Spondylolysis

A Review and Treatment Approach

Kimberly S. Peer >" Jeanna M. Fascione

Low back pain, specifically "spondylo" conditions, has traditionally been misunderstood and often times ill-treated. A thorough understanding of the function of pars interarticularis and its relationship to the entire vertebral unit and low back health are essential for successful treatment and rehabilitation outcomes. Lifestyle awareness and controlled progression through the inflammation, stabiiization, strength, and functional rehabilitation phases provide primary guidance for patients. In addition, a broad spectrum of pharmacological, psychological, therapeutic modality, and newer surgical techniques must be considered in the overall treatment plan. Having a strong understanding of the anatomy, biomechanics, treatment, and rehabilitation of this condition, will help the allied healthcare provider better meet the individualized needs of spondylolysis patients.

pondylolysis is a stress fracture defecl in the pars inter-articularis of the vertebrae. Initial symptoms may be similar to other common lower back ailments. This condition is presenl in up to 6% of the population and is chnically recognized as a stress reaction or stress fiacture of the pars inter-articularis (Sairyo, Katoh, et al., 2005). Allhough adolescents are most susceptible, ihey are often asymptomatic until their age and their weighl-bearing forces increase (Hodge, 1991; Standaert, Hening, Halpern. & King, 2000). Spondylolysis is introduced from anatomical and biomechanicai perspectives then further discussed from a treatment and rehabilitation perspective, includingsui^ical, clinical, and psychological aspects.

Genetic predispositions, including weak crosssectional aieas of the cortical bone area of the pars and relative coiiicai bone density, aiso affect the relative incidence of injui7 (Hodge, 1991; Nance & Hickey, 1999). These factors affect the efficiency in which the neural arch absorbs forces (Standaert et al., 2000). It should also be noted that approximately 50-8 i % of those suffering from spondylolysis conditions also have spondylolisthesisthe complete bilateral fracture of the pars inter-articularis resulting in the anterior slippage of the vertebra (TheinNissenbaum, 2005). This specific anatomical consideration is critical when treating any spondylopathic condition to properly design an appropriate management plan. It is equally necessai-y to recognize the effects of the associated slippage and/or compressive forces that affect the suiTOunding articular surfaces, discs, and neurological structures. The following live subcategories for spondylolysis exist: dysplastic, isthmic, degenerative, traumatic, and pathogenic (Nance & Hickey, 1999; Standaert et al., 2000). Each presents unique considerations for the orthopaedic nurse and other healthcare providers. Although beyond the scope of this article to elaborate on each of these categories, a brief description is provided. Dysplastic spondylopathic conditions involve congenital abnormalities, such as an attenuated pars, whereas isthmic conditions involve lesions of the pars interarticularis resulting from stress fractures, elongation, or acute fractures. Degenerative spondylolysis involves segmental instability and iilterations of the articular processes due to degeneration of the intewertebral discs, whereas traumatic spondylolysis results fi'om acute fractures in various places on the neural arch, not including the pars. Finally, pathological spondylolysis occurs fiom various bone diseases or inlections and their complications. This article focuses primarily on isthmic spondylolysis resulting from fatigue fractures. The classic mechanism of injuiy involves mechanical stress to the pars interarticularis over a longer time frame typically caused from hyperextension and rotation forces (Iwamoto, Takeda, & Wakano, 2004). Biomechanically, the compressive and iorsional lorces may be amplified by alterations in alignKimberly S. Peer, EdD, ATC, LAT, Kent State University, Kent, OH Jeanna M. Fascione, BS, Kent State University, Kent, OH, The authors have no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

Anatomy and Mechanism of Injury

Spondylolysis is a defect fracture, dissolvance, or break in the neural arch between the superior and inferior articulating processes (Hodge, 1991; Rodts, 2002). This area of the vertebral arch, classically dehned as the pars inter-articularis, is fibrocartilaginous ralher than bony in .spondylolysis conditions (Harvey, 2005) (see Figure lj. Typically caused from excessive hyperextension forces, this condition is often associated with hypermobility of the lower back (Thein-Nissenbaum & Boissonnault, 2005). Commonly associated wilh alhlctic participation, gymnasts, football linemen, weightlifters. wrestlers, and divers are most vulnerable (Harvey, 2005; Hodge, 1991).
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Superior facet Pars

Infwior (act

FIGURE 1 . The pars inter-articularis (Mayfield Clinic, 2006) (www.mayfieldclinic.com/PESPOND. htm).

ment or spinal trunk muscular imbalances. Such imbalances cause the pelvis to shift into an anterior pelvic tilt position, forcing the lumbar region of the spine into prolonged hyperextension. Muscular imbalances, such as tight hamstrings with weak back extensors, abdominals, hip llexors, lateral lumbar flexors, and lumbar rotatoT' musculature, may also contribute to low back pain, including spondylolysis (Prentice. 2004). Such lorces over time result in hairline fractures and may eventually progress to a complete separation of bone (Hall, 2003). Allhough an acute mechanism may result in spondylolysis, the progix'ssivc breakdown of the pars most commonly occurs before the acute damage.

arch region defect as a crack in the pars inter-articularis, which reflects as a partial or complete separation of the spinous process and the superior articular process. A common tei^m that relates to this diagnostic description is the visualization of the "collar" on the "Scottie dog" (Rodts, 2000; Starkey & Ryan, 2002). The collar shows the non-displaced fi-acture of the pal's inter-articularis (see Figure 2). Although radiographic images have been the primaiy diagnostic imaging too! in the past, recent techniques have become more accepted tools including the computed axial tomography (CAT) scan (CS), single photon emission computed tomography (SPECT), and rpagnetic resonance imaging (MR!) (see Figures 3 and 4). These scans are more sensitive to pars lesion identification (Hodge, 1991; Standaert. 2002). These newer techniques also allow more complicated angles of images to be taken to accommodate the complex stnucture of the lower spine. Orthopedic assessment tests can be performed by the clinician to indicate spondylolysis. Several specific orthopedic tests include the single leg stance test (see Figure 5) and single leg raise (Starkey & Ryan, 2002).

Surgical Procedure and Options to the Surgery

Although surgical treatment is typically used after conservative methods have been exhausted, several options do exist. Surgical options are used in 9 to 15% of those diagnosed with symptomatic spondylolysis (Standaert et al.. 2000). Surgical procedures typically attempt a direct repair of the pais. Internal fixation devices have more recently been used over the previously considered "gold standard" spinal fusion procedure (Mihara, Onari. Cheng, David, & Zdeblick. 2003). Translaminar screw fixation, cerclage wiring loop, and pediculolaminar hook screws are a lew specific examples of such specific internal techniques (Roca, Iborra, Cavanilles-Walker, & Alberti, 2005). These newer techniques presei"ve more segmental motion by directly repairing the isthmic defect. The pedicle screw-hook fixation procedure results in the placement of a bone graft and stabilizing rod into the pars (Roca et al., 2005). The pedicle screws are placed in the vertebi a and the defecl is packed with a cancellous bone graft taken from the iliac crest. Once filled, a rod is

Diagnostic Techniques ana Implications

Evaluation of a suspected spondylolysis requires careful consideration of several critical questions: Can the spine function as a weight-bearing unit? Is there neurological encroachment? and What was the mechanism of injuiy? The history will provide considerable guidance; however, radiographic studies are typically prescribed (Lenke, Bridwell, & O'Brien, 2000). Oblique radiographic and newer imaging techniques assist in the diagnosis ol spondylolysis. They indicate the location of the neural

Pedtde

FIGURE 2. Normal anatomy and spondylolysis depicting the Scottie dog appearance (Anderson, Hall, & Martin, 2000).
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FIGURE 3. X-ray image of spondyiolisthesis in the lumbar spine (Schoen, 2000).

inserted into the screw head and the device is loaded with compressive forces (see Figure 6). Patients are permitted to stand after 3 days and must wear a lumbosacral support lor approximately 2 months after surgei-y or until fusion is healed. Another less invasive endoscopic procedure known as the Gill involves the removal of the loose lamina to relieve associated nei^e root impingement (Sairyo, Goel, et al., 2005). Although this procedm^e allows an early

FIGURE 5. Single leg stance test (Anderson, Hall, & Martin, 2000). The single leg stance test involves the patient lifting one leg and placing the trunk into hyperextension. A positive is determined by pain in the lumbar spine or sacroiliac area indicating shear forces placed on the pars interarticularis. The pain may be either unilateral or bilateral.

return to regular activities, long-term evaluations have shown further postsurgical slippage and problematic distribution of forces. These biomechanical shifts may require additional surgery, making this procedure less popular.
MODALmES AND PHARMACOLOGICAL TREATMENTS

Therapeutic modalities are incorporated into the management plan for two main reasons: to relieve pain or to increase blood flow to the area to promote healing. Ice may be applied to the localized area during acute inflammation or an episode of chronic inflammation to interrupt the pain cycle. Ice may also be applied to reduce inflammation so surrounding structures may be relieved of secondary pressure associated with swelling. Once pain levels are controlled, pulsed ultrasound and therapeutic isometric contractions of suirounding musculature may be initiated to promote additional blood flow. This increases collagen, neovascuiar, and myofibroblast production and facilitates localized waste removal and supplies the injured lesion with the needed components for the healing process (Houglum, 2005).
FIGURE 4. MRI view of spondylolisthesis of the lumbar spine (Schoen, 2000).

The use of electrical bone stimulatorsinternally implanted or externalhas increased to promote healing. The treatment duration for the more commonly used

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bilitation objective to prioritize bony healing and gap closure of the pars, the use of such drugs would inhibit or slow this process, preventing the patient from healing. An additional pharmacological consideration involves the improvement of bone density. It is reported that decreased bone density contributes to decreased cortical bone density and trabecular porosity, which are predisposing factors for fatigue fi'actures (Peer & Newsham, 2005). Stress fractures associated with spondylolysis are more likely to occur with associated thinning. If the patient has had a history of osleoporosi.s or osteopenia as diagnosed with a bone density scan (DEXA), alendronate sodium is a pharmacological option. Commonly recognized as Fosamax (Merck & Co., Inc., 2000). its mechanism involves the specific inhibition of osteoclastmediated bone resorption. This process increases bone density and defers the development of fatigue fractures associated with spondylolysis.

Rehabilitation
Rehabilitation is recommended for symptomatic and poslsurgical patients. A long hislory of back pain, persistent ache, low back fatigue, midrange hesitation with spinal bending, lumbosacral ache with extreme range movement for 15 to 30 seconds, and localized tenderness with palpation are indications for treatment (Prentice, 2004). Poslei'ior hamstring pain or weakness and refeired pain into the hip and groin region may also be secondan' indications that support the need for rehabilitation. Rehabilitation is typically conducted conservatively and is guided by patient tolerance and pain (Harvey, 2005). The objectives of the rehabilitation program are to promote bony healing, relieve associated pain, and optimize physical function (Nance & Hickey, 1999; Standaert et al., 2000). Patient education that teaches avoiding positions of irritation is the primary focus to decrease compression and manage flare ups. In the early stages, modest stabilization, flexibility, and strengthening exercises are introduced to take stress off the area of lesion. Hyperextension should be avoided at all times duiing this initial consenative phase. Aftera secure base of stability has been established, more aggressive strengthening and functional activities are added in a pain-free progression. The progression attempts to maintain pain alleviation, improve spinal range of motion, and increase functional abilities (Thein-Nissenbaum & Boissonnault, 2005). The rehabilitation program should progress through the following four stages: control pain and inflammation, daily stabilization, strength and flexibility, and functional movement. Postuial awareness and activities of daily living must be emphasized throughout the rehabilitation phases. The patienl musl be taught the proper biomechanics for sitting, lying, standing, walking, and picking up objects (Schoen, 2000). Educating the patient on how daily activities place the lumbar spine into the mechanism of injuiy must be addressed by the orthopaedic nursing professional and rehabilitation specialists. Neuromuscular stabilization techniques, including activation of the transversus abdominis and otht-i- core stabilizer muscles, assist to control the spondylolysis area

FIGURE 6 Lateral x-ray showing pedicle screw fixation in patient, 3 years following surgery (Schoen, 2000).

e.xternal bone stimulator is typically 1 full year with a daily 30-minute fi"equency signal of 15.3 and 76.6 Hz wilh a peak amplitude of 40 uT (Stasinopoulus, 2003) (see Figure 7). PhaTTnacological inten'enLion may include pain relief medications consisting of a variety of over-the-counter and prescribed phaiTnaceuticals (Harvey. 2005). Although the use of nonsteroidai anti-inflammatory drugs (NSAIDs) Is common for pain control and inflammation in the orthopedic patient, they should nol be use for spondylolysis conditions because they slow ihe bone growth and healing (Houglum, 2005). As a primary reha-

FicuRE 7. Bone stimulators (DePuy Spine, 2006).

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(Prentice, 2004). A neutral spine position must be emphasized early and used throughout the rehabilitation program to reduce pressuie on the pars. Isometric holds in various positions and limited ranges of motion allow the patient to gain strength and control through his or her range of sensitivity. As pain and inflammation subside, strength, endurance, and flexibility training musl be progressed according lo Wolffs law (Wolff, 1982) by gradually increasing the demands placed on the tissue. This stage of rehabilitation prepares the patient for future ftmctional activities. Agility, balance, and coordination e.xercises are incorporated as proprioceptive and plyometric tools. Finally, functional exercises that mimic the patient s primary* movements are incoiporated to allow the naturally execution of functional activities outside of the rehabilitation setting. These are supported through home exercises using various equipment, such as stability balls, foam rollers, hand weights, and other inexpensive home exercise instruments. Tables 1 through 4 demonstrate several examples of exercises that may be incorporated into each stage of treatment. During the treatment plan, extreme care must be taken to avoid extension and rotational shearing motions because these movements place unforgiving stress on the laminar structures of the vertebrae. Therefore, a posterior pelvic tilt is often maintained through strength and flexibility activities (.see Figures 8 and 9). Strengthening stress should be primarily placed on the musculature responsible for spine stabilization. Musculature with oblique and transverse fiber arrangements are essentially what hold each individual vertebral segment in place and protect the bony spine from forceful torsion and everyday motions. Comprehensive core stabilization must be incorporated and include exercises for the serratus anterior, external oblique abdominis, internal oblique abdominis, quadratus lumborum, rotators, erector spinae, and rectus abdominis. Because of the biomechanical and anatomical relationships, accessoi'y muscles must be trained to achieve pelvic stability and promote biomechanical efficiency. Hip flexor, hamstrings, low back extensors, lumbar rota-

tors, lumbar lateral flexors, hip adductors, abductors, and I'otator exercises must be incoiporated. Upper-back and mid-back, chest, and other upper extremity exercises may also be incorporated to encourage an upright posture. Improved daily posture, in conjunction with daily aerobic physical activity, encourages relief from the compressive forces placed on the spine. Once motion control and biomechanical balance are maintained and ihe latigue fracture has been given ample time to heal, a single leg stance and other fimctional movement patterns may be tested to determine return to activity stains. Approximately 5.5 months are needed to return to full activity if appropriate modifications and rehabilitation are followed (Iwamoto et al., 2004). Negative spondylolysis assessment signs, such as frequent exacerbations and decreased fimction, as well as additional diagnostic reevaluation results ultimately determine return to activity.

Psychological Considerations for Rehabilitation

As a patient deals with injury, he or she experiences a grieving process that includes denial, anger, bargaining, depression, and acceptance (Norris, 2000). All stages may not be reached, and relapse may occur at any time. As a healthcare provider, it is important to understand and recognize this impact on the treatment and rehabilitation process lo appropriately and successfully communicate with the patienl. It is imperative to recognize that return to activity does not solely depend on physical improvement but also on emotional and psychological aspects of the individual.
PROTEaiVE BRACING

Bracing lor the spondylolysis patient is often used immediately postsurgery and/or as a conservative means of treating a nonsurgical case. Numerous braces exist, and the selection is dependent on the physician's discretion. During rehabilitation, bracing is not recommended during most ol the strength training phases because it restricts the core movement and actually inhibits mus-

TABLE 1 . PHASE 1 : P A I N MANAGEMENT AND EXERCISE INITIATION

Examples Modalities Ice Heat Ultrasound Electrical Stimulation Bag or whirlpool Wet Depends on patient response Daily bone stimulator for pars Involved musculature stimulation/activation

Flexibility Cardiovascular Therapeutic exercise

Accessory musculature and progress to core musculature Non-weight bearing and with pain-free range of motion Abdominal Multifidus activation Active sitting Isometric pelvic neutral and pelvic tilts Isometric Sit on pillow or stability ball for extended time periods daily

Goals: control pain, reduce uncontrolled inflammation, initiate involved musculature activation, and initiate full patient conditioning,

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TABLE 2. PHASE 2: SiABiLizATroN ANO STRENGTHENING

Exercise Examples Core Abdominal/low back Upright cable rows, thera-band rotations, front cable pull down, body holds, crunches (frontal and oblique), leg extension on stability ball Crunch hold, heel digs, wall sit, controlled superman Single leg press, prone leg extension (not hyperextension) Supine single leg raise, seated leg extension, reverse lung Leg curls, supine stability ball curls, stiff legged dead lift Lateral leg raises, resisted seated ab/adduction, side lunges, standing single leg rotation with thera-band v^aJst resistance Latissimus pull downs, chin-ups, upper trapezium rows, bench press, dumbbell fly, dips

Accessory Isometric Limited range of motion

Core and accessory Gluteus Quads/hip flexor Hamstring Ab/Adduaors Upper core

Goals: activate appropriate musculature needed for daily living, initiate strengthening exercises within a pain-free range, and correct injury mechanism and postural errors to prevent further damage and hasten recovery, increase daily conscious postural awareness, avoid contraindicated positions, maintain flexibility and cardiovascular conditioning.

TABLE 3. PHASE 3 : CONTINUED STRENGTHENING

Concept Application Resistance Repetitions

Exercise Applications Increase repetitions/isometric hold times for endurance development and increase resistance and lower repetitions for strength development (8 to 12 repetitions are ideal for the combination of strength and endurance development) Increased ROM expands the functional range and encourages tissue adaptation Increased difficulty or decreased stability allows an exercise level to progress Use medicine balls, thicker thera-bands, heavier loads for 6 or fewer repetitions for strength Hold isometric contractions for longer, increase repetitions to 20 or more for endurance

Range of motion (ROM)

Increase passive and active stretches and resistance training ranges to develop endrange strength and stability Add perturbations, eliminate visual cues, add distractions, incorporate an unstable surface of support

Difficulty/stability

Goals: progress exercises initiated throughout Phase 2. continually develop strength and endurance, incorporate movement exercises, and lay the foundation for functional exercise progression.

TABLE 4. PHASE 4; PROGRESSIVE FUNCTIONAL PREPARATION

Drills Functional component practice

Repetitive and plyometric in nature Add sport implement Agility/coordination Specific application

Butt kicks, high knees, skips, karakas, rope jumps, speed steps Ball kicks, ball passes, retrieving movements Multidirectional movement around cones and other obstacles with speed alterations Functional and activities of daily living component development

Goals: progressively advance from functional drills to tolerable game- or work-like conditions and appropriately challenge ail cardiovascular, muscular, and proprioceptive components needed to return to full activity.

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all injuries may be progressively applied to each situation. The nursing management focuses on reducing symptoms, maintaining range of motion, coirecting postural iiTegularities, and preventing further structural damage. Oi'thopaedic nurses can contribute to the successful management of spondylolysis patients by working collaboratively with other allied healthcare professionals once an understanding of the anatomy, mechanism of injuiy, treatment, and rehabilitation options are understood and appreciated.
FIGURE 8. Posterior pelvic tilt stabilization and strengthening exercise (Bandy & Sanders, 2001, p. 278). The posterior pelvic tilt exercise is used to encourage the patient to maintain a pelvic-neutral position needed for daily activities, as well as performance-specific activities throughout rehabilitation. This exercise also strengthens the abdominals and gluteal musculature. The following substitutions should be avoided: using legs to move the pelvis rather than the abdominal and back muscles, arching the back, and pushing the abdominals outward instead of contracting the naval toward the spine.
REFERENCES

cle activation. However, the use ol a low-back corset or bract' may be used to temporarily alleviate pain and taiigue (Prentice, 2004). Bracing may also be recommended during higher intensity activities once core stabilization is achieved. With a supportive brace, gross spinal motions are somewhat limi ted, but inter-segmental motion o\' the lower lumbai' spine is not (Siandaert, 2002). This practice limits hyperextension motion and controls vigorous movements while providing constant proprioceptive feedback and awareness, which constantly reminds the patient to maintain appropriate postural and biomechanical positioning. In addition, the extra support provides the patient with psychological confidence that may allow him or her to function in a more natural way.

Conclusion
Although treating spondylolysis may seem complicated, a successful and thorough recovery may be achieved. The basic rehabilitation principles that are applied to

FIGURE 9. Straight leg raisestrengthening and flexibility for spondylolysis patients (Bandy & Sanders, 2001, p. 277).
Orthopaedic Nursing March/April 2007 Volume 26 Number 2

Anderson, M. K., Hall, S. J., & Martin, M. (2000). Spnrts injury management (2nd ed.}. Philadelphia: Lippincott Williams & Wiikins. Bandy, W. D,, Sanders, B. (2001). Therapeutic exercise: Techniques for iulen'ciilion. (pp 277-278) Philadelphia: Lippincott, Williams and Wiikins. DePuy Spine. (2006). Spinalogic, Inc. Retrieved August 18, 2006, h'om www.DePuy.com Hall, S. (2003). Basic biomechanics. New York: McGraw-Hill Higher Education. Hai-vey, C. V. (2005). Spinal surgery patient care. Orthopaedic Nursing. 24. 426-*40. Hodge, B. (1991). Common spinal injuries in athletes. Nursing Clinics of North America. 26, 211-219. Houglum, P. (2005). Therapeutic exercise for musculoskeletal injuries. Champaign: Human Kinetics. Iwamoto, J., Takeda^ T., & Wakano, K. (2004). Returning athletes with sevei'e low back pain and spondylolysis to original sporting activities with conservative treatment. Scandinavian Journal of Medicine & Scieitce in Sports. 14, 346-351. Lenke, L. G., Bridwell, K. H., & O'Brien, M. F. (2000). Fractures and dislocations of the spine. In Pern', C, R., &i Elstrom, J. A. (Eds.), Handbook of fractures (2nd ed.) (pp. 187-227). New York: McGraw-Hill. Mayfield Clinic. The Pans Inter-Articularis. Retrieved August 18, 2006. from www.mayfieldclinic.com. Merck &. Co., Inc. (2000). Fosamax {alendi'onate sodium) Tablets and oral solution. Patient Information [Brochure]. Mihara, H., Onari, K., Cheng, B., David, S., & Zdeblick. T. (2003). The biomechanical effects of spondylolysis and its treatment. Spine. 28(3). 235-238. Nance, D. K., & Hickey, M. (1999). SpondyloHsthesis in children and adolescents. Oilhopaeilic Nursing. 18, 21-27. Nonis, C. (2000). Sports injuries: Diagnosis and management. Oxford: Butterworth-Heineniann. Peer, S., & Newsham, K. (2005, May/June). A case study on osteoporosis in a male athlete: Looking beyond the usual sufipecls. Orthopaedic Nursitig. 24, 193-201. Prentice, W. E. (2004), Rehabilikition techniques for sports medici}ie and athletic training. New York: McGraw Hill. Roca, J.. Iborra, M., Cavanilles-Walker. J., & Alberti, G. (2005). Direct repair of spondylolysis using a new pedicle screw hook fixation: Clinical and CT-assessed study: an analysis of 19 patients. Journal of Spinal Disorders & Techniques, /8(1), 82-89. Rodts, M. F. (2002). Disorders of the spine. In Maher, A. B., Satmond, S. W., & Pellino, T. A.(Eds.), Orthopaedic nursing (3rd ed.) (pp. 515-550). Philadelphia: W. B. Saunders Co. Sairyo, K., Goel, V., Masuda. A., Biyani, A., Ebraheim, N.. Mishiro, T., et al. (2005). Biomechanical rationale of endo.scopic decompression for lumbar spondylolysis as an effective minimally in\'asive procedureA study

based on the finite clement analysis. Minimal Invasive Starkey, C, & Ryan, J. (2002). Evaluation of Orthopedic and Neurosttrgeiy, 48. 119-122. Athletic Injtiries. Philadelphia: F. A. Davis Company. Sairvo. K., Katoh, S., Sasa, T., Yasui, N., Goel, V., Vadapaiii, Stasinopoulus, D. (2003). Review: Treatment of spondylolyS., et al. (2005). Athletes with unilateral spondylolysis sis with external electrical stimulation in young athletes: are at risk of stress fi-acture at the contralateral pedicle A critical literature review. British Journal of Sports and Pars intra-aiiicuiaris: A clinical and biomechanical Medicine, 38. 352-354. study. The American Joumal of Sports Medicine, 33(4). Thein-Nissenbaum, J., & Boissonnault, W. (2005, May). 583-590. Dilferential diagnosis of spondylolysis in a patient with Schoen, D. C. (2000). Adult orthopaedic }iursing. Philadelphia: chronic low back pain. Journal of Orthopaedic & Sports Lippincott. Physical Therapy, 35(5), 319-326. Siandaert, C. (2002). Practical management: Spondylolysis Wolff, J. (1982). Das Gesetz der Transformation derKnochen. in the adolescent athlete. Clinical Journal of Sports Berlin, A. Hirschwald, Published with support from the Medicine. 12, 119-122. Royal Academy oi Science.s in Berlin. English translation Standaert, C, Herring, S., Halpern, B., & King, O. (2000). by P. Maquet and R. Fuiions. Berlin: Springer-Verlag; Spondylolysis. Physical Medicine and Rehabilitation 1986. Clinics of North America, //(4), 785-803.

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CE Test
Spondylolysis: A Review and Treatment Approach
Instructions: Read the article on page 104. Take the test, recording your answers in the test answers section [Section B) of the CE enrollment torm. Each question has oniy one correct answer. Compiete registration intormation (Section A) and course evaluation (Section C). Maii compieted test with registration fee to: Lippincott Wiiiiams & Wiikins, CE Group. 333 7th Avenue, 19th Floor, NewVork. NY 10001. Within 4-6 weeks after your CE enroiiment form is received, you will be notified of your test results. If you pass, you wiii receive a certificate of earned contact hours and answer key. if you fail, you have the option ol taking the test again at no additional cost. A passing score for tills fesf is 13 correct answers. Need CE STAT? Visit www.nursingcenfer.com for immediate resuits, other CE activfties. and your personaiized CE planner tcol. No intemet access? Call 800-787-8985 for other rush service options, Questions? Contact Lippincott Williams & Wilkins: 800-787-8985 Registration Deadline: April 30,2009
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CE TEST QUESTIONS
G E N E R A L P U R P O S E : To introduce spondylolysis from anatomical and biomechanical perspectives ttien further discuss it from a treatment and rehabiiitation perspective including surgical, clinical, and psychological aspects. LEARNING OBJECTIVES: After reading this article and taking this test, you should be able to: 1. Doscrit)e spondylolysis, including characteristics, types, and risk factors. 2. Outline the various treatment options for spondylolysis. 1 . Spondylolysis is a defect fracture, dissolvance, or break in which part of the vertebrae? a, superior articulating process b. neural arch c, inferior articulating process d. ventral body 2. At highest risk for spondylolysis are a. runners. b. tennis players. c. swimmers, d. gymnasts. 3. A complete bilateral fracture of the pars inter-articularis is called a. spondylolisthesis. b. spondylitis. c. spondylizema, d. spondylexartnrosis. 4. Which type of spondylolysis involves lesions of the pars interarticularis resulting from stress fractures, elongation, or acute fractures? a. isthmic b. pathogenic c. degenerative d. dysplastic 5. Which type of spondylolysis involves congenital abnormalities such as an attenuated pars? a. traumatic b. degenerative c. dysplastic d. pathogenic 6. Which type of spondylolysis involves various bone diseases or infection and their complications? a. degenerative b. pathogenic c. isthmic d. traumatic 7. Characteristic of the fracture involved in spondylolysis is that it is a. comminLited. b. impacted. c. nondisplaced. d. steilate. 8. What percentage of those diagnosed with symptomatic spondylolysis is treated surgically? a. b. c. d 9% to 15% 16% to 22% 23% to 29% 30% to 36%

9. Which surgical procedure repairs spondylolysis by placing a bone graft and a stabilizing rod into the pars? a. cerclage wiring loop placement b. translaminar screw fixation c. flie Gill procedure d. pedicle screw hook fixation 10. Which of the following surgical procedures is endoscopic and has a history of post-surgical slippage? a. cerclage wiring ioop placement b. translaminar screw fixation c. the Gili procedure d. pedicle screw-hook fixation

11 . The initial therapeutic modality used to control the pain of spondylolysis is a, ice. b, isometrics. c, pulsed ultrasound. d, eiectricai bone stimulators.

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12. The treatment duration for the more commonly used external bone stimulator is usually a. tliree months. b. six months. c. nine months. d. one year, 13. Non-steroidal anti-inflammatory drugs (NSAIDs) should not be used to treat spondylolysis because they a. cause gastrointestinal bleeding. b. siow bone growth and healing, c. do not relieve the pain adequately. d. cause bone demineralization, 14. Which is often prescribed to defer the development of fatigue fractures associated with spondylolysis? a. acetaminoptien b. atorvastatin c. alendronate d. adatimumab

15. A a. b. c. d.

primary indication for rehabilitation is posterior hamstring pain. upper back tatigue. referred pain into tbe bip region. localized tenderness with palpation.

16. T h e primary focus of rehabiiitation is to teach patients to a. avoid positions of irritation. b. relieve their back pain. c. follow tbe tberapeutic plan. d. learn hyperextension exercises. 17. The final phase of the rehabilitation program is called a. control pain and inflammation. b. daily stabiiization, c. functional movement. d. strength and fiexibiiity. 18. Bracing is recommended a. dunng rehabilitation. b. to alieviate fatigue. c. for strength training, ci. at ail times post surgery.

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Orthopaedic Nursing March/April 2007 Spondylolysis: A Review and Treatment Approach
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Orthopaedic Nursing March/April 2007 Volume 26 Number 2

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