Recurrent Stress and Sport Injuries of the Lumbar Spine
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1 Recurrent Stress and Sport Injuries of the Lumbar Spine Yigal Mirovsky Assaf Harofeh Medical Center Zerifin, Israel
2 Function -Force couple between the upper and lower extremities. - Absorbs and transmit forces while providing support and balance. -Transforms lateral bending into axial torque needed to rotate the pelvis.
3 Structures involved Injuries to the spine affect the limbs and injuries to the limbs affect the spine
4 Structures involved *Bones *Cartilage *Muscles & Ligaments *Nerves
5 Patterns of Injury *Acute injury *Repetitive activity
6 Patterns of Injury Acute injury -Fractures -Tendon ruptures -Disc hernia
7 Repetitive Activity - Contact sport - Non contact Sport
8 Repetitive Activity *Ballet *Skating *Hockey *Football *Weight Lifting *Rowing *Swimming
9 Epidemiology 10% of sports injuries are related to the spine
10 Epidemiology Low Back Pain -82% in elite female rowers. (Howell 1984) Recurrent Hyper flexion motion
11 Epidemiology Low Back Pain -30% in elite female competitive gymnasts. (Jackson 1976) Recurrent Hyper flexion motion
12 Biomechanics Forces involved. -Heperflexion -Hyperextension -Compression - Torsion
13 Mechanism of injury Poor Technique Poor Conditioning Abnormal Anatomy
14 Mechanism of injury Poor Technique 1. Warm up Stretching exercises. Amateurs are injured > Professionals -Limited accessibility -Limited facilities
15 Mechanism of injury Poor Technique 2. Lack of supervision -Advancement to difficult exercises without proper attention to strength. -Correcting seat height. -Personal adjacements of the facility.
16 Mechanism of injury Poor Conditioning Abnormal compensatory lordotic positioning (weight lifting and gymnastics) - Strengthening the abdominal muscles - Pelvic tilt and sit-up exercises
17 Mechanism of injury Anatomical Susceptibility -Adolescent growth spurt. -Muscles. -Congenital anomalies.
18 Physical Activity * LBP is more common in less physically active men. Svensson et al *Sports activity in general is not a risk factor. Frymoyer 1983.
19 Physical Activity 937 former Athletes vs. 620 Referents (Ages 36-64). Videman 1994
20 Physical Activity
21 Physical Activity
22 Physical Fitness *Lesser risk for chronic LBP. *More rapid recovery after LBP episode.
23 Physical Fitness 1652 Fire Fighters - Fittest men had fewer injuries than the less fit. - Less worker compensation claims following fitness program. Cady et al 1985
24 Physical Fitness Fitness training vs. control *Same amount of injuries *Quicker recovery in the trained subjects Dehlin et al 1981
25 Physical Fitness Future LBP is not influenced by *Aerobic capacity Gyntelberg 1974, Troup et al 1987 *Cardiovascular fitness Battie 1989 Long term disability is associated with lower level of aerobic capacity
26 Physical Fitness Improved conditioning have a significant effect on the recovery rate after acute LBP Nachemson 1989
27 Physical Exercises 739 recreational orienteers (mean age 33) The cumulative occurrence of LBP is 47% Van Der Linden 1988
28 Body Response to Injury Spondylolytic Response. Discogenic Response. Apophyseal Fractures. Mechanical Low Back Pain.
29 Biomechanics Tensile & Shear forces over the Pars articularies in normal Flexion and Extension: Newton over 0.75 cm 2 at L5
30 Biomechanics Experimental Pars fracture in 14 years old model 570 Newton's for 1536 cycles
31 Biomechanics POSTURE The amount of anterior shear in the lumbar spine is related to the amount of postural lordosis ( Weiss 1975)
32 Biomechanics Pars interarticularies defect - Recurrent hyperextension (Hall 1986 and Jackson 1974) - Recurrent hyperextension and hyperflexion (Letts 1986)
33 Spondylolytic Response Frequent in sports activities that involves recurrent hyperextension
34 בדיקה גופנית - הסתכלות
35 טווחי תנועה
36 תשובה * Phalen Dickson sign (Knee bent Hip flexed posture). * Pelvic tilt * Protrusion of rib cage * Sacral kyphosis & Hyperlor. * Loss of trunk height. * Flank creases * Hamstring tightness * Rare neurologic findings
37
38 אבחנה מבדלת Spondylolisthesis. Juvenile Disc. Infection. Extraspinal Pathology: -Hips (Perthes, Slipped epiphysis) -Knees Tumor: -Intradural -Extradural
39
40 צילומים
41 MRI
42 דרגת הספונדילוליסטזיס Meyerding
43 Oblique
44 Bone scan -
45 CT
46
47 Classification Macnab Dysplastic spondylolisthesis 2. Isthmic spondylolisthesis 3. Degenerative spondylolisthesis 4. Traumatic spondyloisthesis 5. Pathologic spondylolisthesis -Iatrogenic spondylolisthesis
48 חלוקת הספונדילוליסטזיס
49 Marcetti-Bartolozzi Classification The term Isthmic should be avoided. Pars defect may appear in Acquired and Developmental conditions High Dysplastic: Usually L5-S1, Symptomatic in Adolescents, Wedged L5, Domed and Vertical Sacrum, true Lumbosacral Kyphosis, Progressive Low Dysplastic: Young Adults, Associated with Spina Bifida, Slippage Characterized by translation without angulation or kyphosis
50
51
52 Level -L/5-S/1: 82% -L/4-L/5: 11% -L/2-L/4: 1% -Other: 6%
53 Population 4% of the population Blacks<Whites Women<Men Eskimos 60%
54 Activity -Young Sportsman: 11%-35% -Italian gymnastic team: 50% -Weight lifters: 36% Football, Judo,Throwers, Etc.
55
56 Risk Factor for Progression Clinical. Radiographic.
57 Clinical Risk Factor for Progression Female. Prepubescence. Younger age at presentation.
58 Radiographic Risk Factor for Progression Dysplastic>Isthmic. 30%-50% of slippage. Trapezoidal L5 (Lumbar Index). Domed and Vertical Sacrum. Radiographic Measurements: -Slip angle>55º (Normal 0º-10º). -Lumbosacral Kyphosis<100º. Slip Angle Lumbosacral Angle
59 Radiographic Measurements Sacral Inclination Lumbosacral Angle 20-30
60
61 איפה ה- Pars?
62 Parsinterarticularis defect
63 Mechanism of Injury Hyperlordosis * Shear stresses over the pars are greatest in extension. * Frequent in Scheuermann. * Frequent in sports that are associated with hyperextension.
64 Mechanism of Injury Repetitive Extension
65
66
67 Symptoms Back Pain * Disc Degeneration. * Facet Arthrosis. * Nerve root impingement. * Ligament Tension. Wiltse 1977
68 Symptoms- Leg Pain -Radicular Pain 14% * Disc above. * Fibrocartilagenous mass. * Stretching of nerves.
69
70 Conservative - Rest. - Bracing. - Medication. - Rehabilitation.
71 WHO SHOULD BE FUSED Intractable Pain High Grade and younger than 10y. Isthmic L4-L5? Neurologic signs.
72
73 LEVELS M.R.I Discography
74
75 APPROACH POSTERIOR. ANETRIOR. COMBINED.
76 No instrumentation Children. Less than 50% of listhesis. One level.
77 REDUCTION
78 REDUCTION
79 REDUCTION Cauda Equina. Slip > 50%. Major clinical deformity. Anterior global sagital imbalance. Following failed in situ fusion. Surgeon experience. patient acceptance of risk.
80 Reduction - Stages Laminectomy. Screws insertion. Post.Lat. Fusion. Clamps & Rods. Reduction device. Reduction.
81 EXAMPLE NO. 1
82 EXAMPLE NO. 3
83 Spondylolytic Response Variants: -Stress fracture of the Transverse process. -Stress fracture of the lamina.
84 Spondylolytic Response Variants/Symptoms and Findings -LBP radiating to the thighs. -Painful extension. -Tight Hamstrings. -Normal Neurology.
85 Spondylolytic Response Variants/Treatment -Brace if warm Tc. -Rest. -Stretching. -Laminectomy.
86 Discogenic Response. Frequent in truck drivers
87 Discogenic Response. Associated with increased risk for DD: -Gymnastics -Weight lifting -Soccer
88 Discogenic Response. Disc Degeneration
89 Discogenic Response. Disc Degeneration/Symptoms and Findings -Mechanical LBP. -Decreased motion. -No neurologic deficit.
90 Discogenic Response. Disc Degeneration/Treatmenr -Limited rest/nsaid/limited Bracing. -Physiotherapy. -Muscle Strengthening. -Surgery: *Minimal (IDET, Ablasion,RF) *Fusion *Artificial Disc.
91 Apophyseal Fractures. Recurrent hyperflexion of the spine Scheuermann
92 Apophyseal Fractures. *Skeletally Immature spine -Limbus vertebra -Posterior slip of the vertebral ring.
93 Apophyseal Fractures. *Gymnast. *Thoracolumbar Junction. *1-3 Levels.
94 Apophyseal Fractures. Predisposing Factor Tight Lumbar-Dorsal Fascia that resist foreword flexion of the Lumbar spine
95
96
97 מה הלאה?
98
99
100
101 Apophyseal Fractures. Treatment -Semi rigid Thermoplastic brace (with 15 Degr. Of lumbar lordosis). - For 23 Hours a day until bony healing.
102
103 Apophyseal Fractures. *Restitution of height over 9-12 months. * Resume sport/dance in brace when become asymptomatic.
104
105
106
107 Mechanical Low Back Pain. Cause Mechanical strain on ligaments and joints
108 Mechanical Low Back Pain. Symptoms Non Specific back pain
109 Mechanical Low Back Pain. Physical Findings -Increased Lumbar Lordosis. -Hamstring Spasm. -Tight Lumbar Fascia.
110 Mechanical Low Back Pain. Treatment - Stretching of the tight structures. - Strengthening the Abdominal muscles, pelvic tilt and antilordotic posture. - O degree of anterior opening Brace for 3-4 months if exercises are not effective
111 Muscles and Ligaments Muscles 1. Rupture. 2. Inflammation.
112 Muscles and Ligaments Rupture -Weightlifters. -Discus Thrower -Football -Handball -Basketball -Volleyball -Wreslers. -Boxers
113 Muscles and Ligaments Rupture -Minor rupture. -Usually long back extensors. Symptoms -Piercing pain on each motion. -Local Tenderness
114 Muscles and Ligaments Rupture/Treatment -Rest for 3-8 weeks. -Local heat/analgetics/nsaid -Controlled muscle training after few days.
115 Muscles and Ligaments Inflammation (OVERUSE) -Skiers. -Javelin. -Racket sport -Throwers.
116 Muscles and Ligaments Inflammation /Symptoms -Pain during exertion. -Aching after exertion. -Tenderness over bony attachments. -Pain provocation with triggered contraction.
117 Muscles and Ligaments Inflammation /Treatment -Limited rest. -Local heat. -Analgetics/NSAID/Creams -Local injection of steroids.
118 Take Home Message Sports activity in general is not a risk factor Repetitive motion mainly in hyperextension is the most Dangerous. Be careful in risky population: Adolescent growth spurt, Congenital anomalies. Poor Training Technique, Conditioning and Fitness increase the risk for LBP. Bone and Soft tissue injuries have a better prognosis than Cartilage injuries. Participation in sport in general is not associated in general with increased risk to suffer in the future from LBP.
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