Pediatric Spondylolysis ICD-10
- M43.10 - Spondylolisthesis, site unspecified
- M43.11 - Spondylolisthesis, occipito-atlanto-axial region
- M43.12 - Spondylolisthesis, cervical region
- M43.13 - Spondylolisthesis, cervicothoracic region
- M43.14 - Spondylolisthesis, thoracic region
- M43.15 - Spondylolisthesis, thoracolumbar region
- M43.16 - Spondylolisthesis, lumbar region
- M43.17 - Spondylolisthesis, lumbosacral region
- M43.18 - Spondylolisthesis, sacral and sacrococcygeal region
- M43.19 - Spondylolisthesis, multiple sites in spine
Pediatric Spondylolysis ICD-9
- 738.4 (acquired spondylolisthesis or spondylolysis)
Pediatric Spondylolysis Etiology / Epidemiology / Natural History
- Spondylolysis = disruption of the pars interarticularis.
- Generally from cyclic loading of the inferior articualr facet onto the inferior lamina and pars interarticularis. May be genetic risk factors.
- Spondylolisthesis = anterior vertebral tanslation in relation to the caudal vertebra.
- Slip progression occurs in 5% of pts, is more common in girls and is rare after skeletal maturity.
- Asymptomatic incidence: spondylolysis = 6%; spondylolisthesis = 3% (Belfi LM, Spine 2006;31:E907).
- Associated with football (lineman), gymnasts, ballet, figure skating, wrestlers, divers.
- Etiology: dysplastic, congenital, isthmic, degnerative, traumatic, patholigc.
- Risk factors: increasing age, obesity, lordotic angle, pelvic inclination (Sonne-Holm S, Eur Spine J 2007;16:821).
Pediatric Spondylolysis Anatomy
- L5-S1 slip affects L5 nerve roots.
Pediatric Spondylolysis Clinical Evaluation
- Low back pain aggravated by spine hyperextension. May have sciatic/radicular symptoms.
- Pain reproduced with back hyperextended while standing and performing a single leg hyperextension on the ipsilateral side of the lesion.
- Often have hip flexor and hamstring tightness.
- Crouched gait.
Pediatric Spondylolysis Xray / Diagnositc Tests
- A/P and Lateral views. Oblique views(30° ). Consider flexion/extension views. Xray findings (pars defect, vertebral slippage) do not correlate with clinical symptoms (Fredrickson BE, JBJS 1984;66A:699).
- SPECT(single photon emission computerized tomography) is most sensitive in detecting early spondylolysis.
- CT (3-mm reverse gantry): best defines lesion.
- MRI: reverse angle oblique axial T1 images and dual echo steady state images best demonstrate lesion. (Udeshi UL, Clin Radiol 1999;54:615).
Pediatric Spondylolysis Classification / Treatment
- Meyerding Grading
-Grade II; 26-50%
-Grade III; 51-75%
-Grade V: >100% (spondyloptosis)
- Lumbar corsets or rigid thoracolumbar braces. PT with abdominal strengthening, psoas and hamstring stretching. May consider electromagnetic stimulation for nonunions.
- Most patients with spondylolysis or grade 1 spondylolisthesis do not need surgical treatment
- pts who have persistent pain unresponsive to conservative measures, consider Posterolateral arthrodesis of two or more vertebrae or direct repair of the defect by bone grafting and internal fixation
- Grade IV: generally treated with posterior spinal fusion with or without instrumentation
- Grade V: Spondylo-optosis, consider vertebrectomy
- Surgery: indicated for intractable pain with ADLs, spondylolisthesis >50%, progressive slippage, neurolic deficit. Surgical options include instrumented or noninstrumented posterolateral fusion, interbody fusion. Slip reduction has not demonstrated long-term clinical benefits verses insitu fusion. Consider vertebral resection for Grade V spondylolisthesis (Gaines RW, Spine 2005;30:S66).
Pediatric Spondylolysis Associated Injuries / Differential Diagnosis
- Spina bifida occulta
- Tumor (malignancy/primary)
- Facet arthrosis
Pediatric Spondylolysis Complications
Spondylolysis Follow-up Care
- May return to sports when painfree with full ROM and strength.
- @12% of patients with bilateral pars defects and minor slippage will shown progression.
Pediatric Spondylolysis Review References
- Staendaert CJ, Br J Sports Med 2000;34:415
- Pedersen AK, Hagen R: Spondylolysis and spondylolisthesis: Treatment by internal fixation and bone grafting of the defect. J Bone Joint Surg Am 1988;70:15-24.
- Lenke LG, ICL 2003;52:525.
- Lovell and Winter's Pediatric Orthopaedics 2012