitation might influence recovery after surgery; and not all surgical procedures have the same success rate.

It is generally accepted that sports movements that require lumbar hyperextension and rotation contribute to the risk of development of spondylolysis; especially when the spine is immature[22-26]. Spondylolysis is a stress fracture of the pars interarticularis that sometimes occurs during the growth phase, and severe symptoms might only develop when sporting activities become more intense in the mature phase[13]. Micheli et al[27] have demonstrated that adolescent athletes are ultimately shown to have a stress fracture of the pars interarticularis, whereas adult athletes are found to have spondylolysis associated with low back pain. Thus, strategies to prevent stress fractures of the pars interarticularis might be most important in athletes who are in the growth phase.

The limitations of the present study need to be discussed. First, there was no standard definition of return to sports activities. Second, the sports levels might not have been consistent across the studies. Third, most of the studies were retrospective studies with small sample sizes, which suggests lower quality of derived evidence according to evidence-based medicine. Thus, further clinical studies of spondylolysis are needed, particularly longitudinal studies, to increase our understanding of the natural history of this disorder, and controlled clinical trials to study the type and extent of treatment necessary to optimize patient outcomes.

The results of this study showed that the outcomes of conservative and surgical treatment of spondylolysis in athletes appeared to be satisfactory in terms of their ability to return to sports activities. Although the percentage of athletes who returned to sports activities after conservative and surgical treatment was similar, the interval until their return to sports activities was longer after surgery than after conservative treatment. Further clinical studies of spondylolysis are needed to determine the type and extent of treatment necessary to optimize outcomes in athletes in terms of their ability to return to sports activities.

COMMENTS
Background

Spondylolysis is a common injury that causes low back pain in athletes. Enabling patients to return to sports activities is at the heart of sports medicine, and achieving that goal frequently presents significant challenges to the sports physician. However, the efficacy of conservative and surgical treatment of spondylolysis in athletes has not been established.

Innovations and breakthroughs

This study showed that the outcomes of conservative and surgical treatment of spondylolysis in athletes appeared to be satisfactory in terms of their ability to return to sports activities. Although the percentage of athletes who returned to sports activities after conservative and surgical treatment was similar, the interval until their return to sports activities was longer after surgery than after conservative treatment.

Applications

Further clinical studies of spondylolysis are needed to determine the type and extent of treatment necessary to optimize outcomes in athletes in terms of their ability to return to sports activities.

Terminology

Spondylolysis is a stress fracture of the pars interarticularis that sometimes occurs during the growth phase, and severe symptoms might only develop when sporting activities become more intense in the mature phase.

Peer review

Overall this is a well presented overview, however,there are some major comments on the design to be addressed.

Footnotes

Peer reviewers: Salih Özgöçmen, MD, Professor, Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Erciyes University, School of Medicine, Gevher Nesibe Hospital, 38039 Kayseri, Turkey; Volker Schöffl, MD, PhD, MHBA, Department of Sportorthopedics and Shoulder and Ellbow Surgery, Klinikum Bamberg, Bugerstr. 80, 96049 Bamberg, Germany

S- Editor Cheng JX L- Editor Kerr C E- Editor Lin YP

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