Successful Bony Healing For An Adult Patient With Isthmic Spondylolysis At Terminal Stage After Conservative Treatment: A Case Report

Abstract

Purpose: Spondylolysis, a defect or fracture of the pars interarticularis due to mechanical stress, is a common cause of lower back pain (LBP) in children and adolescents. Although conservative treatment has been shown to be most effective for young patients at early or progressive stage, few studies have reported the outcomes of conservative treatment for adult spondylolysis at terminal stage. We present the possibility of bony healing in the isthmic defect at terminal stage after conservative treatment.

Patients and methods: A 50-year-old male patient complaining of moderate LBP was diagnosed as having L5 bilateral pars defect accompanied with related grade I spondylolisthesis though radiological evaluation. Magnetic resonance imaging revealed the sclerotic change in the defect of the isthmus, indicating spondylolysis at the terminal stage. This patient was treated with conservative management including lower back muscle functional exercises and medication when necessary.

Results: After five years of follow-up, the patient had a good recovery without reoccurrence. The repeated radiography and computed tomography demonstrated the pars defect had disappeared and been replaced by trabeculation, with no evidence of progressive segmental instability or vertebrae slip.

Conclusion: Symptomatic adult patients with isthmus spondylolysis at terminal stage might still have an opportunity to be effectively managed with rigorous conservative treatment for obtaining bony healing. However, the progression of listhesis or persistent debilitating pain should warrant consideration for surgical treatment.

Keywords: bony union; isthmus; lower back pain; pars interarticularis; spondylolisthesis.

Figure 1

Lumbar plain radiographs of the 50-year-old male patient at his first visit to our orthopedic clinic. Notes: (A) Anteroposterior and lateral films showed bilateral defects of the pars interarticularis with grade I spondylolisthesis at L5, and SBO at L5 and S1 with isolated spinous processes. (B) Double-oblique films demonstrated bilateral spondylolysis with irregular hardened edge formation. (C) Flexion–extension films revealed no segmental instability. Arrows indicate spondylolysis. Arrowheads indicate SBO. Abbreviation: SBO, spina bifida occulta.

Figure 2

CT scans and sagittal two-dimensional reconstruction of the 50-year-old male patient at his first visit to our orthopedic clinic. Note: Bilateral isthmic defects with sclerotic change at L5. Abbreviation: CT, computed tomography.

Figure 3

MRI of the 50-year-old male patient at his first visit to our hospital. Notes: Low intensities in the bilateral defects of the pars interarticularis at L5 and no nerve compression or canal stenosis at the level of L5–S1. Arrows indicate spondylolysis. Abbreviations: MRI, magnetic resonance imaging; T2WI, T2-weighted image; T1WI, T1-weighted image; STIR, short tau inversion recovery.

Figure 4

The repeated lumbar radiographs after five-year follow-up. Notes: (A) Double-oblique views demonstrated the defects of the pars were replaced by trabeculation but still left some sclerotic remnants. (B) Dynamic films demonstrated no progressive instability of the lumbar spine. Arrows indicate the bony healing of the defects of the pars interarticularis.

Figure 5

The repeated CT scanning and sagittal two-dimensional reconstruction after 5-year follow-up. Note: Most of the defects of the isthmus at L5 had satisfactory bony healing and the healed parts of the pars became elongated and narrow, but left a little non-union at the right-hand side. Abbreviation: CT, computed tomography.