Lumbar spondylolysis is a stress fracture of the pars interarticularis. We have evaluated the site of origin of the fracture clinically and biomechanically. Ten adolescents with incomplete stress fractures of the pars (four bilateral) were included in our study. There were seven boys and three girls aged between 11 and 17 years. The site of the fracture was confirmed by axial and sagittal reconstructed CT. The maximum principal tensile stresses and their locations in the L5 pars during lumbar movement were calculated using a three-dimensional finite-element model of the L3-S1 segment. In all ten patients the fracture line was seen only at the caudal-ventral aspect of the pars and did not spread completely to the craniodorsal aspect. According to the finite-element analysis, the higher stresses were found at the caudal-ventral aspect in all loading modes. In extension, the stress was twofold higher in the ventral than in the dorsal aspect. Our radiological and biomechanical results were in agreement with our clinical observations

A radiographic suvey has been carried out of 147 first-degree relatives of forty-seven patients treated in Edinburgh for spondylolisthesis of the fifth lumbar vertebra; twelve patients had the dysplastic (congenital) type and thirty-five an isthmic defect. The survey identified 19 per cent of relatives with spondylolysis, and index patients with each type of spondylolisthesis had relatives with the opposite type. Index patients with the dysplastic form had a higher proportion of affected relatives (33 per cent) than had those with the isthmic type (15 per cent), but both figures were significantly in excess of the estimated frequency for the general population of under 1 per cent and 5 per cent respectively. Spina bifida occulta at the fifth lumbar or first sacral level or both, and lumbosacral segmental defects were commoner amongst all individuals with spondylolysis than amongst unaffected relatives (dysplastic form 94 per cent, isthmic type 32 per cent, unaffected relatives 7 per cent). However, there was no single instance of a neural tube defect (anencephaly, spina bifida with or without meningocele, other generalised vertebral anomalies or spinal dysraphism) amongst 826 first-, second- or third-degree relatives. It is concluded that the developmental defects of the vertebrae associated with spondylolysis are not aetiologically related to the neural tube defects. The one in three risk of spondylolysis to near relatives of patients with the dysplastic form of spondylolisthesis is emphasised in order that the deformity in their sibs and children can be recognised at any early age

Reports of spondylolysis in vertebrae other than those of the lower lumbar spine are rare. We report 32 patients with upper lumbar spondylolysis who have been studied clinically, radiologically and scintigraphically. Twenty patients had bilateral lesions, and seven of those with unilateral lesions had structural changes or anomalies in the opposite posterior arch. Positive scans were found to be associated with a short clinical history, and indicated stress-related lesions. Our findings suggest that mechanical factors may play a role in the aetiology of spondylolysis in the upper lumbar spine similar to that which they play in the lower lumbar spine, and that local structural anomalies may contribute to abnormal loading of these vertebrae

We report the occurrence of spondylolysis and/or spondylolisthesis of the lumbar vertebrae in five patients with osteopetrosis, four of them having multiple lesions. The case histories indicate that spondylolysis had developed in the pathological bone as a result of increased stress and that it is an acquired lesion

A method is described whereby fractures of the neural arch similar to those in spondylolysis are produced experimentally. The forces, bending moments and displacements required to initiate the fractures are given; The mechanical aspects in the aetiology of spondylolysis are explained by a simplified two-dimensional force analysis

Lateral oblique radiographs are considered important for the identification of spondylolytic lesions, but these projections will give a clear view only when the radiological beam is in the plane of the defect. We studied the variation in orientation of spondylolytic lesions on CT scans of 34 patients with 69 defects. There was a wide variation of angle: only 32% of defects were orientated within 15° of the 45° lateral oblique plane. Lateral oblique radiographs should not be considered as the definitive investigation for spondylolysis. We suggest that CT scans with reverse gantry angle are now more appropriate than oblique radiography for the assessment of spondylolysis. Variation in the angle of the defect may also need consideration when direct repair is being planned

We injected methylene blue dye into 32 of the facet joints immediately above the defects in 17 consecutive patients with bilateral spondylolysis (34 defects). In 30 of these the dye flowed into a central cavity in the defect of the pars interarticularis and in 20 it passed into the facet joint below the defect. We found macroscopic cavities in 32 of the defects which communicated with the adjacent facet joints and had fibrous capsules. Histological examination showed focal areas of synovial lining consistent with a synovial pseudarthrosis. In most patients requiring surgery for spondylolysis, the defect is a synovial pseudarthrosis which communicates with the facet joint above it, and less often with the facet joint below it. We suggest that stress fractures of the pars may fail to heal because of the presence of synovial fluid from a nearby facet joint

The lumbar spines of 485 skeletons of adult South African "Whites" and "Blacks" of both sexes were examined to determine the incidence and morphology of defects in the pars interarticularis. The overall incidence was 3.5%, without significant variation between races and sexes. The incidence of lumbar spina bifida in the whole sample was 1.9%, but was 11.8% in those skeletons with spondylolysis. Some instances of unilateral spondylolysis demonstrated obvious callus formation, suggesting a capability for normal repair. It is possible that the defects in bilateral cases represent established non-union of fractures of the pars interarticularis resulting from excessive mobility, and are not due to dysplasia of bone. It is noted, for the first time, that the superior facets of affected vertebrae are abnormally enlarged, and that the inferior facets of the separate neural arch are characteristically elliptical

Aims

Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies.

We present a case of L2/3 interspinous bursitis treated with extraspinal injections. No previous investigations have used fluoroscopically guided spinal injections to confirm the clinical relevance of the MRI features of this type of bursae. Autopsy studies have revealed an increased incidence of interspinous lumbar bursal cavities with advancing age. Afflicted patients present with localised, midline lower lumbar pain exacerbated by extension. In young athletes these symptoms can mimic spondylolysis. MRI is useful in detecting soft-tissue injury of the posterior elements. Fluoroscopically guided diagnostic and therapeutic extraspinal injections can be used for confirmation and treatment of pain from such bursae

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

A study of spondylolysis and spondylolisthesis in 142 children and adolescents is reported. In twelve of the seventy-nine patients followed for over a year the affected vertebra slipped further by 10 per cent or more. Increasing slip occurred mainly during the adolescent growth spurt, and was greater when spinal bifida or other vertebral anomalies were present. If at presentation the slip is less than 30 per cent then further slip beyond 30 per cent is unlikely. Decompression posteriorly is advised when signs of nerve pressure are present. Indications for spinal fusion are suggested; the intertransverse method of fusion was used in sixty-nine patients

1. An anatomical study of the bony structure of the pars interarticularis of the fourth and fifth lumbar vertebrae has been made in specimens from seven cadavers aged seventeen to sixty-seven. 2. Layers of cortical bone have been described antero-laterally and postero-medially which are thickest in the narrowest region of the pars. 3. In one specimen from a seventeen-year-old male, a healing fracture was found in the antero-lateral layer of cortical bone in the right neural arch of the fourth lumbar vertebra. 4. The stresses to which the pars is subject consist primarily of shear forces applied to the articular processes. The significance of these stresses to the etiology of spondylolysis is discussed

We studied 23 patients with spondylolysis of the fifth lumbar vertebra (L5) and 20 with spondylolytic spondylolisthesis at this level. All were more than 40 years of age. The transverse processes at L5 were significantly wider in the former group than in the latter. We also dissected 56 cadavers to study the morphological relationship between the transverse process of L5 and the iliolumbar ligament, and found that the wider transverse process is associated with increased width of the posterior band of the iliolumbar ligament. If a patient with pars defects has wide transverse processes at L5, the lumbosacral junction may be stabilised by wide posterior bands of the iliolumbar ligament and the fifth lumbar vertebra by the ligament, preventing anterior displacement

Some radiological features of the lumbar spine of 84 patients with spastic diplegia were compared with 50 control subjects. The average age of the patients was 20.1 years (3 to 39). Spondylolysis of the fifth lumbar vertebra was found in 21%, four times more frequently than in normal subjects. No patient under nine years of age had spondylolysis and the frequency increased with age. The average angle of lumbar lordosis in spastic patients in the standing position was greater than in normal subjects, and increased with age. The patients had a decreased sacrofemoral angle which caused an increase in Ferguson's angle and explained the increased angle of lumbar lordosis

Lumbar spondylolysis can heal with conservative treatment, but few attempts have been made to identify factors which may affect union of the defects in the pars. We have evaluated, retrospectively, the effects of prognostic variables on bony union of pars defects in 134 young patients less than 18 years of age with 239 defects of the pars who had been treated conservatively. All patients were evaluated by CT scans when first seen and more than six months later at follow-up. The results showed that the spinal level and the stage of the defects were the predominant factors. The site of the defects in the pars, the presence or development of spondylolisthesis, the condition of the contralateral pars, the degree of lumbar lordosis and the degree of lumbar inclination all significantly affected union

We reviewed the radiographs of 325 unselected patients with defects in the pars interarticularis of L5 to study whether the incidence of vertebral slip in spondylolysis of L5 remained unchanged after the age of 20 years. MRI was also carried out on 111 of the patients to investigate the relationship between the shape of the transverse process of L5 and the degeneration of the discs adjacent to this level. The incidence of spondylolisthesis increased with age from 17% in the second decade to 51% in the sixth. The transverse process was significantly more slender in patients with less degeneration at L4/5 and advanced degeneration at L5/S1 than in patients with advanced degeneration at L4/5 and less degeneration at L5/S1. Vertebral slip secondary to an isthmic defect of L5 after the age of 20 years was confirmed and the adjacent disc degeneration was significantly related to the vertical thickness of the transverse process of L5

We analysed the complications encountered in 102 consecutive patients who had posterolateral lumbosacral fusion performed with transpedicular screw and rod fixation for non-traumatic disorders after a minimum of two years. Of these, 40 had spondylolysis and spondylolisthesis, 42 a degenerative disorder, 14 instability after previous laminectomy and decompression, and six pain after nonunion of previous attempts at spinal fusion without internal fixation. There were 75 multilevel and 27 single-level fusions. There were 76 individual complications in 48 patients, and none in the other 54. The complications seen were screw misplacement, coupling failure of the device, wound infection, nonunion, permanent neural injury, and loosening, bending and breakage of screws. Screw breakage or loosening was more common in patients with multilevel fusions (p < 0.001). Screws of 5 mm diameter should not be used for sacral fixation. Forty-six patients had at least one further operation for one or several complications, including 20 fusion procedures for nonunion. The high incidence of complications is a disadvantage of this technically-demanding method

Two different classifications of discograms have been used in a prospective study of 279 injected discs in 100 patients. The five-stage classification of Adams, Dolan and Hutton (1986) showed increased degeneration in the lower lumbar discs and more degenerative changes in men than in women. Exact reproduction of the patient's pain on injection was more common in fissured or ruptured discs than in less degenerate discs, with 81% sensitivity and 64% specificity of the discogram for pain. The additional information obtained by comparing computerised tomography (CT) with discograms was minimal. Discography was found to be useful in the evaluation of chronic low back pain in patients whose ordinary CT scans, myelograms and flexion-extension radiographs were normal. In spondylolysis and spondylolisthesis, discography can disclose whether fusion needs to be extended above the lytic level, and it may show if the pain in patients who have had posterolateral fusion is discogenic. Thus, discography gives information which is useful in deciding whether to operate on patients with chronic low back pain