SPINE Volume 39, Number 12, pp E734-E738 ©2014, Lippincott Williams & Wilkins
CASE REPORT
Rationale in the Management of 4-Level Lumbar Spondylolyses With or Without Instability and/or Spondylolisthesis S. Vidyadhara, MS, DNB, FNB
Study Design. Case report. Objective. To report the first case of 4-level lumbar spondylolysis in the literature. Summary of Background Data. Although there are quite a few reported cases of 2- or 3-level spondylolysis, none reported on 4-level spondylolysis. Management guidelines have not been suggested in literature. Methods. A 48-year-old female presented with long-standing severe spinal instability, low back pain, and bilateral neurogenic claudication. Management of the patient with 4-level spondylolysis, varied clinical profile of each of the levels with respect to clinical symptoms and treatment based on the usefulness of pars block is described. Results. Two levels were treated with intervertebral fusions, 1 level with pars repair, and conservative treatment of the last level pars lysis yielded in good clinicoradiological outcome in our patient. Conclusion. Success of management of multiple lyses depends on the choice of appropriate treatment for each level separately. Pars block is a good invasive investigation to detect the symptomatic levels in a complex situation. Key words: spondylolyses, instability, pars repair, fusion. Level of Evidence: N/A Spine 2014;39:E734–E738
P
ars interarticularis has been an area of interest to spine surgeons for long. Its defect can be merely an incidental finding in 5% of normal population.1–6 Multiple level lumbar spondylolysis is rare and is reported in 1% to 5% of all patients with lyses.7–11 By virtue of its rarity, its management guidelines are still not very clear. There are only few From the Spine Care Center, Manipal Hospital, HAL Airport Road, Bangalore, Karnataka, India. Acknowledgment date: March 23, 2012. Revision date: December 27, 2013. Acceptance date: January 21, 2014. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work. Address correspondence and reprint requests to Vidyadhara S, MS, DNB, FNB, Spine Care Center, Manipal Hospital, HAL Airport Road, Bangalore-560017, Karnataka, India; E-mail: [email protected] DOI: 10.1097/BRS.0000000000000324
E734
reports on the surgical management.12–17 We herewith report for the first time in literature a patient with 4-level lumbar spondylolysis along with a step-wise approach in their management based on the utilization of pars block.
CASE REPORT A 48-year-old female presented with insidious onset, gradually progressive spinal instability and pain in the low back (visual analogue scale score of 8) with difficulty in change of postures for around 12 years. She had developed bilateral neurogenic claudication for 7 years. She had a walking capacity of 10 m. On examination, she was found to have a step at L4–L5 level and severe flattening of the low back. The patient had a stooped-forward posture and severe restriction of all movements, particularly the spinal extension with an instability catch. Straight leg raising test was negative and severe bilateral hamstring tightness was present. Patient had normal neurology and weakness (grade IV) of L5 and S1 muscles on provocative walking. Preoperative radiographs revealed bilateral lysis of L2, L3, L4, and L5 vertebral pars with grade 2 spondylolisthesis of L4 over L5 (Figure 1). On flexion-extension radiographs there was evidence of angular instability at L5–S1 (motion of 27°). Computed tomographic (CT) scan revealed pars defects much more accurately (Figure 2). Magnetic resonance image scan showed gross degeneration of the L4–L5 and L5–S1 discs with significant central and lateral canal stenosis (Figures 3, 4). However, discs at L2–L3 and L3–L4 were well preserved. Pars block was done serially at L2, L3, L4, and L5 using various combinations at an interval of 2 days between procedures as shown in Table 1. In all the procedures, L4 pars were blocked bilaterally. There was significant reduction in pain after L4 pars block alone but not complete. Pain relief was much better with an additional L5 pars block and further improved by L3 pars block. It was noted that the patient had complete relief of back pain after blocking L3, L4, and L5 pars. L2 pars block alone did not give any pain relief to the patient. The aim of surgery is to stabilize and fuse the unstable motion segments and to decompress the cauda equina adequately circumferentially. As the patient had symptomatic listhesis at L4–L5 and angular instability L5–S1 level, she
www.spinejournal.com
May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E734
24/04/14 3:57 AM
CASE REPORT
Four-Level Spondylolyses • Vidyadhara
Figure 1. Standing anteroposterior and lateral flexionextension radiographs.
underwent posterior lumbar interbody fusion at both levels. Pars repair using two 4.5-mm cortical screws was preferred for symptomatic L3 lysis in view of normal disc and a stable motion segment. Asymptomatic L2 lysis was left alone.
The patient was mobilized on first postoperative day and check radiograph revealed good implant positioning (Figure 5). At the 2-year follow-up, the patient had complete resolution of all her back symptoms (visual analogue scale score of 0) and also neurological claudication. She could walk for 5 km at a stretch without any pain or numbness. Painless range of movement of lumbar spine was reduced to 50% of normal. Standing radiograph revealed good fusion, and limited CT scanning was performed to reconfirm the anterior interbody fusion and pars repair.
DISCUSSION
Figure 2. Sagittal CT scan of the lumbar spine revealing the pars defect at L2–L5 bilaterally. CT indicates computed tomography; Rt, right; Lt, left. Spine
Lumbar spondylolysis (break in pars interarticularis) is often an incidental finding on lumbosacral radiographs. Its prevalence is 4% to 6% in general population.1–6 Multilevel lumbar spondylolysis (contiguous or skip lesion) is rare and only few case series have been published so far in English literature.7–12 Incidence of multiple lumbar spondylolysis seems to be 1.2% to 5.6%. Spondylolysis can be asymptomatic in many, or can cause clinical and radiological instability in some, but when associated with spondylolisthesis, (usually grade 1–2) can give rise to lower limb symptoms suggestive of spinal canal stenosis. Cause of lumbar spondylolysis is still unclear. There are both hereditary and acquired risk factors, with an increased prevalence in males and athletes or dancers participating in certain high-risk sports as a result of repetitive trauma.13 Isthmic spondylolysis is considered to represent a fatigue fracture of pars interarticularis of the neural arch.14 In our case, we found a rare presentation of 4-level lysis, 3 of whom had become symptomatic with no preceding history of significant trauma/injury. We presume that the condition is due to postural stress in our patient having a predisposing genetic weakness of pars. Standing radiographs are mainstay in the diagnosis of spondylolysis and associated spondylolisthesis. However, pars is better seen on the oblique view radiographs. Standing flexion-extension radiographs depict the anteroposterior and angular movements of adjacent vertebrae. According White and Punjabi radiological criteria, lumbar functional spinal unit is unstable if angular movement between 2 adjacent vertebrae is more than 21° and/or has more than 4-mm translation in anteroposterior plane. Computed tomography gives www.spinejournal.com
E735
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E735
24/04/14 3:57 AM
CASE REPORT
Four-Level Spondylolyses • Vidyadhara
Figure 3. MR images demonstrating spinal canal stenosis at L4–L5 and L5–S1 levels. MR indicates magnetic resonance.
best visualization of pars defect. Traumatic spondylolysis can be picked up early on bone scan or single photon emission computed tomography scan. Magnetic resonance imaging is mandatory for all patients prior to intervention to visualize the amount and extent of neural compression. Pars block has been described using CT or fluoroscopy guidance by pain physicians. It is very helpful as diagnostic and therapeutic tool, especially in acute traumatic pars fractures. We extended its use in delineating symptomatic lysis in multilevel symptomatic pars defects to plan a treatment strategy for the first time in literature. In traumatic pars fracture series, treatment is rest, braces/ orthoses, and rehabilitation strategies. Even in nontraumatic cases, patients most often respond well to conservative treatment with spinal mobilization and strengthening exercises. In the past, in multilevel lysis radical fusion of all defects and intervening normal vertebrae was recommended. However, we differ from this and advocate that when surgery is indicated, it must be rationalized. Choice of treatment of pars defect depends on the particular problem (Table 2). When surgery is the way forward, available options are pars repair, posterolateral fusion, transforaminal lumbar interbody fusion, or posterior lumbar interbody fusion. In patients with isolated lyses and only spinal instability and back pain, pars repair could be most optimal and logical E736
solution. It is biological and a motion preservation surgery. Although direct repair of pars would be the most desired treatment, there are specific prerequisites prior to contemplating its usefulness. It is contraindicated in more than grade 1 spondylolisthesis, and its role in multilevel spondylolysis is not studied. Chung et al15 reported 10 patients with 2-level bilateral spondylolysis treated successfully using pedicle screw–hook construct along with autogenous bone grafting. Ogawa et al16 reported 2-level spondylolysis in 5 cases and 3 levels in 2 cases, all treated successfully by segmental wire fixation and bone grafting. In patients with uni/bilateral pars lysis, spinal instability (grade 1), and minimal lower limb symptoms, Wiltse posterolateral fusion would achieve fusion without need to decompress nerve roots. In patients with significant unilateral lower limb radicular symptoms secondary to neural compression at the pars defect due to hypertrophic osseofibrocartilagenous tissue with or without spondylolisthesis, transforaminal lumbar interbody fusion may be a better option. However, in patients with spondylolytic spondylolisthesis with bilateral neurogenic claudication, posterior lumbar interbody fusion or transforaminal lumbar interbody fusion could be better as they achieve good neural decompression and also interbody fusion.17 All patients who undergo fusion surgical procedures have the problems of stiffness and adjacent segment degeneration.
www.spinejournal.com
May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E736
24/04/14 3:57 AM
CASE REPORT
Four-Level Spondylolyses • Vidyadhara
Figure 5. Postoperative radiographs.
CONCLUSION This is the first reported case in literature of 4-level lyses with varied clinical and radiological presentation and treatment. Choice of treatment of pars defect can range from observation to posterior lumbar interbody fusion. Each patient must
TABLE 2. Management Protocol for
Multilevel Spondylolysis Based on Clinicoradiological Findings
Asymptomatic/incidental spondylolysis on radiographs Observation Acute traumatic fractures Conservative treatment: braces followed by exercises Chronic localized pain Figure 4. MR image depicting axial sections of foraminal stenosis at L4–L5 and L5–S1 levels. MR indicates magnetic resonance.
TABLE 1. Sequential Pars Block and Inference Day 1: Pars block of bilateral L4 only (reduction in pain to 5/10) Inference: L4 lysis + listhesis caused 50% pain Day 3: Pars block of bilateral L2, L3, and L4 (reduction in pain to 3/10) Inference: L5 lysis + listhesis caused 30% pain Day 5: Pars block of bilateral L2, L4, and L5 (reduction in pain to 2/10) Inference: L3 lysis caused 20% pain Day 7: Pars block of bilateral L3, L4, and L5 (reduction in pain to 0/10) Inference: L2 lysis caused no pain Spine
Pars block Spinal instability and back pain alone Back school exercises for at least 3 mo Pars repair in adolescents and young adults before disc degeneration PLF in adults and elderly Spinal instability and back pain with radiculopathy ± spondylolisthesis TLIF Spinal instability and back pain with neurogenic claudication ± spondylolisthesis TLIF/PLIF TLIF indicates transforaminal lumbar interbody fusion; PLIF, posterior lumbar interbody fusion; PLF, posterolateral fusion.
www.spinejournal.com
E737
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E737
24/04/14 3:57 AM
CASE REPORT be individually evaluated with problem specific interventions. Assess each and every level separately. Pars block is a good invasive investigation to detect the symptomatic levels in complex situations. Success of management of multiple lyses depends on the choice of appropriate treatment for the particular problem.
➢ Key Points First reported case of 4-level spondylolyses in literature. Pars block is appropriate in choosing various treatments. Guide to choice of treatment described.
References
1. Lowe J, Libson E, Ziv I, et al. Spondylolysis in the upper lumbar spine. A study of 32 patients. J Bone Joint Surg Br 1987;69:582–6. 2. Hefti F, Brunazzi M, Morscher E. Natural course in spondylolysis and spondylolisthesis. Orthopade 1994;23:220–7. 3. Saraste H. Symptoms in relation to the level of spondylolysis. Int Orthop 1986;10:183–5. 4. Saraste H, Nilsson B, Brostrom LA, et al. Relationship between radiological and clinical variables in spondylolysis. Int Orthop 1984;8:163–74. 5. Saraste H. Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis. J Pediatr Orthop 1987;7:631–8.
E738
Four-Level Spondylolyses • Vidyadhara
6. Saraste H, Brostrom LA, Aparisi T. Prognostic radiographic aspects of spondylolisthesis. Acta Radiol Diagn (Stockh) 1984;22:427–32. 7. Al-Sebai MW, Al-Khawashki H. Spondyloptosis and multiple level spondylolysis. Eur Spine J 1999;8:75–7. 8. Beningfield SJ, Heselson NG. Multiple lumbar spondylolyses with transverse process pseudoarthroses. A case report. S Afr Med J 1989;75:544–5. 9. Eingorn D, Pizzutillo PD. Pars interarticularis fusion of multiple levels of lumbar spondylolyses. A case report. Spine 1985;10: 250–2. 10. Mathiesen F, Simper LB, Seerup A. Multiple spondylolyses and spondylolistheses. Br J Radiol 1984;57:338–40. 11. Privett JT, Middlemiss JH. Multiple lumbar spondylolyses. Br J Radiol 1975;48:866–9. 12. Chang JH, Lee CH, Wu SS, et al. Management of multiple-level spondylolysis of the lumbar spine in young males: a report of six cases. J Formos Med Assoc 2001;100:497–502. 13. McTimoney CA, Micheli LJ. Current evaluation and management of spondylolysis and spondylolisthesis. Curr Sports Med Rep 2003;2:41–6. 14. Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil 2007;88:537–40. 15. Chung CH, Chiu HM, Wang SJ, et al. Direct repair of multiple levels lumbar spondylolysis by pedicle screw laminar hook and bone grafting: clinical, CT, and MRI-assessed study. J Spinal Disord Tech 2007;20:399–402. 16. Ogawa H, Nishimoto H, Hosoe H, et al. Clinical outcome after segmental wire fixation and bone grafting for repair of the defects in multiple level lumbar spondylolysis. J Spinal Disord Tech 2007;20:521–5. 17. Ravichandran G. Multiple lumbar spondylolyses. Spine 1980; 5:552–7.
www.spinejournal.com
May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E738
24/04/14 3:57 AM
CASE REPORT
Rationale in the Management of 4-Level Lumbar Spondylolyses With or Without Instability and/or Spondylolisthesis S. Vidyadhara, MS, DNB, FNB
Study Design. Case report. Objective. To report the first case of 4-level lumbar spondylolysis in the literature. Summary of Background Data. Although there are quite a few reported cases of 2- or 3-level spondylolysis, none reported on 4-level spondylolysis. Management guidelines have not been suggested in literature. Methods. A 48-year-old female presented with long-standing severe spinal instability, low back pain, and bilateral neurogenic claudication. Management of the patient with 4-level spondylolysis, varied clinical profile of each of the levels with respect to clinical symptoms and treatment based on the usefulness of pars block is described. Results. Two levels were treated with intervertebral fusions, 1 level with pars repair, and conservative treatment of the last level pars lysis yielded in good clinicoradiological outcome in our patient. Conclusion. Success of management of multiple lyses depends on the choice of appropriate treatment for each level separately. Pars block is a good invasive investigation to detect the symptomatic levels in a complex situation. Key words: spondylolyses, instability, pars repair, fusion. Level of Evidence: N/A Spine 2014;39:E734–E738
P
ars interarticularis has been an area of interest to spine surgeons for long. Its defect can be merely an incidental finding in 5% of normal population.1–6 Multiple level lumbar spondylolysis is rare and is reported in 1% to 5% of all patients with lyses.7–11 By virtue of its rarity, its management guidelines are still not very clear. There are only few From the Spine Care Center, Manipal Hospital, HAL Airport Road, Bangalore, Karnataka, India. Acknowledgment date: March 23, 2012. Revision date: December 27, 2013. Acceptance date: January 21, 2014. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work. Address correspondence and reprint requests to Vidyadhara S, MS, DNB, FNB, Spine Care Center, Manipal Hospital, HAL Airport Road, Bangalore-560017, Karnataka, India; E-mail: [email protected] DOI: 10.1097/BRS.0000000000000324
E734
reports on the surgical management.12–17 We herewith report for the first time in literature a patient with 4-level lumbar spondylolysis along with a step-wise approach in their management based on the utilization of pars block.
CASE REPORT A 48-year-old female presented with insidious onset, gradually progressive spinal instability and pain in the low back (visual analogue scale score of 8) with difficulty in change of postures for around 12 years. She had developed bilateral neurogenic claudication for 7 years. She had a walking capacity of 10 m. On examination, she was found to have a step at L4–L5 level and severe flattening of the low back. The patient had a stooped-forward posture and severe restriction of all movements, particularly the spinal extension with an instability catch. Straight leg raising test was negative and severe bilateral hamstring tightness was present. Patient had normal neurology and weakness (grade IV) of L5 and S1 muscles on provocative walking. Preoperative radiographs revealed bilateral lysis of L2, L3, L4, and L5 vertebral pars with grade 2 spondylolisthesis of L4 over L5 (Figure 1). On flexion-extension radiographs there was evidence of angular instability at L5–S1 (motion of 27°). Computed tomographic (CT) scan revealed pars defects much more accurately (Figure 2). Magnetic resonance image scan showed gross degeneration of the L4–L5 and L5–S1 discs with significant central and lateral canal stenosis (Figures 3, 4). However, discs at L2–L3 and L3–L4 were well preserved. Pars block was done serially at L2, L3, L4, and L5 using various combinations at an interval of 2 days between procedures as shown in Table 1. In all the procedures, L4 pars were blocked bilaterally. There was significant reduction in pain after L4 pars block alone but not complete. Pain relief was much better with an additional L5 pars block and further improved by L3 pars block. It was noted that the patient had complete relief of back pain after blocking L3, L4, and L5 pars. L2 pars block alone did not give any pain relief to the patient. The aim of surgery is to stabilize and fuse the unstable motion segments and to decompress the cauda equina adequately circumferentially. As the patient had symptomatic listhesis at L4–L5 and angular instability L5–S1 level, she
www.spinejournal.com
May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E734
24/04/14 3:57 AM
CASE REPORT
Four-Level Spondylolyses • Vidyadhara
Figure 1. Standing anteroposterior and lateral flexionextension radiographs.
underwent posterior lumbar interbody fusion at both levels. Pars repair using two 4.5-mm cortical screws was preferred for symptomatic L3 lysis in view of normal disc and a stable motion segment. Asymptomatic L2 lysis was left alone.
The patient was mobilized on first postoperative day and check radiograph revealed good implant positioning (Figure 5). At the 2-year follow-up, the patient had complete resolution of all her back symptoms (visual analogue scale score of 0) and also neurological claudication. She could walk for 5 km at a stretch without any pain or numbness. Painless range of movement of lumbar spine was reduced to 50% of normal. Standing radiograph revealed good fusion, and limited CT scanning was performed to reconfirm the anterior interbody fusion and pars repair.
DISCUSSION
Figure 2. Sagittal CT scan of the lumbar spine revealing the pars defect at L2–L5 bilaterally. CT indicates computed tomography; Rt, right; Lt, left. Spine
Lumbar spondylolysis (break in pars interarticularis) is often an incidental finding on lumbosacral radiographs. Its prevalence is 4% to 6% in general population.1–6 Multilevel lumbar spondylolysis (contiguous or skip lesion) is rare and only few case series have been published so far in English literature.7–12 Incidence of multiple lumbar spondylolysis seems to be 1.2% to 5.6%. Spondylolysis can be asymptomatic in many, or can cause clinical and radiological instability in some, but when associated with spondylolisthesis, (usually grade 1–2) can give rise to lower limb symptoms suggestive of spinal canal stenosis. Cause of lumbar spondylolysis is still unclear. There are both hereditary and acquired risk factors, with an increased prevalence in males and athletes or dancers participating in certain high-risk sports as a result of repetitive trauma.13 Isthmic spondylolysis is considered to represent a fatigue fracture of pars interarticularis of the neural arch.14 In our case, we found a rare presentation of 4-level lysis, 3 of whom had become symptomatic with no preceding history of significant trauma/injury. We presume that the condition is due to postural stress in our patient having a predisposing genetic weakness of pars. Standing radiographs are mainstay in the diagnosis of spondylolysis and associated spondylolisthesis. However, pars is better seen on the oblique view radiographs. Standing flexion-extension radiographs depict the anteroposterior and angular movements of adjacent vertebrae. According White and Punjabi radiological criteria, lumbar functional spinal unit is unstable if angular movement between 2 adjacent vertebrae is more than 21° and/or has more than 4-mm translation in anteroposterior plane. Computed tomography gives www.spinejournal.com
E735
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E735
24/04/14 3:57 AM
CASE REPORT
Four-Level Spondylolyses • Vidyadhara
Figure 3. MR images demonstrating spinal canal stenosis at L4–L5 and L5–S1 levels. MR indicates magnetic resonance.
best visualization of pars defect. Traumatic spondylolysis can be picked up early on bone scan or single photon emission computed tomography scan. Magnetic resonance imaging is mandatory for all patients prior to intervention to visualize the amount and extent of neural compression. Pars block has been described using CT or fluoroscopy guidance by pain physicians. It is very helpful as diagnostic and therapeutic tool, especially in acute traumatic pars fractures. We extended its use in delineating symptomatic lysis in multilevel symptomatic pars defects to plan a treatment strategy for the first time in literature. In traumatic pars fracture series, treatment is rest, braces/ orthoses, and rehabilitation strategies. Even in nontraumatic cases, patients most often respond well to conservative treatment with spinal mobilization and strengthening exercises. In the past, in multilevel lysis radical fusion of all defects and intervening normal vertebrae was recommended. However, we differ from this and advocate that when surgery is indicated, it must be rationalized. Choice of treatment of pars defect depends on the particular problem (Table 2). When surgery is the way forward, available options are pars repair, posterolateral fusion, transforaminal lumbar interbody fusion, or posterior lumbar interbody fusion. In patients with isolated lyses and only spinal instability and back pain, pars repair could be most optimal and logical E736
solution. It is biological and a motion preservation surgery. Although direct repair of pars would be the most desired treatment, there are specific prerequisites prior to contemplating its usefulness. It is contraindicated in more than grade 1 spondylolisthesis, and its role in multilevel spondylolysis is not studied. Chung et al15 reported 10 patients with 2-level bilateral spondylolysis treated successfully using pedicle screw–hook construct along with autogenous bone grafting. Ogawa et al16 reported 2-level spondylolysis in 5 cases and 3 levels in 2 cases, all treated successfully by segmental wire fixation and bone grafting. In patients with uni/bilateral pars lysis, spinal instability (grade 1), and minimal lower limb symptoms, Wiltse posterolateral fusion would achieve fusion without need to decompress nerve roots. In patients with significant unilateral lower limb radicular symptoms secondary to neural compression at the pars defect due to hypertrophic osseofibrocartilagenous tissue with or without spondylolisthesis, transforaminal lumbar interbody fusion may be a better option. However, in patients with spondylolytic spondylolisthesis with bilateral neurogenic claudication, posterior lumbar interbody fusion or transforaminal lumbar interbody fusion could be better as they achieve good neural decompression and also interbody fusion.17 All patients who undergo fusion surgical procedures have the problems of stiffness and adjacent segment degeneration.
www.spinejournal.com
May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E736
24/04/14 3:57 AM
CASE REPORT
Four-Level Spondylolyses • Vidyadhara
Figure 5. Postoperative radiographs.
CONCLUSION This is the first reported case in literature of 4-level lyses with varied clinical and radiological presentation and treatment. Choice of treatment of pars defect can range from observation to posterior lumbar interbody fusion. Each patient must
TABLE 2. Management Protocol for
Multilevel Spondylolysis Based on Clinicoradiological Findings
Asymptomatic/incidental spondylolysis on radiographs Observation Acute traumatic fractures Conservative treatment: braces followed by exercises Chronic localized pain Figure 4. MR image depicting axial sections of foraminal stenosis at L4–L5 and L5–S1 levels. MR indicates magnetic resonance.
TABLE 1. Sequential Pars Block and Inference Day 1: Pars block of bilateral L4 only (reduction in pain to 5/10) Inference: L4 lysis + listhesis caused 50% pain Day 3: Pars block of bilateral L2, L3, and L4 (reduction in pain to 3/10) Inference: L5 lysis + listhesis caused 30% pain Day 5: Pars block of bilateral L2, L4, and L5 (reduction in pain to 2/10) Inference: L3 lysis caused 20% pain Day 7: Pars block of bilateral L3, L4, and L5 (reduction in pain to 0/10) Inference: L2 lysis caused no pain Spine
Pars block Spinal instability and back pain alone Back school exercises for at least 3 mo Pars repair in adolescents and young adults before disc degeneration PLF in adults and elderly Spinal instability and back pain with radiculopathy ± spondylolisthesis TLIF Spinal instability and back pain with neurogenic claudication ± spondylolisthesis TLIF/PLIF TLIF indicates transforaminal lumbar interbody fusion; PLIF, posterior lumbar interbody fusion; PLF, posterolateral fusion.
www.spinejournal.com
E737
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E737
24/04/14 3:57 AM
CASE REPORT be individually evaluated with problem specific interventions. Assess each and every level separately. Pars block is a good invasive investigation to detect the symptomatic levels in complex situations. Success of management of multiple lyses depends on the choice of appropriate treatment for the particular problem.
➢ Key Points First reported case of 4-level spondylolyses in literature. Pars block is appropriate in choosing various treatments. Guide to choice of treatment described.
References
1. Lowe J, Libson E, Ziv I, et al. Spondylolysis in the upper lumbar spine. A study of 32 patients. J Bone Joint Surg Br 1987;69:582–6. 2. Hefti F, Brunazzi M, Morscher E. Natural course in spondylolysis and spondylolisthesis. Orthopade 1994;23:220–7. 3. Saraste H. Symptoms in relation to the level of spondylolysis. Int Orthop 1986;10:183–5. 4. Saraste H, Nilsson B, Brostrom LA, et al. Relationship between radiological and clinical variables in spondylolysis. Int Orthop 1984;8:163–74. 5. Saraste H. Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis. J Pediatr Orthop 1987;7:631–8.
E738
Four-Level Spondylolyses • Vidyadhara
6. Saraste H, Brostrom LA, Aparisi T. Prognostic radiographic aspects of spondylolisthesis. Acta Radiol Diagn (Stockh) 1984;22:427–32. 7. Al-Sebai MW, Al-Khawashki H. Spondyloptosis and multiple level spondylolysis. Eur Spine J 1999;8:75–7. 8. Beningfield SJ, Heselson NG. Multiple lumbar spondylolyses with transverse process pseudoarthroses. A case report. S Afr Med J 1989;75:544–5. 9. Eingorn D, Pizzutillo PD. Pars interarticularis fusion of multiple levels of lumbar spondylolyses. A case report. Spine 1985;10: 250–2. 10. Mathiesen F, Simper LB, Seerup A. Multiple spondylolyses and spondylolistheses. Br J Radiol 1984;57:338–40. 11. Privett JT, Middlemiss JH. Multiple lumbar spondylolyses. Br J Radiol 1975;48:866–9. 12. Chang JH, Lee CH, Wu SS, et al. Management of multiple-level spondylolysis of the lumbar spine in young males: a report of six cases. J Formos Med Assoc 2001;100:497–502. 13. McTimoney CA, Micheli LJ. Current evaluation and management of spondylolysis and spondylolisthesis. Curr Sports Med Rep 2003;2:41–6. 14. Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil 2007;88:537–40. 15. Chung CH, Chiu HM, Wang SJ, et al. Direct repair of multiple levels lumbar spondylolysis by pedicle screw laminar hook and bone grafting: clinical, CT, and MRI-assessed study. J Spinal Disord Tech 2007;20:399–402. 16. Ogawa H, Nishimoto H, Hosoe H, et al. Clinical outcome after segmental wire fixation and bone grafting for repair of the defects in multiple level lumbar spondylolysis. J Spinal Disord Tech 2007;20:521–5. 17. Ravichandran G. Multiple lumbar spondylolyses. Spine 1980; 5:552–7.
www.spinejournal.com
May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPINE120481_LR E738
24/04/14 3:57 AM
