can you say spondylolysis?

Monday, March 24, 2014

A vertebra has a simple role. Stack up 22 of them and you end up with a spinal column that holds the torso upright allowing it to move, protects the spinal cord and is the conduit allowing nerves to exit the cord. Each vertebra fits snuggly with the one above and below with a variety of interlocking parts. Architecture in the body is sometimes poorly designed and the lower lumbar vertebrae may not be able to handle the movement and weight placed upon them by the whole of the upper body. In younger athletes, especially those who have to bend and extend repeatedly, stress fractures can occur at the pars interarticularis, causing pain and spasm, potentially bringing budding careers to a screeching halt.

pars

Timing is everything and the lumbar stress fracture suffered by Kansas Jayhawk 7 footer, Joel Embiid, perhaps came at the worst possible time for his team, just before March Madness. Analysts blamed his absence as one of the reasons for the team’s early exit from the tournament. From Mr. Embiid’s perspective, there probably was no good time to be injured…ever.

The technical term for a lumbar stress fracture is spondyloysis (spondylo=vertebra + lysis=break). The pars interarticularis is placed under significant pressure from the weight of the body when it is asked to bend and stretch. Repeated impact may cause the integrity of the bone to start to give way. Microscopic cracks may eventually cause the pars to break completely through. Some patients have genetics to blame because they are born with thinner vertebral bones. Growth spurts can weaken the bone making it more prone to injury, but most often it is the repetitive activity that causes the bone to fail.

As with most injuries, pain is the first indication of a problem. Broken bones hurt, whether they are microscopic stress fractures or complete broken bones (remember that broken, fractures and cracked all mean the same thing). This is soon followed by muscle spasm as the body tries to protect itself. Low back muscle spasm causes the back to stiffen and the hamstrings then may tighten as the body attempts to maintain posture. X-rays may be helpful in making the diagnosis and a pars defect, a polite way of describing a fracture of the bone, may be identified. The fracture may be one sided or bilateral and the 5th lumbar vertebra is the most common level of injury, followed less frequently by the 4th lumbar vertebra. It makes sense because these are the lowest veterbrae of the lumbar spine and are under the most weight and strain.

Making the diagnosis in the early stage of spondylolysis is important because the injury is treated with time and rest allowing bones to heal. Patience is needed because it can take 12 weeks or more and there are complications to be had if the athlte rushes back to activity. If there are bilateral pars defects or fractures, there is a possibility that the vertebral column might slide forward potentially causing irritation and inflammation to the nerves leaving the spinal canal. This slippage is called spondylolisthesis (listhesis=dislocation). Should this occur,, CT or MRI imaging may be required for diagnosis and surgery needed to stabilize the lumbar vertebrae.

Spondylolysis and spondylolisthesis are common injuries that afflict young athletes. Population studies show that 3-4% of the general young adult population will have spondyloysis, but up to 15% of athletes will have damage that can be seen on plain x-ray. Of those athletes with spondylolysis, almost half will have spondylolisthesis. Athletes increase their risk of developing a stress fracture if they have poor technique, poor posture, lack core stability, strength and flexibility and are guilty of overtraining. While it is a medical mantra that most overuse injuries can be prevented, it’s tough understanding the mechanical stresses that are placed on the lumbar spine of a seven foot tall athlete. With time, Joel Embiid will likely heal nicely and by next fall will be playing in the pros instead if college.

There is a lot to learn from his saga. Athletes often look up to those playing at the next level for guidance and inspiration. Mr. Embiid understood the lesson of listening to one’s body and doing the right thing by it. He might have been able to push through his injury and perhaps his Jayhawks might have won a couple of extra games this year…or he could have turned his back into disaster with a lifetime of pain. Aspiring elite athletes and weekend warriors need to appreciate that playing through pain is not necessarily a winning strategy.

image source: chathamorthopaedics

 

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