Direct surgical repair of spondylolysis in athletes: indications, techniques, and outcomes

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  • 1 Department of Neurosurgery and
  • 2 The Spine Center, Cedars-Sinai Medical Center, Los Angeles, California
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Object

Athletes present with back pain as a common symptom. Various sports involve repetitive hyperextension of the spine along with axial loading and appear to predispose athletes to the spinal pathology spondylolysis. Many athletes with acute back pain require nonsurgical treatment methods; however, persistent recurrent back pain may indicate degenerative disc disease or spondylolysis. Young athletes have a greater incidence of spondylolysis. Surgical solutions are many, and yet there are relatively few data in the literature on both the techniques and outcomes of spondylolytic repair in athletes. In this study, the authors undertook a review of the surgical techniques and outcomes in the treatment of symptomatic spondylolysis in athletes.

Methods

A systematic review of the MEDLINE and PubMed databases was performed using the following key words to identify articles published between 1950 and 2011: “spondylolysis,” “pars fracture,” “repair,” “athlete,” and/or “sport.” Papers on both athletes and nonathletes were included in the review. Articles were read for data on methodology (retrospective vs prospective), type of treatment, number of patients, mean patient age, and mean follow-up.

Results

Eighteen articles were included in the review. Eighty-four athletes and 279 nonathletes with a mean age of 20 and 21 years, respectively, composed the population under review. Most of the fractures occurred at L-5 in both patient groups, specifically 96% and 92%, respectively. The average follow-up period was 26 months for athletes and 86 months for nonathletes. According to the modified Henderson criteria, 84% (71 of 84) of the athletes returned to their sports activities. The time intervals until their return ranged from 5 to 12 months.

Conclusions

For a young athlete with a symptomatic pars defect, any of the described techniques of repair would probably produce acceptable results. An appropriate preoperative workup is important. The ideal candidate is younger than 20 years with minimal or no listhesis and no degenerative changes of the disc. Limited participation in sports can be expected from 5 to 12 months postoperatively.

Abbreviation used in this paper: rhBMP-2 = recombinant human bone morphogenetic protein–2.

Object

Athletes present with back pain as a common symptom. Various sports involve repetitive hyperextension of the spine along with axial loading and appear to predispose athletes to the spinal pathology spondylolysis. Many athletes with acute back pain require nonsurgical treatment methods; however, persistent recurrent back pain may indicate degenerative disc disease or spondylolysis. Young athletes have a greater incidence of spondylolysis. Surgical solutions are many, and yet there are relatively few data in the literature on both the techniques and outcomes of spondylolytic repair in athletes. In this study, the authors undertook a review of the surgical techniques and outcomes in the treatment of symptomatic spondylolysis in athletes.

Methods

A systematic review of the MEDLINE and PubMed databases was performed using the following key words to identify articles published between 1950 and 2011: “spondylolysis,” “pars fracture,” “repair,” “athlete,” and/or “sport.” Papers on both athletes and nonathletes were included in the review. Articles were read for data on methodology (retrospective vs prospective), type of treatment, number of patients, mean patient age, and mean follow-up.

Results

Eighteen articles were included in the review. Eighty-four athletes and 279 nonathletes with a mean age of 20 and 21 years, respectively, composed the population under review. Most of the fractures occurred at L-5 in both patient groups, specifically 96% and 92%, respectively. The average follow-up period was 26 months for athletes and 86 months for nonathletes. According to the modified Henderson criteria, 84% (71 of 84) of the athletes returned to their sports activities. The time intervals until their return ranged from 5 to 12 months.

Conclusions

For a young athlete with a symptomatic pars defect, any of the described techniques of repair would probably produce acceptable results. An appropriate preoperative workup is important. The ideal candidate is younger than 20 years with minimal or no listhesis and no degenerative changes of the disc. Limited participation in sports can be expected from 5 to 12 months postoperatively.

Abbreviation used in this paper: rhBMP-2 = recombinant human bone morphogenetic protein–2.

Spondylolysis is usually an asymptomatic pars interarticularis defect caused by a stress fracture in one or both sides of the neural ring. These fractures can lead to stimulation of the free nerve endings and cause significant back pain, mostly in young athletes ages 12–16 years.1,6 The goals of treatment are the alleviation of pain and the restoration of stability. Conservative management with activity restriction for pain control followed by 3–6 months of lordotic bracing is recommended.10 Despite changes in their daily activities and secession from all strenuous sports, some patients will continue to experience low-back pain. Although the incidence of unmanageable back pain in these competitive athletes is low, some individuals experience debilitating symptoms that could prevent them from pursuing their passion for sports.32 Direct surgical repair of spondylolysis is well documented as an effective treatment in young patients in whom nonoperative treatment fails.1,6,7,28,39

Surgical Repair of Spondylolysis

Indications for Surgical Repair

Surgical repair of spondylolysis is indicated in cases in which low-back pain has not resolved after at least 6 months of activity modification and other nonoperative treatment modalities. Increasing pain, worsening neurological problems, and progressive listhesis also are indications for surgical consideration.10,17 Historically, patients with high-grade spondylolisthesis are considered for multilevel fusions whereas lower grade slips or spondylolysis without any slips is suited for direct repair.32,34 Athletes younger than 20 years are treated with direct repair of the pars defect. Once their pain is controlled, these athletes can start muscle strengthening and range of motion exercises that, with aggressive rehabilitation programs, will have the best chance of returning them to their desired sports.

Preoperative Management

Preoperative studies should illustrate a lytic defect, minimal spondylolisthesis, healthy disc, and negligible movement of the vertebra. Plain anteroposterior and lateral flexion and extension radiographs can clearly demonstrate any degree of slippage or any motion abnormality in the vertebrae.35 These studies should be supplemented with CT scans to define the bony anatomy of the pars.6,10 The addition of SPECT scanning allows the detection of an occult and acute stress fracture that would otherwise be missed on plain radiographs.10 Moreover, it would ensure the presence of metabolic activity in the lysis as the cause of pain, a factor that would increase the surgical chances of osseous union.6 Finally, proper evaluation of the disc is done via MR imaging, which allows further investigation of the canal to rule out any other soft tissue causes of back pain. The routine use of discography is not recommended given the inherit risks of the technique, the fact that the integrity of the disc can be evaluated with MR imaging studies, and the young age of candidates for direct repair. Disc space is considered acceptable if its height is at least two-thirds its normal height and if the slippage is < 10 mm.12 Once the above studies are obtained, direct repair of lumbar spondylolysis is ruled out if there is 1) Grade 2 or higher spondylolisthesis; 2) dysplastic lamina, which could make fixation unlikely; 3) significant disc degeneration at the level of the lysis; and 4) a patient age > 20 years.6,17

Overview of Surgical Techniques

In 1968, Kimura23 reported on bone grafting without internal fixation for spondylolytic defects. Although in 1968 Scott began using a wiring technique to augment bone grafting of the lytic defect, his results were not published until 1986.28,36 Many authors use the Scott wiring method, whereas others have modified the technique to include pedicle screws or cable instead of wire.39 In 1970, Buck7 documented the use of a lag screw across the lysis, and many authors have described their outcomes following this technique. In 1984, Morscher et al.27 reported that the Buck technique of using a 3.5-mm lag screw did not work well with a thin or dysplastic lamina, and they advocated using laminar fixation with a hook screw device specially made for this purpose. That device, a modified Harrington hook that accepts a bone screw, is no longer available from the original manufacturer.6 Other authors have reported using pedicle screws to secure the lamina with either a rod-hook construct or a V-shaped rod under the spinous process.1,12,29,39

Basic Surgical Technique

A standard midline approach to the lumbar spine is performed with care taken to preserve the multifidi attachment to the lateral capsules of the L4–5 and L5–S1 facet joints (unless pedicle screws will be used) and to keep the supraspinous and interspinous ligaments intact. The pars defect is exposed and fibrous tissue is removed. Direct exposure of the pars defect is unnecessary if the lytic defect is in the coronal plane. Internal fixation is applied next. Through a 3-cm window over the posterior inferior iliac spine, a small amount of cancellous bone can be harvested from the iliac crest. Some have reported harvesting cancellous bone from the ala of the sacrum, whereas others use cancellous allograft or off-label rhBMP-2 (Medtronic Sofamor Danek).9,29 The graft is placed as an onlay at the pars defect with care taken not to place the graft ventral to the defect, a location which could compromise the exiting nerve root. Resection of the caudal 3–5 mm of the inferior facet joints of the cephalad vertebra is recommended no matter what internal fixation is selected. Theoretically, this resection reduces the possibility of the inferior facets impinging into the pars region when the patient stands or loads the spine, particularly during hyperextension.

Single Lag Screw Fixation (Buck)

After exposing the pars defect and lamina bilaterally, the inferior edge of the lamina is squared off using a bur.7 A drill is introduced at this edge and is directed upward, forward, and slightly outward to pass through the pars and across the pars defect. Direct visualization should confirm the passing of the drill through the pars defect, and the drill trajectory should remain wholly within bone. A screw of appropriate length is placed through this path, and again the screw must be seen to pass through the pars defect. The screws are partially withdrawn, and an autologous bone graft from the iliac crest is placed in the pars defect. The screws are readvanced forward through the pars defect, securing the bone grafts in place and stabilizing the construct (Fig. 1). A less invasive modification of the Buck method involves stereotactic navigation using the O-arm (Medtronic, Inc.).5 After exposing the spinous process, a trajectory across the pars defect is determined via navigation. A Kirschner wire is passed through this trajectory, and a cannulated screw is placed over the wire across the defect.

Fig. 1.
Fig. 1.

Drawing showing single lag screw fixation as described by Buck, 1970.

Hook Screw Fixation (Morscher)

Autologous cancellous bone grafts from the iliac crest are first placed into the pars defects.27 Then, 2.5-mm holes are drilled at the bases of the superior articular processes bilaterally. Special screws whose tips consist of a cancellous thread and whose bases consist of a machine thread are used. The screw head is designed to allow attachment to a hook that hooks over the lamina. The screws are inclined so that they form a 40° angle with the superior vertebral endplate. The screws are also placed approximately 20° divergent from each other. The hooks are attached to the screw heads and fastened via a lock nut. The distal end of the hook is hooked underneath the lamina. The lock nut is tightened to achieve appropriate compression over the defect (Fig. 2).

Fig. 2.
Fig. 2.

Drawing showing hook screw fixation as described by Morscher et al., 1984.

Cerclage Wire Fixation (Scott)

The pars defects, laminae, and transverse processes are exposed.28,36 The soft tissues on the anterior edge of the transverse processes are freed from the transverse processes. The sclerotic margins of the pars defects are drilled down to expose healthy bone, and the transverse process, superior facet, and lamina are decorticated. A 2-mm hole is drilled in the base of each transverse process, and a 4-mm hole is drilled in the base of the spinous process. A wire is passed through the hole in the transverse process and draped superiorly over the top of the transverse process. The other end of the wire is passed through the hole of the spinous process and draped inferiorly around the bottom of the spinous process. The same procedure is performed on the contralateral side. Autologous cancellous bone from the iliac crest is used to fill the pars defect, and strips of corticocancellous bone from the iliac crest are laid over the pars defect beneath the wires, extending from the base of the transverse process to the lamina. The wires are tightened, providing compression and stabilization across the pars defects (Fig. 3).

Fig. 3.
Fig. 3.

Drawing depicting wire fixation as described by Scott, 1987.

Pedicle Screw Cable Fixation (Songer)

The bone graft is inserted into the pars defect between the pedicle above and the lamina below.38 Pedicle screws are placed with the entry point just below the facet joint. A cable is passed underneath the left laminae, threaded through the right pedicle screw head, and finally draped around the cranial end of the spinous process. The 2 ends of the cable are tied together. A second cable is passed in a similar fashion under the right laminae and through the left pedicle screw head. The ends of the cables are crimped to apply tension to the cables (Fig. 4).

Fig. 4.
Fig. 4.

Pedicle screw with cable fixation as described by Songer and Rovin, 1998.

Pedicle Screw Hook Fixation

Using biplanar fluoroscopy, the intersection of the transverse process, superior articular process, and pars interarticularis is cannulated with an awl for a pedicle screw. The provisional tract is tapped and a screw is placed. A high-speed bur is used to decorticate the area of the pars defect, removing the callus formation. Custom iliac crest allograft or off-label rhBMP-2 is fashioned and carefully tapped into place with a mallet. Sublaminar hooks are applied bilaterally and connected to the pedicle screw using a titanium rod. The rod is affixed to the construct using set screws, which are then tightened to the manufacturer's recommended torque (Fig. 5).39

Fig. 5.
Fig. 5.

Posterior (A) and inferior (B) views of the pedicle screw hook fixation as described by Tokuhashi and Matsuzaki, 1996. Postoperative lateral radiograph (C) showing bilateral pedicle screw hook construct at L-5 to correct a pars defect.

A minimally invasive modification of this method involves placing the pedicle screws under fluoroscopy by using Jamshidi needles and cannulated screws.29 Laminar hooks are placed underneath the lamina and connected to the pedicle screws.

Pedicle Screw Rod Fixation

After exposing the pars defect, transverse process, and lamina, these areas are decorticated with a high-speed drill. Pedicle screws are placed bilaterally using a standard technique. The autologous bone grafts from the iliac crests are placed in the pars defects. A U-shaped rod is placed underneath the spinous process of the affected level, and the ends of the rod are secured to each pedicle screw. Tightening the rod to the screws provides compression and stabilization across the pars defects (Fig. 6).12

Fig. 6.
Fig. 6.

Sagittal (left) and axial (right) positioning of the pedicle screw rod instrumentation as described by Gillet and Petit, 1999.

Postoperative Routine

The postoperative course and radiographic studies are managed and tailored by each surgeon and his or her rehabilitation team. In the early postoperative period, most authors have recommended plain radiographs for asymptomatic patients and CT or MR imaging studies only if symptoms persist or new symptoms appear; however, fusion and attenuation of pars fractures are mostly assessed 3–6 months from surgery by performing CT scanning.5,12,29,32 Early mobility and ambulation, as well as the avoidance of heavy lifting and strenuous activities for the first 3 months, are highly encouraged.5,12,29 Additionally, patients are discouraged from any hyperextension or flexion movement in the first 3 postoperative months.6,12 As regards to postoperative physical therapy, the literature does not provide enough reliable data; some authors recommend avoiding any physical therapy exercises as long as 3 months from the operation.6,29 As most patients are younger adult and teenage athletes, however, they typically have a fast recovery and are able to return to sports conditioning within 6 months of their operations.5,12,29,32

At our institution, we follow up patients with plain anteroposterior/lateral and oblique radiographs 4 and 10 weeks from the surgery and with CT scanning in 6 months to confirm pars stabilization. Additionally, we gradually ease them into physical therapy exercises within 4 weeks after surgery while a team of physiatrists strictly monitors their progress. A team of pain specialists weans them from all narcotics within the first 2 months and, in general, by 10 weeks after surgery they are eased back into their sport activities but with limitations. They are fully released to competitive activities within 5–6 months postoperation.

In the literature, many studies outline the natural history, nonoperative treatment, and prevalence of lumbar spondylolysis in athletes. However, the literature lacks a review article on the most common surgical techniques for pars fractures and their respective outcomes in athletes. The objective in the present study was to review the surgical techniques for and outcomes of the treatment of symptomatic spondylolysis in athletes.

Methods

Literature Review

Both the PubMed and MEDLINE databases were searched to identify articles that had been published between 1950 and 2011 which were pertinent to the methods and outcomes of the surgical treatment of spondylolysis in athletes. The key words used in the search were “spondylolysis,” “pars fracture,” “repair,” “sports,” and/or “athlete.” Inclusion criteria were full-length English-language papers or abstracts, surgical treatment, athlete outcomes, prospective studies, and retrospective studies. Exclusion criteria were non–English-language papers or abstracts and inadequate information about outcomes and/or surgical treatment. The efficacy of the surgical treatment of spondylolysis in athletes was clarified. The primary end points were descriptions of the procedures in and the outcomes of surgical treatment.

An initial search using the key words “spondylolysis” and/or “sport” returned 262 articles. The search was further limited to the English-language literature (223 articles) and a patient age of 24 years or younger (123 articles). Two separate authors (D.D. and A.S.) reviewed abstracts from these articles, yielding 123 articles for detailed review.

Of these 123 articles, 105 were excluded from analysis because they failed to meet the surgical treatment criterion or to report postoperative outcomes. The remaining 18 articles were included in our analysis. Articles were reviewed for data on methodology (retrospective vs prospective), type of treatment, number of patients, mean patient age, and mean follow-up. Specifics on the patient and the fracture included which competitive sport, level of fracture, degree of spondylolisthesis, complications, and need for reoperation. Clinical outcome data, based on patient reporting and preoperative evaluation, were also recorded when available. In addition, we used modified Henderson criteria that subjectively assessed the patient's pain and ability to return to sports (Table 1).16

TABLE 1:

Subjective assessment of pain and the ability to return to work and sporting activities

GradeDescription
excellentno pain; return to normal occupation & normal sport
goodoccasional pain after strenuous activity; return to normal occupation & less strenuous sport
poorpain persists; unable to return to occupation & participate in sport

Statistical Analysis

All descriptive statistics were calculated using JMP 7.02 (SAS Institute). Averages for age, duration of follow-up, and Henderson criteria were calculated. Additionally, studies documenting patient-reported outcomes were summarized.

Illustrative Cases

History and Examination

A 23- and a 19-year-old male professional athlete both presented with several-year histories of ongoing and worsening low-back pain. At that time, both patients were being considered for competition at the highest level, and they described their symptoms as worsening with increased activity and training. The main symptom was primarily axial midlumbar back pain with occasional radiation into the gluteal region. It was aggravated by lumbar hyperextension and rotation positions and was relieved by rest. Prior to our evaluation, both patients had undergone nonoperative treatment including exhaustive physical therapy, core body strengthening, transcutaneous electrical nerve stimulation, massage, bracing, and trigger point injections. Both denied experiencing any weakness, radicular symptoms, or bowel or bladder incontinence. Each had been treated with intermittent extended periods of rest and inactivity but the symptoms would recur once training was restarted. In light of their high performance sports demands, each patient refused any invasive needle injections and permanent activity limitations or modifications. Subsequent advanced imaging was performed, and CT scans of the lumbar spine in both patients demonstrated bilateral L-5 pars fractures (Fig. 7). A SPECT CT scan confirmed increased activity at the bilateral pars fractures. Lateral flexion and extension lumbar spine radiographs showed no evidence of significant dynamic spondylolisthesis, and MR imaging showed preserved discs at L4–5 and L5–S1. Additionally, there were no signs of significant central or foraminal stenosis.

Fig. 7.
Fig. 7.

Illustrative case. Preoperative sagittal (A and B) and axial (C) reconstruction images showing bilateral L-5 spondylolytic defects.

After a discussion of each patient's high functional demands and an explanation of the procedure's risks and benefits, we agreed to perform an intrasegmental bilateral pars repair using a pedicle screw rod fixation technique in each patient.

Operation

Using a standard limited midline approach centered over the L-5 lamina, we exposed the bilateral pars pseudarthroses with care not to disturb the facet capsule of L4–5. Under microscopic visualization, we used a high-speed drill bit to resect the sclerotic bony ends of the pars fracture. The underlying L-5 nerve root was identified and decompressed as it traversed the foramen. Pedicle screws were inserted into the bilateral L-5 pedicles in a laterally based trajectory to avoid facet abutment. An appropriately contoured curved rod was passed across the midline under the interspinous ligament and spinous process of L-5. The rod was affixed to each screw, causing direct compression across the pars facture sites. Once the instrumentation was secured, the bilateral pars region was grafted with locally harvested autograft (and demineralized bone matrix, if necessary).

Postoperative Course

Following the operation, each patient gradually returned to regular activity within 4 weeks under a strict physical therapy regimen. Follow-up radiographs were obtained (Fig. 8). Both patients were completely weaned off narcotic medications and returned to sports conditioning for the next 8–10 weeks. A full return to competitive sports occurred at approximately 5 months posttreatment.

Fig. 8.
Fig. 8.

Illustrative case. Postoperative anteroposterior (left) and lateral (right) radiographs showing positioning of the pedicle screw rod instrumentation.

Results

We identified 9 studies that specifically included athletes. One of these studies was a case report, whereas the rest were case series. One was a prospective study and the rest were retrospective. All studies involved surgical treatment. Nine studies of nonathletes were used to compare the results of the techniques applied to repair spondylolysis; all of these studies were retrospective case series involving surgical treatment. Tables 2 and 3 show the outcomes of surgical treatment in athletes and nonathletes. Eighty-four athletes and 279 nonathletes with a mean age of 20 and 21 years, respectively, were reviewed (Fig. 9). Cricket, soccer, and baseball were the most common athletics described in the studies reviewed (Fig. 10). The studies did not consistently document when a spondylolisthesis was present, but among the studies that did, there seemed to be a trend toward a higher likelihood of spondylolisthesis in nonathletes. Most of the fractures were at L-5 in both patient groups, specifically 96% in athletes and 92% in nonathletes. The average follow-up period was 26 months for athletes and 86 months for nonathletes. According to the modified Henderson criteria, 84% (71 of 84) of the athletes returned to their sports activities (Fig. 11). The time interval until their return ranged from 5 to 12 months. Of the remaining athletes, 7 returned to a less strenuous sport and 6 did not return to any sports in the study period.

TABLE 2:

Literature review of athletes with spondylolysis who underwent direct surgical repair*

Authors & YearNo. of PtsDirect Repair Method (no. of pts)SportMean Age in Yrs (range)% Pts w/Bilat Defects% Pts w/SpondylolisthesisNo./Vertebral LevelAverage FU in Mos (range)Outcome in % of Pts
Hardcastle et al., 199210Buckcricket20.9 (15–25)50109 L5, 1 L417.9 (6–47)90
Ranawat et al., 20039Buckcricket21.750NANA68 (22–120)100
Reitman & Esses, 20024Bucksoccer, gymnastics, baseball17.8 (13–22)NA25L526 (21–38)100
Noggle et al., 20085pedicle screws, rod & laminar hookvariety15.8 (15–17)100NAL57.2 (6–9)100§
Debnath et al., 200322modified Buck (19) & Scott (3)variety20.2 (15–34)68NANA795 (Buck), 0 (Scott)
Brennan et al., 20081modified Buckbaseball17100100L56100
Bozarth et al., 20073Scott & Songersoccer, baseballNANANANANA100
Nozawa et al., 200320Scottvariety23.7 (12–37)NANA19 L5, 2 L4, 1 L4–53.5 (1.38.6)**75
Gillet & Petit, 199910pedicle screws, V-shaped rodtennis††26 (16–48)NA09 L5, 1 L435 (7–64)60§

* FU = follow-up; NA = not available; Pts = patients.

† If no number is listed in parentheses, all patients underwent listed method of repair.

‡ Returned to preoperative sports performance (athletes).

§ Asymptomatic or with minimal symptoms.

¶ Excellent outcome by Henderson criteria, that is, no pain; return to normal occupation and normal sport.

** Values expressed in years.

†† One athlete.

TABLE 3:

Literature review of nonathletes with spondylolysis who underwent direct surgical repair

Authors & YearNo. of PtsDirect Repair MethodMean Age in Yrs (range)% Pts w/Bilat Defects% Pts w/SpondylolisthesisNo./Vertebral LevelAverage FU in Yrs (range)Outcome in % of Pts
Ivanic et al., 2003113Morscher16.9 (7.5–39)NA95111 L5, 1 L4, 1 L4–510.9 (1–15.5)93*
Johnson & Thompson, 199222modified Scott15.5918221 L5, 1 L4473
Schlenzka et al., 200625Scott18.2NANA20 L5, 3 L4, 2 L314.8 (11–16)64*
23segmental fusion16.1NANAall L515 (13–19)87*
Songer & Rovin, 19987pedicle screws & cables20.5 (12–32)NA43all L525.5 (19–37)71*
Buck, 197016BuckNANANANANA81*
Kakiuchi, 199716pedicle screws, rod & laminar hook32.4 (12–60)NA3813 L5, 1 L2–3, 1 L3–4, 1 L325.2 (24–28)81*
Debusscher & Troussel, 200723pedicle screws, rod & laminar hook34 (16–52)1005220 L5, 3 L459 (6–113)100§ ≤30 yrs old (12 pts); 73§ >30 yrs old (11 pts)
Altaf et al., 201120pedicle screws, U-shaped rod13.9 (9–21)NA45all L54 (2.3–7.3)90§
Askar et al., 200314Scott17.4 (13–24)1003612 L5, 1 L4, 1 L310.9 (8–15)43*

* Asymptomatic or minimal symptoms.

† Excellent outcome according to Henderson criteria, that is, no pain; return to normal occupation and normal sport.

‡ Values expressed in months.

§ Excellent according to Oswestry Disability Index criteria (0%–20% disability index).

Fig. 9.
Fig. 9.

Bar graph illustrating age distribution (in years) of athletic patients who underwent direct surgical repair in the reviewed studies.

Fig. 10.
Fig. 10.

Pie graph illustrating the distribution of the types of sports played by patients who underwent direct surgical repair in the reviewed studies.

Fig. 11.
Fig. 11.

Bar graph illustrating the subjective assessment of pain and the ability to return to work and sporting activities (from Henderson, 1966) in the reviewed studies.

Age-Related Outcomes

Direct surgical repair of spondylolysis has largely focused on patients younger than 30 years old. Most authors theorize that the outcomes are better for younger patients because their discs are less degenerative and more suitable for direct repair. The study by Ivanic et al.17 is most often cited as evidence for a 20-year age cutoff. In that study, 113 patients were treated using the Morscher technique. Of the 20 treated patients older than 20 years of age, 35% had pseudarthroses, whereas only 8.6% of the 93 patients younger than 20 years had pseudarthroses. There was persistent postoperative pain in 4 of the 20 patients older than 20 years and in only 4 of the 93 patients younger than 20 years. In a case series by Nozawa et al.,30 among 20 athletes treated using a Scott wiring technique, 13 were older than 20 years of age. Among the treated patients, 70% of those older than 20 years of age had an excellent clinical outcome, whereas 86% of the patients 20 years old or younger had an excellent clinical outcome.

Johnson and Thompson21 used a modified Scott technique and found “satisfactory” results for all 19 patients under 25 years of age. In the patients older than 25 years, 2 of 3 had “poor” results. Debusscher and Troussel9 discussed their case series in which they used pedicle screw hook fixation with 12 patients 30 years of age or younger and 11 patients older than 30 years. In the younger group, all patients had a good or excellent clinical outcome, whereas only 73% of patients in the older group had a similar outcome.

Outcomes of Specific Techniques

Single Lag Screw Fixation (Buck)

Outcomes following the Buck fixation have been widely published for both nonathletes and professional athletes in a variety of sports. The published outcomes for athletes in our extensive literature search consistently showed that > 90% of patients eventually return to their preoperative sports performance.5,8,14,31,32 Outcomes for nonathletes show similar but slightly lower success rates, possibly because athletes are often known to be highly motivated in their recovery process.7

Hook Screw Fixation (Morscher)

The literature is lacking in data on outcomes following hook screw fixation in athletes, but there are several reports on the procedure in nonathletes. In a retrospective study of 113 patients, Ivanic et al.17 found that > 90% of patients had excellent clinical outcomes after hook screw fixation with a mean follow-up of 10.9 years.

Cerclage Wire Fixation (Scott)

Many authors have published outcomes of the Scott method in both athletes and nonathletes. The data consistently show outcomes that are not as favorable as those for other direct repair techniques. Many studies show between 60% and 80% of patients having an excellent clinical outcome.3,21,30,35

Pedicle Screw Cable Fixation (Songer)

In 1998, Songer and Rovin38 published a small study showing the outcomes associated with a new pedicle screw cable fixation technique. The study involved 7 patients, 5 of whom had excellent clinical outcomes. Bozarth et al.4 modified the Songer technique in 3 patients and found that they all had excellent clinical outcomes. Our literature search did not yield further data on this technique.

Pedicle Screw Hook Fixation

Data from several retrospective studies on pedicle screw hook fixation with small numbers of nonathlete patients have been published. Noggle et al.29 showed an excellent clinical outcome in 5 of 5 patients. Two slightly larger studies, one by Kakiuchi22 and another by Debusscher and Troussel,9 showed about 80% of patients having an excellent clinical outcome.

Pedicle Screw Rod Fixation

Data on pedicle screw and rod fixation have been published by 2 different authors. Gillet and Petit12 used a V-shaped rod, whereas Altaf et al.1 used a U-shaped rod. Both were small studies of 10 and 20 patients, respectively. Gillet and Petit found excellent clinical outcomes in only 60% of patients, whereas Altaf et al. documented excellent outcomes in 90% of patients. It is difficult to draw conclusions about this technique with only 2 small studies.

Discussion

Sports involving repetitive hyperextension of the spine along with axial loading seem to most predispose athletes to spondylolysis. Specifically, these actions are thought to overload the posterior elements, leading to pars fractures.24 Nearly all sports carry some elevated risk of spondylolysis. The sports with relatively high incidences of such injuries include gymnastics, football, hockey, diving, wrestling, baseball, volleyball, racquet sports, and weightlifting, with gymnastics and football generally considered to have the highest risk.2,6,8,10,11,18–20,24–26,28,30 Two studies have estimated the incidence of low-back pain in athletes with spondylolysis to be 79.8% in high school football players, 72.5% in high school rugby players, and 80.5% in college football players.18,19 Soler and Calderón37 documented the prevalence of spondylolysis in Spanish professional athletes, and the results are summarized in Table 4. According to these data, activities such as rowing, gymnastics, volleyball, weightlifting, and track and field carry the highest risk of symptomatic spondylolysis.

TABLE 4:

Prevalence of asymptomatic and symptomatic spondylolysis in elite athletes from Spain

SportNo. of AthletesPrevalence of Spondylolysis (no. [%])Athletes w/Spondylolysis Who Were Symptomatic (no. [%])
track & field (races, heptathlon, & others)68569 (8.9)32 (52.5)
gymnastics23533 (14.0)19 (57.6)
combat sports (boxing, karate, & others)20723 (11.1)9 (39.1)
swimming17618 (10.23)6 (33.3)
weightlifting8511 (12.9)6 (54.5)
rowing7713 (16.88)8 (61.5)
volleyball707 (10.0)4 (57.1)

Gymnastics is widely considered to carry one of the highest risks for pars fractures, probably because gymnasts regularly combine hyperextension of the spine with large axial forces. Studies have shown the incidence of spondylolysis among gymnasts to be anywhere from 11% to 14%.20,37 Hall13 recorded the impact forces produced by collegiate gymnasts executing various acrobatics using a force pad. Back handsprings led to the greatest mean lumbar curvature, as well as to a high mean force of vertical impact. Other maneuvers, such as front and back walkovers and front handsprings, resulted in large lumbar curvatures with front handsprings carrying a particularly high impact force.13

The incidence of pars fractures has been found to be up to 15% in college football players.26 Although various positions are affected, linemen seem to be at particular risk for spondylolysis. Ferguson et al.11 hypothesized that this finding was due largely to the motions of blocking, specifically extension of the lumbar sacral spine combined with the axial force of collision. Unlike other positions, linemen experience these stresses regularly and repeatedly with every play, ostensibly placing them at particular risk.

In cricket, fast bowlers seem to be most at risk for spondylolysis. One study found that the incidence of pars interarticularis defects among young fast bowlers was 55%.14 In this case, hyperextension, lateral flexion, and thoracolumbar rotation in combination with the jerk force of bowling were hypothesized to cause spondylolysis.31 Repeated as many as 500 times per week, these motions put immense stresses on the spine.15

Tennis also carries an elevated risk of pars injury. Hyperextension is thought to be the cause of these injuries, specifically those that occur during a serve.25 In attempts to “top spin” a serve, this hyperextension may be even more pronounced. The modern forehand shot and two-handed play with its repetitive rotation also result in additional hyperextension.2

Baseball has also been associated with pars fractures. In professional Japanese baseball players, the incidence of pars fractures has been anywhere from 27.5% to 53.5%, far higher than in the general population.34 Similar to injuries seen in cricket, the pitching motion is hypothesized to cause most pars fractures, probably as a result of hyperextension of the spine and the rapid rotation associated with launching the ball.

Return to Athletics

For the athlete undergoing direct repair of spondylolysis, a return to preinjury athletic performance is often the primary goal. Authors reporting on surgical outcomes in athletes with these injuries use a variety of methods to measure outcome. In 1966, Henderson16 proposed a set of criteria to measure the outcome in patients undergoing surgical treatment for spondylolisthesis (Table 1). These criteria are still used today and provide an overall view of outcomes in a large patient population.

Although the literature contains limited data on athletes, the available data reveal that professional athletes can undergo various methods of surgical treatment and achieve excellent outcomes and a return to their previous athletic performance (Fig. 12). Buck's is a popular technique for the surgical treatment of spondylolysis in athletes, with half of the studies on athletes utilizing this technique. The procedure also yields consistently high outcomes, with > 90% of athletes able to return to their previous athletic performance.5,8,15,31,32 Other methods, such as pedicle screw hook fixation, show potential, but the limited available data make it difficult to draw conclusions.

Fig. 12.
Fig. 12.

Bar graph illustrating the published results of techniques used to repair spondylolysis in athletes.

There is no consensus on when an athlete can return to play. In a survey, Scoliosis Research Society members reported greatly varied recommendations regarding a return to sports following surgery for scoliosis.33 The most common recommendation for a noncontact, low-impact sport was after 6 months. For contact sports, the most common recommendation was after 12 months; however, 13% of responding clinicians recommended never returning. For collision sports, 60% of responding clinicians did not favor ever resuming the sport.

After fusion for spondylolisthesis surgery, the recommendations of the Scoliosis Research Society members were similar to those made following scoliosis surgery. The most common recommendation for a noncontact, low-impact sport was after 6 months. For contact sports, the most common recommendation was after 12 months, although 14% of responding clinicians who had treated low-grade slips and 21% of responding clinicians who had treated high-grade slips recommended never returning. For collision sports, between 49% and 58% of responding clinicians did not favor ever resuming the sport.

This survey illustrates the wide differences of opinion regarding the timing and safety of returning an athlete to his or her sport following spinal surgery. Factors that must always be considered include the amount of time that has elapsed since surgery, the instrumentation that has been used, and the degree of contact or collision common to the athlete's sport, which could endanger the surgical repair and, consequently, the athlete's safety.

Complications of the Techniques

Authors report a variety of potential complications with these techniques. Hardware failure is uncommon but has been reported with all of the techniques, including screw breakages, wire and cable fractures, and wires pulled out from the transverse process.30,32,38 For example, Ranawat et al.31 reported the case of a professional fast bowler who had undergone L3–S1 fusion after conservative treatment had failed. During play the next season, the patient noticed swelling in the lumbar region. It was discovered that a screw had broken, and the patient was taken to surgery to remove the screw. Screw breakage happened a second time during the season, and thus all hardware from the fusion was removed.

Nonunion has been reported in several cases.8,17,21 Pseudarthroses have been reported not uncommonly, with Ivanic et al.17 finding that 15 of 113 patients treated with the Morscher technique had pseudarthroses and 5 required second surgeries. Rarely, authors report persistent low-back pain after surgery.38 In general, the available studies on direct repair techniques are too small to accurately gauge complication rates.

Conclusions

For a young athlete with a symptomatic pars defect, any of the described techniques of repair will probably produce acceptable results. An appropriate preoperative workup is important. The ideal candidate is younger than 20 years of age with minimal or no listhesis and no degenerative changes of the disc. Limited participation in sports can be expected from 5 to 12 months postoperatively. Familiarity with the various fixation techniques and anticipation of the anatomical variations will allow the surgeon to select the most appropriate surgical technique for repairing lytic defects in the lumbar spine.

Disclosure

Dr. Rasouli is a consultant for DePuy Spine and Synthes. Dr. Kim is a consultant for EBI/Biomet. Dr. Johnson is a consultant for Alphatec, Pioneer, and Spine Wave.

Author contributions to the study and manuscript preparation include the following. Conception and design: Drazin. Acquisition of data: Drazin, Jeswani, Ching, Rosner, Rasouli. Analysis and interpretation of data: Drazin, Shirzadi, Ching, Rasouli, Pashman. Drafting the article: Drazin, Shirzadi, Jeswani, Ching, Rosner, Kim. Critically revising the article: Johnson, Drazin, Shirzadi, Jeswani. Reviewed submitted version of manuscript: Drazin, Johnson, Rasouli, Kim, Pashman. Study supervision: Johnson.

Acknowledgments

The authors thank Sherry Brandon, for her help in preparing the illustrations in this paper, and Harry Ching and Jack Rosner, for their help with the figures and tables. In addition, they would like to thank Wendy Marx for her editorial support.

References

  • 1

    Altaf F, , Osei NA, , Garrido E, , Al-Mukhtar M, , Natali C, & Sivaraman A, : Repair of spondylolysis using compression with a modular link and screws. J Bone Joint Surg Br 93:7377, 2011

    • Search Google Scholar
    • Export Citation
  • 2

    Alyas F, , Turner M, & Connell D: MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. Br J Sports Med 41:836841, 2007

    • Search Google Scholar
    • Export Citation
  • 3

    Askar Z, , Wardlaw D, & Koti M: Scott wiring for direct repair of lumbar spondylolysis. Spine (Phila Pa 1976) 28:354357, 2003

  • 4

    Bozarth GR, , Fogel GR, , Toohey JS, & Neidre A: Repair of pars interarticularis defect with a modified cable-screw construct. J Surg Orthop Adv 16:7983, 2007

    • Search Google Scholar
    • Export Citation
  • 5

    Brennan RP, , Smucker PY, & Horn EM: Minimally invasive image-guided direct repair of bilateral L-5 pars interarticularis defects. Neurosurg Focus 25:2 E13, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Brigham CD: Direct repair of lumbar spondylolysis in athletes. Oper Tech Sports Med 13:108113, 2005

  • 7

    Buck JE: Direct repair of the defect in spondylolisthesis. Preliminary report. J Bone Joint Surg Br 52:432437, 1970

  • 8

    Debnath UK, , Freeman BJ, , Gregory P, , de la Harpe D, , Kerslake RW, & Webb JK: Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes. J Bone Joint Surg Br 85:244249, 2003

    • Search Google Scholar
    • Export Citation
  • 9

    Debusscher F, & Troussel S: Direct repair of defects in lumbar spondylolysis with a new pedicle screw hook fixation: clinical, functional and Ct-assessed study. Eur Spine J 16:16501658, 2007

    • Search Google Scholar
    • Export Citation
  • 10

    Dunn IF, , Proctor MR, & Day AL: Lumbar spine injuries in athletes. Neurosurg Focus 21:4 E4, 2006

  • 11

    Ferguson RJ, , McMaster JH, & Stanitski CL: Low back pain in college football linemen. J Sports Med 2:6369, 1974

  • 12

    Gillet P, & Petit M: Direct repair of spondylolysis without spondylolisthesis, using a rod-screw construct and bone grafting of the pars defect. Spine (Phila Pa 1976) 24:12521256, 1999

    • Search Google Scholar
    • Export Citation
  • 13

    Hall SJ: Mechanical contribution to lumbar stress injuries in female gymnasts. Med Sci Sports Exerc 18:599602, 1986

  • 14

    Hardcastle P, , Annear P, , Foster DH, , Chakera TM, , McCormick C, & Khangure M, : Spinal abnormalities in young fast bowlers. J Bone Joint Surg Br 74:421425, 1992

    • Search Google Scholar
    • Export Citation
  • 15

    Hardcastle PH: Repair of spondylolysis in young fast bowlers. J Bone Joint Surg Br 75:398402, 1993

  • 16

    Henderson ED: Results of the surgical treatment of spondylolisthesis. J Bone Joint Surg Am 48:619642, 1966

  • 17

    Ivanic GM, , Pink TP, , Achatz W, , Ward JC, , Homann NC, & May M: Direct stabilization of lumbar spondylolysis with a hook screw: mean 11-year follow-up period for 113 patients. Spine (Phila Pa 1976) 28:255259, 2003

    • Search Google Scholar
    • Export Citation
  • 18

    Iwamoto J, , Abe H, , Tsukimura Y, & Wakano K: Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school and college football players: a prospective study. Am J Sports Med 32:781786, 2004

    • Search Google Scholar
    • Export Citation
  • 19

    Iwamoto J, , Abe H, , Tsukimura Y, & Wakano K: Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school rugby players: a prospective study. Scand J Med Sci Sports 15:163168, 2005

    • Search Google Scholar
    • Export Citation
  • 20

    Jackson DW: Low back pain in young athletes: evaluation of stress reaction and discogenic problems. Am J Sports Med 7:364366, 1979

  • 21

    Johnson GV, & Thompson AG: The Scott wiring technique for direct repair of lumbar spondylolysis. J Bone Joint Surg Br 74:426430, 1992

  • 22

    Kakiuchi M: Repair of the defect in spondylolysis. Durable fixation with pedicle screws and laminar hooks. J Bone Joint Surg Am 79:818825, 1997

    • Search Google Scholar
    • Export Citation
  • 23

    Kimura M: [My method of filling the lesion with spongy bone in spondylolysis and spondylolisthesis.]. Seikei Geka 19:285296, 1968. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 24

    Lawrence JP, , Greene HS, & Grauer JN: Back pain in athletes. J Am Acad Orthop Surg 14:726735, 2006

  • 25

    Maquirriain J, & Ghisi JP: The incidence and distribution of stress fractures in elite tennis players. Br J Sports Med 40:454459, 2006

  • 26

    McCarroll JR, , Miller JM, & Ritter MA: Lumbar spondylolysis and spondylolisthesis in college football players. A prospective study. Am J Sports Med 14:404406, 1986

    • Search Google Scholar
    • Export Citation
  • 27

    Morscher E, , Gerber B, & Fasel J: Surgical treatment of spondylolisthesis by bone grafting and direct stabilization of spondylolysis by means of a hook screw. Arch Orthop Trauma Surg 103:175178, 1984

    • Search Google Scholar
    • Export Citation
  • 28

    Nicol RO, & Scott JH: Lytic spondylolysis. Repair by wiring. Spine (Phila Pa 1976) 11:10271030, 1986

  • 29

    Noggle JC, , Sciubba DM, , Samdani AF, , Anderson DG, , Betz RR, & Asghar J: Minimally invasive direct repair of lumbar spondylolysis with a pedicle screw and hook construct. Neurosurg Focus 25:2 E15, 2008

    • Search Google Scholar
    • Export Citation
  • 30

    Nozawa S, , Shimizu K, , Miyamoto K, & Tanaka M: Repair of pars interarticularis defect by segmental wire fixation in young athletes with spondylolysis. Am J Sports Med 31:359364, 2003

    • Search Google Scholar
    • Export Citation
  • 31

    Ranawat VS, , Dowell JK, & Heywood-Waddington MB: Stress fractures of the lumbar pars interarticularis in athletes: a review based on long-term results of 18 professional cricketers. Injury 34:915919, 2003

    • Search Google Scholar
    • Export Citation
  • 32

    Reitman CA, & Esses SI: Direct repair of spondylolytic defects in young competitive athletes. Spine J 2:142144, 2002

  • 33

    Rubery PT, & Bradford DS: Athletic activity after spine surgery in children and adolescents: results of a survey. Spine (Phila Pa 1976) 27:423427, 2002

    • Search Google Scholar
    • Export Citation
  • 34

    Sakai T, , Sairyo K, , Suzue N, , Kosaka H, & Yasui N: Incidence and etiology of lumbar spondylolysis: review of the literature. J Orthop Sci 15:281288, 2010

    • Search Google Scholar
    • Export Citation
  • 35

    Schlenzka D, , Remes V, , Helenius I, , Lamberg T, , Tervahartiala P, & Yrjönen T, : Direct repair for treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in young patients: no benefit in comparison to segmental fusion after a mean follow-up of 14.8 years. Eur Spine J 15:14371447, 2006

    • Search Google Scholar
    • Export Citation
  • 36

    Scott JH: The Edinburgh repair of isthmic (Group II) spondylolysis. J Bone Joint Surg Br 69:491, 1987

  • 37

    Soler T, & Calderón C: The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med 28:5762, 2000

  • 38

    Songer MN, & Rovin R: Repair of the pars interarticularis defect with a cable-screw construct. A preliminary report. Spine (Phila Pa 1976) 23:263269, 1998

    • Search Google Scholar
    • Export Citation
  • 39

    Tokuhashi Y, & Matsuzaki H: Repair of defects in spondylolysis by segmental pedicular screw hook fixation. A preliminary report. Spine (Phila Pa 1976) 21:20412045, 1996

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Contributor Notes

Address correspondence to: J. Patrick Johnson, M.D., The Spine Center, Cedars-Sinai Medical Center, Los Angeles, California 90048. email: Spineexperts@aol.com.
  • View in gallery

    Drawing showing single lag screw fixation as described by Buck, 1970.

  • View in gallery

    Drawing showing hook screw fixation as described by Morscher et al., 1984.

  • View in gallery

    Drawing depicting wire fixation as described by Scott, 1987.

  • View in gallery

    Pedicle screw with cable fixation as described by Songer and Rovin, 1998.

  • View in gallery

    Posterior (A) and inferior (B) views of the pedicle screw hook fixation as described by Tokuhashi and Matsuzaki, 1996. Postoperative lateral radiograph (C) showing bilateral pedicle screw hook construct at L-5 to correct a pars defect.

  • View in gallery

    Sagittal (left) and axial (right) positioning of the pedicle screw rod instrumentation as described by Gillet and Petit, 1999.

  • View in gallery

    Illustrative case. Preoperative sagittal (A and B) and axial (C) reconstruction images showing bilateral L-5 spondylolytic defects.

  • View in gallery

    Illustrative case. Postoperative anteroposterior (left) and lateral (right) radiographs showing positioning of the pedicle screw rod instrumentation.

  • View in gallery

    Bar graph illustrating age distribution (in years) of athletic patients who underwent direct surgical repair in the reviewed studies.

  • View in gallery

    Pie graph illustrating the distribution of the types of sports played by patients who underwent direct surgical repair in the reviewed studies.

  • View in gallery

    Bar graph illustrating the subjective assessment of pain and the ability to return to work and sporting activities (from Henderson, 1966) in the reviewed studies.

  • View in gallery

    Bar graph illustrating the published results of techniques used to repair spondylolysis in athletes.

  • 1

    Altaf F, , Osei NA, , Garrido E, , Al-Mukhtar M, , Natali C, & Sivaraman A, : Repair of spondylolysis using compression with a modular link and screws. J Bone Joint Surg Br 93:7377, 2011

    • Search Google Scholar
    • Export Citation
  • 2

    Alyas F, , Turner M, & Connell D: MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. Br J Sports Med 41:836841, 2007

    • Search Google Scholar
    • Export Citation
  • 3

    Askar Z, , Wardlaw D, & Koti M: Scott wiring for direct repair of lumbar spondylolysis. Spine (Phila Pa 1976) 28:354357, 2003

  • 4

    Bozarth GR, , Fogel GR, , Toohey JS, & Neidre A: Repair of pars interarticularis defect with a modified cable-screw construct. J Surg Orthop Adv 16:7983, 2007

    • Search Google Scholar
    • Export Citation
  • 5

    Brennan RP, , Smucker PY, & Horn EM: Minimally invasive image-guided direct repair of bilateral L-5 pars interarticularis defects. Neurosurg Focus 25:2 E13, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Brigham CD: Direct repair of lumbar spondylolysis in athletes. Oper Tech Sports Med 13:108113, 2005

  • 7

    Buck JE: Direct repair of the defect in spondylolisthesis. Preliminary report. J Bone Joint Surg Br 52:432437, 1970

  • 8

    Debnath UK, , Freeman BJ, , Gregory P, , de la Harpe D, , Kerslake RW, & Webb JK: Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes. J Bone Joint Surg Br 85:244249, 2003

    • Search Google Scholar
    • Export Citation
  • 9

    Debusscher F, & Troussel S: Direct repair of defects in lumbar spondylolysis with a new pedicle screw hook fixation: clinical, functional and Ct-assessed study. Eur Spine J 16:16501658, 2007

    • Search Google Scholar
    • Export Citation
  • 10

    Dunn IF, , Proctor MR, & Day AL: Lumbar spine injuries in athletes. Neurosurg Focus 21:4 E4, 2006

  • 11

    Ferguson RJ, , McMaster JH, & Stanitski CL: Low back pain in college football linemen. J Sports Med 2:6369, 1974

  • 12

    Gillet P, & Petit M: Direct repair of spondylolysis without spondylolisthesis, using a rod-screw construct and bone grafting of the pars defect. Spine (Phila Pa 1976) 24:12521256, 1999

    • Search Google Scholar
    • Export Citation
  • 13

    Hall SJ: Mechanical contribution to lumbar stress injuries in female gymnasts. Med Sci Sports Exerc 18:599602, 1986

  • 14

    Hardcastle P, , Annear P, , Foster DH, , Chakera TM, , McCormick C, & Khangure M, : Spinal abnormalities in young fast bowlers. J Bone Joint Surg Br 74:421425, 1992

    • Search Google Scholar
    • Export Citation
  • 15

    Hardcastle PH: Repair of spondylolysis in young fast bowlers. J Bone Joint Surg Br 75:398402, 1993

  • 16

    Henderson ED: Results of the surgical treatment of spondylolisthesis. J Bone Joint Surg Am 48:619642, 1966

  • 17

    Ivanic GM, , Pink TP, , Achatz W, , Ward JC, , Homann NC, & May M: Direct stabilization of lumbar spondylolysis with a hook screw: mean 11-year follow-up period for 113 patients. Spine (Phila Pa 1976) 28:255259, 2003

    • Search Google Scholar
    • Export Citation
  • 18

    Iwamoto J, , Abe H, , Tsukimura Y, & Wakano K: Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school and college football players: a prospective study. Am J Sports Med 32:781786, 2004

    • Search Google Scholar
    • Export Citation
  • 19

    Iwamoto J, , Abe H, , Tsukimura Y, & Wakano K: Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school rugby players: a prospective study. Scand J Med Sci Sports 15:163168, 2005

    • Search Google Scholar
    • Export Citation
  • 20

    Jackson DW: Low back pain in young athletes: evaluation of stress reaction and discogenic problems. Am J Sports Med 7:364366, 1979

  • 21

    Johnson GV, & Thompson AG: The Scott wiring technique for direct repair of lumbar spondylolysis. J Bone Joint Surg Br 74:426430, 1992

  • 22

    Kakiuchi M: Repair of the defect in spondylolysis. Durable fixation with pedicle screws and laminar hooks. J Bone Joint Surg Am 79:818825, 1997

    • Search Google Scholar
    • Export Citation
  • 23

    Kimura M: [My method of filling the lesion with spongy bone in spondylolysis and spondylolisthesis.]. Seikei Geka 19:285296, 1968. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 24

    Lawrence JP, , Greene HS, & Grauer JN: Back pain in athletes. J Am Acad Orthop Surg 14:726735, 2006

  • 25

    Maquirriain J, & Ghisi JP: The incidence and distribution of stress fractures in elite tennis players. Br J Sports Med 40:454459, 2006

  • 26

    McCarroll JR, , Miller JM, & Ritter MA: Lumbar spondylolysis and spondylolisthesis in college football players. A prospective study. Am J Sports Med 14:404406, 1986

    • Search Google Scholar
    • Export Citation
  • 27

    Morscher E, , Gerber B, & Fasel J: Surgical treatment of spondylolisthesis by bone grafting and direct stabilization of spondylolysis by means of a hook screw. Arch Orthop Trauma Surg 103:175178, 1984

    • Search Google Scholar
    • Export Citation
  • 28

    Nicol RO, & Scott JH: Lytic spondylolysis. Repair by wiring. Spine (Phila Pa 1976) 11:10271030, 1986

  • 29

    Noggle JC, , Sciubba DM, , Samdani AF, , Anderson DG, , Betz RR, & Asghar J: Minimally invasive direct repair of lumbar spondylolysis with a pedicle screw and hook construct. Neurosurg Focus 25:2 E15, 2008

    • Search Google Scholar
    • Export Citation
  • 30

    Nozawa S, , Shimizu K, , Miyamoto K, & Tanaka M: Repair of pars interarticularis defect by segmental wire fixation in young athletes with spondylolysis. Am J Sports Med 31:359364, 2003

    • Search Google Scholar
    • Export Citation
  • 31

    Ranawat VS, , Dowell JK, & Heywood-Waddington MB: Stress fractures of the lumbar pars interarticularis in athletes: a review based on long-term results of 18 professional cricketers. Injury 34:915919, 2003

    • Search Google Scholar
    • Export Citation
  • 32

    Reitman CA, & Esses SI: Direct repair of spondylolytic defects in young competitive athletes. Spine J 2:142144, 2002

  • 33

    Rubery PT, & Bradford DS: Athletic activity after spine surgery in children and adolescents: results of a survey. Spine (Phila Pa 1976) 27:423427, 2002

    • Search Google Scholar
    • Export Citation
  • 34

    Sakai T, , Sairyo K, , Suzue N, , Kosaka H, & Yasui N: Incidence and etiology of lumbar spondylolysis: review of the literature. J Orthop Sci 15:281288, 2010

    • Search Google Scholar
    • Export Citation
  • 35

    Schlenzka D, , Remes V, , Helenius I, , Lamberg T, , Tervahartiala P, & Yrjönen T, : Direct repair for treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in young patients: no benefit in comparison to segmental fusion after a mean follow-up of 14.8 years. Eur Spine J 15:14371447, 2006

    • Search Google Scholar
    • Export Citation
  • 36

    Scott JH: The Edinburgh repair of isthmic (Group II) spondylolysis. J Bone Joint Surg Br 69:491, 1987

  • 37

    Soler T, & Calderón C: The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med 28:5762, 2000

  • 38

    Songer MN, & Rovin R: Repair of the pars interarticularis defect with a cable-screw construct. A preliminary report. Spine (Phila Pa 1976) 23:263269, 1998

    • Search Google Scholar
    • Export Citation
  • 39

    Tokuhashi Y, & Matsuzaki H: Repair of defects in spondylolysis by segmental pedicular screw hook fixation. A preliminary report. Spine (Phila Pa 1976) 21:20412045, 1996

    • Search Google Scholar
    • Export Citation

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