Spondylolysis and Isthmic Spondylolisthesis: A Guide to Diagnosis and Management

The prevalence of back pain in adolescents and young adults has steadily increased over the past decade. Spondylolysis and isthmic spondylolisthesis are commonly implicated as organic causes of low back pain in this population. These two conditions represent a continuum of a disease process where repetitive loading of the lumbar spine in extension results in a stress reaction, fracture and eventual defect of the pars interarticularis, referred to as spondylolysis. In the setting of bilateral pars interarticularis defects, forward translation of the vertebra may occur, leading to isthmic spondylolisthesis. The pathophysiology behind this disease process is multifactorial with genetic predispositions as well as mechanical factors playing a role. Many patients involved in sports that require repetitive hyperextension of the lumbar spine like diving, weightlifting, gymnastics and wrestling develop spondylolysis and isthmic spondylolisthesis. While patients are typically asymptomatic in mild forms, the hallmark of symptoms in more advanced disease include low back pain, radiculopathy, postural changes and rarely, neurologic deficits. A comprehensive physical exam and subsequent imaging including radiographs, CT and MRI play a role in the diagnosis of this disease process. While the majority of patients improve with conservative management, other require operative management due to persistent symptoms. Due to the risk of disease progression, referral to a spine surgeon is recommended for any patient suspected of having these conditions. This review provides information and guidelines for practitioners to promote an actionable awareness of spondylolysis and isthmic spondylolisthesis.

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