Lumbar Spondylolysis - Nitin Bhatia, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have with me, Dr. Nitin Bhatia. Dr. Bhatia is a spine surgeon, who is the Chief of Spine Surgery, at the University of California Irvine. Dr. Bhatia did his undergraduate training at Stanford. He then went on to Baylor College of Medicine where he completed his M.D. degree. From there, he did orthopaedic surgery training at UCLA. From there, he finished a spine fellowship at the University of Miami. Today, he practices complex spine surgery at University of California Irvine. Good day, Dr. Bhatia.

Dr. Nitin Bhatia: Thank you for having me.

Dr. Sechrest: Dr. Bhatia, today what I would like to turn to now is a relatively common condition of young adults primarily, and sometimes teenagers, but it’s a condition that’s known by this long fancy word called spondylolysis. What does that mean?

Dr. Nitin Bhatia: Spondylolysis means, actually, fracture of the spine; and we have a few different names for spondylolysis. Spondylolysis is the fancy orthopaedic and spine term that we use. The other names for it are ‘pars fracture’ or ‘pars defect’.

Dr. Sechrest: Now let’s define some things. What we’re really talking about is spondylolysis and it usually occurs in the low back. That’s where we’d see it the most, or what’s sometimes called the lumbar spine. You said fracture. So is this something that we get from a car wreck or some type of injury? How does it occur, how does that fracture occur?

Dr. Nitin Bhatia: Interesting, interesting. It’s usually not a specific accident that causes it. It usually occurs, as you mentioned, in the low part of the lumbar spine, or the low part of the low back. Usually at L5, which is the lowest level of the lumbar spine, and it occurs not after a specific trauma, but after repetitive trauma usually hyperextensions; so people who have to extend their low backs repetitively develop this gradual break in that low part of the back.

Dr. Sechrest: We used to see that in, I guess 20 years ago when I was practicing, we used to see this in two populations: gymnasts, because gymnastics were just getting very popular, and cheerleaders, in some; and then in boys or young adult males, we would see it in football players. Now I understand today that we’re seeing it in a lot more different types of activities.

Dr. Nitin Bhatia: You’re exactly right. Those two populations, it’s the teenage gymnasts who do a lot of backbends and extension, as well as football linemen, are kind of classic populations. The reason linemen get it is because when they push on each other in practice and in games, there is a lot of extension of that low back that’s quite repetitive and forceful. Nowadays, as sports have kind of expanded and we have some more of these extreme sports, we see it in different kinds of athletes as well. I see frequently in surfers, and snowboarders, and volleyball players, because of my practice in Southern California, as well as the increasing popularity of these sports with young adults.

Dr. Sechrest: My understanding, my recollection, from long ago, was that if you took x-rays of 100 people you’d probably see this in 6 out of that 100. You would probably be able to pick it up, and some of those folks would not have pain. You would not necessarily be taking those x-rays because the person had back pain. You may be taking them for pre-employment screening or for some other reason and you would see these pars defects, then you would question the patient and they’ve never had any back pain. How likely is that?

Dr. Nitin Bhatia: It’s actually fairly common to see these. As you mentioned, if you took x-rays of 100 teenagers, probably at least a few of them have these fractures and a lot of them are asymptomatic. The good news is, even if you have this pars defect or pars fracture, you can still lead a very pain-free normal life. In fact, a very significant percentage of linemen in the NFL or professional football have these and obviously play high-level sports with them.

Dr. Sechrest: It’s interesting, too. I used to have a lot of patients who would come in and they had been told, or somewhere they’d gotten the information that they were born with this defect that this was a defect that somehow they were born with. My understanding is that this is highly, highly unlikely. That these are defects that occur at some point in childhood and then just don’t heal.

Dr. Nitin Bhatia: Right. There is some discussion amongst us, those in my community, can these occur when you’re very young or even be essentially congenital? If that does occur it’s extremely, extremely rare, and the vast majority of them, 99%+, occur when kids are usually between 11 and 16 years of age from this repetitive hyperextension type injury.

Dr. Sechrest: This is a type of a stress fracture. I mean, I think I’m interpreting what you’re saying is that this is a stress fracture that never heals. It creates scar tissue between the two bone fragments, never heals, bone to bone.

Dr. Nitin Bhatia: Correct.

Dr. Sechrest: Now do these things heal sometimes?

Dr. Nitin Bhatia: Sometimes they do, and the people who we see them heal on are especially people who only have them on one side of their back, because the other side holds everything in place while the one side that’s injured can heal. But usually if you have them on both sides, and especially if the bones have separated a little bit, they usually don’t heal but instead get some kind of fibrous, kind of scar tissue that holds everything in place and allows them to become pain-free and live a normal life.

Dr. Sechrest: Okay. Well, let’s go back and sort of define what type of a patient should be concerned about a spondylolysis. What type of patient do you see in your office and you immediately look at that patient and say, “I’m really concerned that you may have spondylolysis”. What is that typical patient?

Dr. Nitin Bhatia: The typical patient is a teenage patient who is a high-level athlete who comes in and says, “My back’s been hurting me and I’m not exactly sure what caused it”; a lot of pain in the low back, and it’s stopping them now from doing their activities. Most high-level teenage athletes aren’t going to stop performing their athletic activities unless they absolutely need to or have to; and so, if they’re coming in to see me, being that high-level an athlete, something’s possibly going on and that’s who I really get concerned about.

Dr. Sechrest: This is just back pain. It doesn’t spread into the legs. There are no nerves pinched or anything. This is just back pain.

Dr. Nitin Bhatia: Correct.

Dr. Sechrest: Okay. Tell me how you work that patient up? What do you do next to try to figure out what’s going on with this person?

Dr. Nitin Bhatia: Well, we’ve actually recently published a study looking at this group of patients, the teenage and adolescent patients who come in with back pain and we’re not sure what’s going on; and what we’ve found is that the majority of them can be diagnosed if they have a problem at the initial visit, with a good history, a good physical exam, and even plain x-rays. Sometimes though, with this spondylolysis, you can’t see it on a plain x-ray because, even though there’s a small crack, it hasn’t moved and so you don’t see that gap on the x-ray. Then frequently we’ll do a different test, sometimes called a bone scan, which looks at areas of the bone that are healing or injured and it can really very useful for picking up problems in this age group.

Dr. Sechrest: Now, that’s somewhat different than our typical response to any sort of back pain in any other patient. We typically go from no x-rays to an MRI scan. Why not an MRI scan?

Dr. Nitin Bhatia: Well, an MRI scan can actually be useful, and some people suggest getting an MRI scan instead of the bone scan. Nowadays MRI scans are so easy to obtain that it’s probably a reasonable alternative. The reason I prefer the bone scan is because MRI scans are really good at looking at things that are soft – the nerves, the spinal cord, and the discs, and are only okay at looking at the bones. It may show some swelling in the area of the fracture, but it’s somewhat difficult on an MRI scan to really see that fracture very well. With the bone scan, we can do a bone scan plus we do something called a SPECT scan, which is a specialized form of CT scan, which really let’s us see the bone and see exactly what part of the bone has this increased activity from the fracture. So that’s my preference.

Dr. Sechrest: Well, let’s talk a little bit about treatment, at this point, then. If you’ve diagnosed this as a spondylolysis, what are my options for treatment? What are you going to tell that teenager, or that young adult, and possibly his parents?

Dr. Nitin Bhatia: Well, fortunately, the vast majority of these patients do not require any sort of surgery or intervention in regards to injections or surgical treatment. What we try to do first of all is symptomatic care to allow it to heal. So usually that involves activity restriction, frequently stopping sports for approximately 6 weeks to 3 months. If that doesn’t help and the pain continues, we may try a brace that holds the spine in a good position for approximately 3 months. If the pain is still ongoing we may even try things like more physical therapy, even some local injections, plus these are usually teenage and adolescents, we try to avoid surgery if at all possible.

Dr. Sechrest: Now, the ideal situation would be that this is picked up early as a fracture with healing potential and you restrict the patient or brace them and it heals. Will all of them heal? Are these going to heal?

Dr. Nitin Bhatia: Probably not all of them will heal. In fact, probably the majority of them do not heal, but because the body can find a way to keep that area stiff and stable by making extra kind of scar tissue around it, even though it’s not fully healed, and if I got an MRI scan or CT scan I could see the little gap between the bones; they essentially are asymptomatic.

Dr. Sechrest: When do you give up on trying to heal a defect? Do you have the typical spondylolysis that you fully expect to heal and you use very aggressive treatment such as bracing and anything you can try to do, restriction, to try to get it to heal; when do you give up on having it heal and let the patient go back to their regular activities?

Dr. Nitin Bhatia: What we do is if we’ve done everything, if we’ve done the kind of restriction of activity and some bracing and the pain is still going on, we sometimes can get a new bone scan or new scan to take a look. If the bone scan shows that the healing potential is gone, we can get them back doing activities to try to increase the muscle tone and make them a little more pain-free by making the muscles stronger in the low back.

Dr. Sechrest: Let me understand this, what you’re saying is that if you do a bone scan, and you see the bone scan is hot, what we call hot – has increased uptake – you assume that that fracture still has healing potential, so you will restrict that patient?

Dr. Nitin Bhatia: Correct.

Dr. Sechrest: If you do a bone scan, either the first one or 6 weeks later or 3 months later, and it’s cold – it’s not showing any uptake on the bone scan – you assume that that fracture is not going to heal at that point?

Dr. Nitin Bhatia: Correct. The healing potential is probably gone, and in fact if someone comes to me on Day 1 and says, “I have back pain”, and we get the bone scan and it’s cold – there’s no increased uptake – probably that fracture has been there for quite some time and the body has tried to heal it, but it hasn’t healed.

Dr. Sechrest: So, in that case, you wouldn’t even try to heal it. You would essentially treat the symptoms and try to treat their back pain.

Dr. Nitin Bhatia: Correct.

Dr. Sechrest: Now, there are a couple of other things I want to ask you about because I’ve seen them used in the past. One is a bone stimulator, and we use bone stimulators to try to get spine fusions to heal better, we’ve used them in the tibia for years, we use them in all bones that are slow to heal. Is there any place for a bone stimulator to try to get one of these pars fractures to heal?

Dr. Nitin Bhatia: I think that there is. The good thing about a bone stimulator is that it probably doesn’t harm anything, in fact, almost for sure it doesn’t, and it’s very easy to use. It’s essentially a small iPod-looking device with two stickers, or maybe a small brace that goes around the back. It emits electromagnetic waves, or ultrasound waves, that help the bone cells, or stimulates them, to heal. Now the scientific studies show that it may help somewhat. It’s not, if you get a bone stimulator you’re going to heal and if you don’t, you don’t. It’s maybe a few percentage points. But since the risks are extremely low and the benefit is there I think it’s very worthwhile trying.

Dr. Sechrest: So you have to decide whether it’s worth the cost basically?

Dr. Nitin Bhatia: Right.

Dr. Sechrest: Sometimes the way I tell patients, well if you’re chomping at the bit, you’re a high school elite athlete and I’m going to tie you up for 6 weeks, do you want to add the extra cost and another tool to try to get it to heal? And let them make the choice.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: The other thing is what role does surgery have in trying to deal with the spondylolysis, or even a pars fracture? Is there any role for surgery in this treatment?

Dr. Nitin Bhatia: There is a role for surgery, and I think the people who benefit from surgery are people who have pain that is ongoing and that doesn’t respond to fairly extensive conservative treatment. I would treat them for, personally, at least 6 months maybe even a year before we consider surgery; or the high-level athlete who really needs to get to competition fairly quickly.

Dr. Sechrest: What are we talking about? Are we talking about actually going in and trying to repair the fracture? Or are we talking about a more extensive operation like a fusion or something like that?

Dr. Nitin Bhatia: Usually we go in and we try to repair the fracture, especially if the fracture has not moved and the bones haven’t slipped yet. Repairing the fracture can work very well and there are a variety of different techniques for them, but they all essentially use the same thing: you go in and you clean the fracture areas; put some bone graft there, sometimes from the local area, sometimes from the bone bank, and sometimes from the patient’s hip or pelvis; and stabilize it to allow it to heal. Fortunately we usually don’t have to perform a fusion for this particular problem.

Dr. Sechrest: That’s more likely long-term issues with adults that have degeneration at that segment as well.

Dr. Nitin Bhatia: That’s exactly right.

Dr. Sechrest: You know, it’s interesting. We’re doing more and more with different chemicals that we can inject or put into with bone graft or whatever to try to stimulate bone to grow. Are you familiar with any studies or any procedures that are actually just injecting that type of chemical right into that fracture? You know, rather than doing an operation, injecting and getting it to heal?

Dr. Nitin Bhatia: You know, that’s something that we’re working on in the labs. We’ve done it in animals where we can actually take certain proteins and chemical that are from the body, make them in the lab, and then inject them into, we use, rats or rabbits to form bone and create it where we want it. It hasn’t been done in humans and probably the human trials for this are, I’m guessing, 10 or 15 years away. But that’s, if we had the same conversation 30 years from now, probably that’s the treatment we’ll use for.

Dr. Sechrest: So you think at some point we’re just going to be localizing that fracture, getting a bone scan if we’re still using those 30 years from now, seeing that healing potential, and then simply putting a little needle in there and injecting some chemicals and get that bone to knit itself back together.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: That would be a wonderful thing, I think. Tell me a little bit about what the complications and the long-term sequellae of having a spondylolysis are. If I’ve got a child, if it’s my teenage son and he’s an elite athlete, we see he’s got a pars fracture, it doesn’t heal; what’s going to happen the rest of his life?

Dr. Nitin Bhatia: Well, as we mentioned earlier, this happens not uncommonly in the teenage population, and a lot of them don’t heal. Fortunately the vast majority of those teenagers go on to live a normal adult life. They can do everything they want to do, activity-wise, for the teenage women they can have children when they grow up with no problems; but a small subset of them do have early and advanced degeneration of that area, the L5-S1 area, probably because having that fracture and having it not heal, changes the biomechanics of that, and puts increased forces on the joints and the back of the spine as well as the disc in-between those bony areas.

Dr. Sechrest: So the pain that you see coming from that is really more from the disc degeneration of the segment rather than the defect itself?

Dr. Nitin Bhatia: Correct.

Dr. Sechrest: And what do you do in that case? If it just continues to get painful, off and on, finally just becomes painful, what are my choices at that point?

Dr. Nitin Bhatia: Well, usually, that takes 15 or 20 years to progress. We see people who come in their young or mid-thirties and say, “I’ve never had back pain before”. Many of them don’t even know they ever had this fracture as a teenager, and we get the x-rays and most of their spine looks absolutely pristine, as we would expect in someone in their thirties, but that bottom level is collapsed, almost bone-on-bone, and if we get an MRI scan we see that the disc is completely gone or almost completely gone and there’s even some swelling in the bones from that. Fortunately, those patients respond very well to surgery. We can try a variety of other treatments including physical therapy and injections, but because it’s an advanced degenerative problem, with that underlying fracture and instability, surgery is the ultimate treatment for it.

Dr. Sechrest: What do you use to make that decision – surgical – when are you going to tell that patient that surgery is their best option and conservative care is just not worth pursuing?

Dr. Nitin Bhatia: It really depends on their quality of life. This is not a problem that’s going to paralyze the patient. It’s not a problem that they’re going to wake up and not be able to move their legs or feet. It’s just a problem that, eventually, as it becomes worse and worse, it may affect their quality of life because of their pain.

Dr. Sechrest: Do you have any advice to patients? Especially, I think, the young patient that’s just found out they have a spondylolysis, do you have any advice in terms of what they should do to try to postpone that need to prevent anything? What can they do to try to manage this for as long as possible without surgery?

Dr. Nitin Bhatia: Well, I think those things are extremely important. This is a young group of patients. Many of them are very active. Many of them [parents], even though they know that at some point they’ll need surgery, would like to put it off for 5 years or 10 years, because their children are very young or a variety of other reasons. So what we do is we start them with physical therapy to strengthen the core muscles, the muscles in the abdomen and low back that are surrounding this injured area. We also make sure that their weight is under control so, if a patient is overweight, weight loss and appropriate weight maintenance is critically important. If patients are smoking, we try to get them to stop smoking, because smoking can increase the rate of degeneration of that already injured level.

Dr. Sechrest: So normal good health things – no smoking, ideal body weight, and exercise.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: It’s amazing how many things that helps, and this is one of them. Well, thanks. That’s an interesting discussion, I think, about spondylolysis, which is a confusing problem for a lot of people. I think that they do get confused between spondylolysis and another term that’s very close to that called spondylolisthesis. What’s the relationship between the two?

Dr. Nitin Bhatia: Well, there’s a very close relationship between them and I think that’s why a lot of people get confused. Spondylolysis is the actual small fracture that occurs at that bottom L5-S1 level, but spondylolisthesis is the abnormal movement of the bones. So L5 will slide, actually, and move in front of S1. Spondylolysis, which is the fracture, can lead to the spondylolisthesis, which is the abnormal movement. But you can have the fracture, the spondylolysis, without the spondylolisthesis. The bones can stay in good position.

Dr. Sechrest: Oh, that’s much clearer, I think. That really sums it up. Any last comments about spondylolysis, either in terms of the natural history of the disease, advice to patients, or anything we haven’t covered in this discussion?

Dr. Nitin Bhatia: Well, I think, it’s always scary for a family, both a teenage athlete as well as parents; when they find out that they have a fracture in their back. But fortunately, through good care with a good spine surgeon or orthopaedic surgeon, we can treat those fractures well; usually we can avoid surgery; and they can live a very normal life for the rest of their life.

Dr. Sechrest: Well, thanks. Good information and I think this is good advice for patients. Thank you very much.

Dr. Nitin Bhatia: Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you’re an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you’ll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.