Athletic Participation in Children with Symptomatic Spondylolysis in the New York Area

Abstract

Purpose 

The purpose of this study was to assess athletic activities associated with spondylolysis in children and adolescents in a New York metropolitan tertiary referral center.

Methods 

We retrospectively evaluated 137 consecutive cases of symptomatic spondylolysis presenting to one of two pediatric orthopedic spine surgeons. Ten patients who did not participate in any organized athletics were excluded, leaving 127 children for analysis. Data regarding spondylolysis and athletic participation were gathered for analysis.

Results 

One hundred and twenty-seven patients were analyzed (mean age, 13.9 ± 2.2 yr). All patients had initial x-rays, with nearly all obtaining further advanced level imaging to confirm the diagnosis of spondylolysis. Magnetic resonance imaging was obtained in 42.5% of cases, limited computed tomography scan in 29.1% of cases, and single-photon emission computed tomography scan in 23.6% of cases. The most common location of spondylolysis was at the L5 level (74%), of which 43.6% were bilateral. Of the overall cohort, 2.4% had spondylolysis at multiple levels. The most common athletic activities associated with spondylolysis in this cohort were soccer (19.3%), basketball (17.2%), and lacrosse (9.4%).

Conclusion 

Although previous reports have implicated participation in various sports in the development of symptomatic spondylolysis in children, lacrosse and baseball have rarely been associated with spondylolysis. We found that in the New York metropolitan area, soccer, basketball, lacrosse, baseball, tennis, and football were most commonly associated with spondylolysis. Therefore, we emphasize consideration of spondylolysis in these children if they present with low back pain. These results may be used to counsel parents and young athletes about the possibility of spondylolysis as an etiology of lumbar back pain and in educating coaches, teachers, school nurses, and primary care providers.

Sports-related injuries to the spine are seen with increasing frequency in children and adolescents that participate in organized sports. Up to 38% of adolescent athletes with low back pain have radiographic findings of lumbar spondylolysis (²²), compared with 3.5% to 6% in the general population (^5,28), and the rate of spondylolysis in high-level gymnasts has been reported as high as 12.5% (²³).

Even though several theories on the evolution of spondylolysis have been proposed, it is often thought to be a stress reaction and/or repetitive use injury to the lumbar spine. In young athletes, repetitive trauma can cause a mechanical stress injury of the pars interarticularis and may be the most common cause of low back pain in athletic children and adolescents (⁸). Children and adolescents that are involved in sports that require repetitive hyperextension of the lumbar spine have been proven to be at increased risk (^9,15).

Spondylolysis is frequently managed without surgery. Nonoperative treatment consists of avoidance of hyperextension and axial loading activities for 6 to 8 wk. In addition to aggressive physical therapy, bracing has shown to be effective in some cases. Return to sports in a gradual and supervised manner is essential to prevent reinjury. If nonoperative treatment fails, potential surgical strategies include pars repair or posterior fusion of the symptomatic segment.

There is evidence of a hereditary component of spondylolysis as well as a differential distribution by sex. The male-to-female ratio has been reported to be 2/1 (⁵), with some ethnic variation of a lower prevalence of 2% in the African American population (⁶). Associated spine abnormalities such as spina bifida or atypical sacral facets suggest there may be a congenital component in some cases (³). Concerning sports, previous studies have noted elevated rates of spondylolysis among gymnasts, dancers, martial artists, and weight lifters, all of which are exposed to high levels of lumbar extension and axial loading. Recent retrospective studies have demonstrated that there may be regional differences in athletic activities associated with symptomatic spondylolysis (^1,7,21). The purpose of this study is to assess athletic participation in children who presented with spondylolysis in a northeastern US tertiary referral center to determine whether previously reported patterns of sports participation remain consistent in this region.

PATIENTS AND METHODS

One hundred thirty-seven consecutive cases of spondylolysis were evaluated. Data were collected through a retrospective chart review and were surveyed for participation in organized sport activities (outside of school gym class), level of spondylolysis, radiographic imaging used for diagnosis, sex, and age at diagnosis. Although this study is retrospective, the data regarding sports participation were collected prospectively and documented as part of a focused sports history obtained in cases presenting with pediatric and adolescent low back pain, and therefore not subject to recall bias. Ten patients who did not participate in any organized athletics were excluded, leaving 127 children for inclusion in this study. Before initiation of data collection, the study was reviewed and approved by the hospital institutional review board.

All patients presented to one of two pediatric orthopaedic spine surgeons at a single tertiary care academic orthopaedic center between the years 2007 and 2011. Diagnosis of spondylolysis was made on the basis of history and clinical examination, and it was confirmed with radiographic studies. All patients included were symptomatic with low back pain and were managed with a conservative treatment plan. Four patients with Meyerding grade II spondylolisthesis or greater (e.g., slippage >25%) (¹⁸) were excluded. Additional exclusion criteria included previous spine surgery or patients with skeletal dysplasia.

Statistical analysis

Statistical analysis focused on demographic data obtained from chart review. Descriptive analyses were performed using SPSS 17.0 (SPSS Inc., Chicago, IL), including calculation of means, medians, ranges, and cross-tabulation.

RESULTS

One hundred and twenty-seven patients were evaluated in this study with an average age of 13.9 ± 2.2 yr, ranging from 8 to 18 yr old. There were 90 males (71%) and 37 females (29%). All patients had plain x-rays with nearly all obtaining further advanced level imaging to confirm the diagnosis of spondylolysis. Magnetic resonance imaging (MRI) was obtained in 42.5% of cases, lumbar computed tomography (CT) scan in 29.1%, and single-photon emission computed tomography (SPECT) scan in 23.6% of cases (Table 1). In most cases, spondylolysis was located at level L5 (94/127, 74%) or level L4 (28/127, 22.1%); L3 accounted for 1.6% (2/127) of cases. In 2.4% (3/127) of cases, multiple levels were affected. In total, 71 (71/127, 55.9%) unilateral lesions and 56 (56/127, 44.1%) bilateral lesions were detected (Table 2). The most common athletic activities associated with spondylolysis in the New York area cohort were soccer (19.3%), basketball (17.2%), and lacrosse (9.4%). Also, baseball (8.9%), tennis (8.3%), and football (6.8%) were found to be highly prevalent in this cohort of adolescents with spondylolysis. Table 3 displays the prevalence of all athletic sports activities in this cohort.

TABLE 1: Imaging modalities obtained in 127 adolescent athletes with spondylolysis in New York.

TABLE 2: Levels of spondylolysis for 127 adolescent athletes in New York.

TABLE 3: Sports played (by self-report) by 127 adolescent athletes with spondylolysis in New York.

DISCUSSION

There exists a wide variety in available literature regarding noted associations between various athletic activities and spondylolysis. In fact, cohorts of patients with spondylolysis have previously been reported with respect to individual sport (Table 4) or by multiple sports but in a single geographic region (Table 5).

TABLE 4: Incidence of spondylolysis for athletes as reported by region.

TABLE 5: Low back pain and spondylolysis as reported by various sports played.

Several reports have investigated incidence of spondylolysis in uniformly controlled cohorts of athletes participating in specific sports. Elevated incidence of spondylolysis has been reported in sports of particular interest because they frequently involve high levels of truncal flexibility and axial loading of the lumbar spine in extension. Multiple reports (^2,4,12,27) have indicated a high incidence of spondylolysis in gymnasts, ranging from 9% to 21%. It is clear from these data, however, that spondylolysis should be considered in the differential diagnosis of low back pain in other athletes as well.

A careful review of previous studies demonstrated differences in incidence rates of symptomatic spondylolysis among various sports, the rates of which varied by region based on the popularity of those sports in each region. Although the incidence of symptomatic spondylolysis may be more common in gymnastics compared with other sports, much larger numbers of adolescent athletes participate in soccer, basketball, and lacrosse in the northeastern United States. Therefore, reports from the United States (^1,3,13,19) have noted more frequent associations with basketball, weight lifting, baseball, and football, in addition to gymnastics. Conversely, international literature (^20,23,25,26) has shown associations with soccer, gymnastics, and tennis. In Japan, for instance, there was a high incidence of participation in judo (⁹), whereas this was not true of case series from other countries where judo is less popular, further elucidating a potential regional variation based on activity popularity. It can be surmised that spondylolysis should be considered a potential diagnosis for all athletes presenting with low back pain, regardless of sport. Furthermore, incidence rates of sports participation in children and adolescents with spondylolysis may vary on the basis of sport popularity in a given region. Clinicians, parents, coaches, and athletes should be aware of this risk in a young athlete who complains of significant low back pain. The six most common sports identified in our population were soccer, basketball, lacrosse, baseball, tennis, and football.

A limitation of this study is its retrospective design, making it impossible to control for potential confounding variables or patients who play multiple sports. Another weakness is that this study reflects the practice of two pediatric orthopaedic surgeons at a single institution only. Therefore, although this precisely reports on associated sports in New York City, patient demographics, race, and other socioeconomic variables may have been influenced by referral patterns and practice demographics.

Strengths include a homogeneous population from a large tertiary musculoskeletal care facility. This allows us to draw conclusions about sports participation by children with spondylolysis in the greater New York metropolitan area, in which there is a gap in existing knowledge concerning local sports participation in patients with spondylolysis. Furthermore, all patients were symptomatic and confirmed by imaging, conferring clinical relevance to this cohort. Although retrospectively analyzed, data for this study were collected prospectively and entered in the medical record, so recall bias was mitigated.

Our cohort contained several patients who played lacrosse and baseball. Although these sports have a higher prevalence of injuries of the shoulder girdle and the hip (¹⁴), they have not been commonly reported in conjunction with symptomatic spondylolysis in the young athlete. Only Blanda et al. (³) have mentioned baseball as a high-risk sport for spondylolysis in 1993. Lacrosse has not been reported as having associations with back pain to date. In the New York metropolitan area, both sports were highly represented in our cohort of symptomatic patients diagnosed with spondylolysis, largely because of their universal popularity in this region.

Interestingly, only 10 patients of the original 137 (7.3%) with symptomatic spondylolysis were excluded from our study because they did not report any organized sports participation. In other words, patients presenting with symptomatic spondylolysis at our institution were almost universally involved in at least one organized athletic activity, which may have been a contributing cause of injury.

In conclusion, despite previous reports of elevated incidence of spondylolysis in sports requiring high levels of truncal flexibility and loading of the spine in extension (e.g., gymnastics and ballet), we have shown the highest prevalence of spondylolysis in our region in children who participate in soccer, basketball, and lacrosse. Baseball, tennis, and football were commonly associated as well, and all six of these sports are universally popular in New York. This highlights that spondylolysis may not be unique to any one sport or movement pattern in particular; rather, spondylolysis can occur in adolescents who participate in a variety of sports. In the northeastern United States, much larger numbers of adolescent athletes participate in soccer, basketball, and lacrosse. It is therefore not surprising that these sports were associated with overall larger frequency of patients referred for treatment for spondylolysis. These results should be used to counsel parents and young athletes during evaluation of the adolescent athlete for low back pain. In addition, these data may help increase awareness of parents, coaches, teachers, school nurses, and primary care providers about this common cause of low back pain in the adolescent athlete.

The authors declare that they and their family members have no conflict of interest. No institutional, governmental, or corporate source of funding was received for the production of this study. They do not have any professional relationships with companies or manufacturers who will benefit from the results of the present study.

The results of the present study do not constitute endorsement by the American College of Sports Medicine.