Effectiveness of surgical versus conservative treatment for symptomatic unilateral spondylolysis of the lumbar spine in athletes: a systematic review protocol

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Abstract

Review question/objective

This systematic review aims to determine the effectiveness of surgical fixation, performed after a trial period of conservative management, compared to conservative management only for unilateral spondylolysis in athletes.

Review question/objective

More specifically, the objectives are:

Background

Spondylolysis is a common cause of low back pain in athletes, especially amongst adolescent athletes. The incidence of the condition in the general population is between 6%-8%;1,2 however in the athletic population the incidence has been reported as high as 47%.3 Spondylolysis refers to a defect or fracture of the pars interarticularis of vertebrae which can be either unilateral or bilateral. The pars interarticularis is the junction of the pedicle, articular facets and lamina.

Background

Historically stress injuries of the pars interarticularis were thought to be mostly bilateral4 and were noted in young athletes competing in sports requiring repetitive lumbar extension movements such as gymnastics and swimming.5 The growth of professional sport has seen more athletes exposed at a younger age to the repetitive actions which can lead to this condition. This, combined with advances in lumbar spine imaging in the past 20 years has revealed that unilateral spondylolysis is more prevalent than originally thought and further demonstrated that amongst participants in some sports, such as cricket for example, unilateral spondylolyis may in fact be just as common as bilateral spondylolysis.6,7

Background

Studies using Magnetic Resonance Imaging (MRI) or high resolution Computerized Tomography (CT) scanning have estimated that between 32% - 48% of all cases of radiologically confirmed spondylolysis in athletes are unilateral.8,9 Amongst cricket players, it has been shown that up to 55% of young fast bowlers may suffer from unilateral spondylolysis.10 If this injury is not managed appropriately it significantly limits player's ability to pursue their sporting career.10,11 A large amount of research regarding unilateral spondylolyis has involved this specific group of athletes.6,7,10-13

Background

Unilateral spondylolysis occurs when repetitive stresses are placed on the pars interarticularis. The specific combination of repetitive extension, rotation and side flexion creates a shear force on the pars interarticularis that causes stretching of the pars and eventually stress microfracture.4 With ongoing stress an incomplete fracture occurs that can lead to chronic non-union. The condition occurs most commonly at the L5 vertebral level.9 A spondylolytic injury can have substantial impact on athletes, regardless of their chosen sport. The injury can cause significant pain and impediment to activity and lead to significant time away from sport.5,6

Background

Despite growing knowledge regarding the epidemiology and aetiology of unilateral spondylolysis, the optimum management of athletes with this condition still remains unclear. It has been recommended by several review articles on spondylolysis that conservative management including rest; activity modification and physiotherapy, facilitate a patient's return to sports over time.4,5,14 A study by Blanda et al.15 demonstrated that a 6-month protocol of non-operative management led to apparent radiographic union of the unilateral pars interarticularis defect in 87% of patients, however the authors did not report on return to sport or clinical outcome in this group. Sys et al.8 noted similar outcomes for a subgroup of 11 patients with unilateral spondylolyis treated with lumbar bracing for an average of 16 weeks. These patients all achieved CT identified osseous healing of the fracture, with most of the athletes able to return to a previous level of sport.8 These studies indicate that conservative treatment of up to 6 months achieves positive results in most patients. However, it remains unclear in patients who do not respond to conservative treatment within six months, if surgery or ongoing conservative treatment is more beneficial, or even whether it would potentially be more beneficial for patients to have surgical intervention immediately after the initial diagnosis of the injury.

Background

Various methods of surgical fixation have also been described, with surgical fixation only attempted after an initial trial period of conservative management.4,5,14 The general aim of surgical intervention is a direct repair of the pars interarticularis. In the past spinal fusion was used as the first line of surgical treatment, however internal fixation devices have superseded spinal fusion as the gold standard surgical treatment.14 Despite technological advances the role of surgical intervention and its effectiveness remains controversial, and it remains unclear whether athletes with unilateral spondylolysis are able to return to the sports field more rapidly or if they are able to compete to the same level as prior to their injury.

Background

A search of the Cochrane (CENTRAL) and CINAHL databases using the keywords “unilateral spondylolysis”, “surgical versus conservative intervention”, and “systematic review” in an attempt to locate any recently published systematic review and/or protocols for review on the topic. No systematic reviews or protocols looking specifically at unilateral spondylolysis were identified. This highlights the value of the proposed research, which will provide sports rehabilitation practitioners with the first synthesis of the available evidence on the effectiveness of surgical intervention compared to conservative management for unilateral spondylolysis in athletes.

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