Spondylolysis

Spondylolysis can be one sided (unilateral) or both sides are affected (bilateral.) This is the most common cause of back pain in adolescents and usually presents around 11-15 years of age. This is usually due to a weak or defective pars interarticularis which gets injured with repetitive motion. Excessive back bending causes more stress on the pars interarticularis. Excessive rotation can cause a one sided or unilateral spondylolisthesis. Football and gymnastics may be the highest risk sports, but other sports are thought to increase the risk of a pars defect. Neurologic deficits are rare. This mainly presents with back pain, focal tenderness and is treated with bracing and relative rest. Lumbar spine X-rays evaluating the alignment and pars interarticularis is the best first line imaging. A bone scan is a better test to evaluate for a recent or healing fracture. Repeat scans may be necessary to assess for healing and return to play.

Spondylosis – “Popping and crackling”

Spondylosis is degenerative changes of the facet joints (wear and tear of the small joints) which usually occurs with degenerative changes of the disks. In younger individuals, this may be found on imaging but does not cause pain. In older individuals, spondylosis can be a source of low back pain. This can cause deep aching pain in the low back or morning stiffness lasting less than one hour. With activity, the morning stiffness improves. (If morning stiffness lasts greater than one hour, it may be time to see a rheumatologist.)

Diagnosis

On physical exam, there may be focal tenderness over the facet joints and rotation and bending backwards may aggravate the pain. X-rays can show facet osteoarthritis. Best diagnostic way to test for facet joint mediated pain is by diagnostic blocks targeting the small nerves called the medial branches which innervate the facet joints. To confirm the pain is coming from the facet joints, 2 sets of blocks are recommended to avoid false-positives.

Treatments

Physical therapy works on improving flexibility in the hip flexors, addressing posture, pelvic tilt, and core strengthening. Lifestyle changes including weight loss, limiting activities which aggravate the pain, short term use of NSAIDs or acetaminophen may be helpful. Bracing may be helpful in overweight individuals where an enlarged belly produces increased stress on the facet joints. If these measures fail, radiofrequency ablation may be an option after undergoing 2 sets of diagnostic medial branch blocks. Surgery is usually reserved for extensive spondylosis causing sciatic type symptoms or significant narrowing in the spinal canal.