This male U-20 international player presents with an insidious onset of low back pain. He describes developing increasing low back pain over a three month period that was acutely made worse by an overhead kick. It was initially only painful while playing football but at the time of presentation was also painful at rest.
On examination the player had pain with lumbar extension, especially right sided hyperextension. He was also found to have localised midline tenderness over the L4 and L5 spinous processes.
An initial lumbar x-ray series was found to be normal. There is increased signal intensity within the pars interarticularis at L5 on the right. No oedema is seen on the left and there was no antero or retrolisthesis. The CT images show an incomplete fracture of the right pars interarticularis region. The fracture margins are irregular with some evidence of resorption consistent with an acute injury, with fracture extension into the medial aspect of the right lamina present.
This player was succussfully treated with three months of rest from pain provoking activities combined with a progressive core stability programme.
Flexion and extension cause greatest loads at L5-S1 and these stresses are concentrated at the pars. The pars region acts as a bony fulcrum during spinal extension and is therefore vulnerable to repetitive loading. This type of injury is more common in young men with players generally presenting between the ages of 15-16 with an insidious onset of low back pain. The L5 level is most commonly affected (85-95%) follwed by L4 (5-15%).
In general MRI is used to diagnose the injury. CT imaging provides better detail and can provide prognostic information. Poor prognostic signs include wide, round and sclerotic fracture margins. Bilateral lesions are less likely to heal while those at L4 are less likely to heal (10% healing) than those at L5 (60%).
Most acute injuries (narrow and sharp fracture margins) can be successfully treated with a period of rest. This can often be quite prolonged (more than 3 months). More chronic lesions (with wider and more sclerotic looking margins) can be treated more aggressively as they are unlikely to heal. When symptoms are more refractory, surgical treatment (generally with direct repair) can be contemplated.
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