Surgical treatment of L5 spondylolysis in an athlete using custom-made implant

Abstract

Background: Spondylolysis is one of the most common causes of lower back pain in children and adolescents who are professionally involved in sports. It is noted that spondylolysis is observed more often when practicing a number of sports that are associated with repeated axial load and/or hyperextension of the lumbar spine with rotation. In most cases, the treatment of spondylolysis, including cases of its occurrence in professional athletes, is conservative. Surgical treatment is indicated only if conservative treatment is ineffective or if symptoms progress. One of the most common methods of surgical treatment of spondylolysis is to restore the integrity of the arch using various metal structures. The use of additive methods for the manufacture of individual implants currently allows the manufacture of personalized implants with a number of advantages. The article describes the first experience of using an individual implant for surgical treatment of spondylolysis and provides a brief review of the literature.

Clinical case description: A clinical case is presented involving the treatment of a 16-year-old female patient who is a professional gymnast. The report includes a description of the patient’s medical history, clinical manifestations, and specialized diagnostic methods. The preoperative planning, design of a custom implant, the surgical procedure, and long-term treatment outcomes are detailed. A brief literature review highlights the results of conservative treatment, the main indications and methods of surgical therapy for spondylolysis, and justifies the use of a custom-made implant for its surgical treatment.

CONCLUSION: For the surgical treatment of L5 spondylolysis and restoration of vertebral arch integrity without limiting motion on L5-S1 level, the use of a custom-made implant is possible. The use of customized implants may improve outcomes in cases where spondylolysis is combined with abnormalities and individual characteristics of the vertebral bone structures, including the patient’s sports activity.

Keywords

spondylolysis / spondylolysis in athletes / direct spondylolysis repair / additive technologies / personalized implant / custom-made implant

References

[1] Wall J, Cook DL, Meehan WP 3rd, Wilson F. Adolescent athlete low back pain diagnoses, characteristics, and management: A retrospective chart review. J Sci Med Sport. 2024:27(9):618–623. doi: 10.1016/j.jsams.2024.05.004

[2] Wall J., Cook D.L., Meehan W.P. 3rd, Wilson F. Adolescent athlete low back pain diagnoses, characteristics, and management: A retrospective chart review // J Sci Med Sport. 2024. Vol. 27, № 9. Р. 618–623. doi: 10.1016/j.jsams.2024.05.004

[3] Choi JH, Ochoa JK, Lubinus A, et al. Management of lumbar spondylolysis in the adolescent athlete: a review of over 200 cases. Spine J. 2022;22(10):1628–1633. doi: 10.1016/j.spinee.2022.04.011

[4] Choi J.H., Ochoa J.K., Lubinus A., et al. Management of lumbar spondylolysis in the adolescent athlete: a review of over 200 cases // Spine J. 2022. Vol. 22, № 10. Р. 1628–1633. doi: 10.1016/j.spinee.2022.04.011

[5] Gamada H, Tatsumura M, Okuwaki S, et al. Characteristics of lumbar spondylolysis: L5 versus non-L5. BMC Musculoskelet Disord. 2024;25(1):55. doi: 10.1186/s12891-024-07190-x

[6] Gamada H., Tatsumura M., Okuwaki S., et al. Characteristics of lumbar spondylolysis: L5 versus non-L5 // BMC Musculoskelet Disord. 2024. Vol. 25, № 1. Р. 55. doi: 10.1186/s12891-024-07190-x

[7] McDonald BT, Hanna A, Lucas JA. Spondylolysis. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513333/

[8] McDonald B.T., Hanna A., Lucas J.A. Spondylolysis. [Updated 2023 Aug 7]. В: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2024. Режим доступа: https://www.ncbi.nlm.nih.gov/books/NBK513333/

[9] Mortazavi J, Zebardast J, Mirzashahi B. Low Back Pain in Athletes. Asian J Sports Med. 2015;6(2):e24718. doi: 10.5812/asjsm.6(2)2015.24718

[10] Mortazavi J., Zebardast J., Mirzashahi B. Low Back Pain in Athletes // Asian J Sports Med. 2015. Vol. 6, № 2. Р. e24718. doi: 10.5812/asjsm.6(2)2015.24718

[11] Mironov SP, Burmakova GM, Orletsky AK, Tsykunov MB, Andreev SV. Lumbosacral pain in athletes and ballet dancers: spondylolysis and spondylolisthesis. N.N. Priorov Journal of Traumatology and Orthopedics. 2019;(2):5–13. doi: 10.17116/vto20190215

[12] Миронов С.П., Бурмакова Г.М., Орлецкий А.К., Цыкунов М.Б., Андреев С.В. Пояснично-крестцовые боли у спортсменов и артистов балета: спондилолиз и спондилолистез // Вестник травматологии и ортопедии им. Н.Н. Приорова. 2019. № 2. С. 5–13. doi: 10.17116/vto20190215

[13] Patel DR, Kinsella E. Evaluation and management of lower back pain in young athletes. Transl Pediatr. 2017;6(3):225–235. doi: 10.21037/tp.2017.06.01

[14] Patel D.R., Kinsella E. Evaluation and management of lower back pain in young athletes // Transl Pediatr. 2017. Vol. 6, № 3. Р. 225–235. doi: 10.21037/tp.2017.06.01

[15] Hasler CC. Back pain during growth. Swiss Med Wkly. 2013;143:w13714. doi: 10.4414/smw.2013.13714

[16] Hasler C.C. Back pain during growth // Swiss Med Wkly. 2013. Vol. 143. Р. w13714. doi: 10.4414/smw.2013.13714

[17] Fujii K, Katoh S, Sairyo K, Ikata T, Yasui N. Union of defects in the pars interarticularis of the lumbar spine in children and adolescents. The radiological outcome after conservative treatment. J Bone Joint Surg Br. 2004;86(2):225–31. doi: 10.1302/0301-620x.86b2.14339

[18] Fujii K., Katoh S., Sairyo K., Ikata T., Yasui N. Union of defects in the pars interarticularis of the lumbar spine in children and adolescents. The radiological outcome after conservative treatment // J Bone Joint Surg Br. 2004. Vol. 86, № 2. Р. 225–31. doi: 10.1302/0301-620x.86b2.14339

[19] Sairyo K, Sakai T, Yasui N. Conservative treatment of lumbar spondylolysis in childhood and adolescence: the radiological signs which predict healing. J Bone Joint Surg Br. 2009;91(2):206–9. doi: 10.1302/0301-620X.91B2.21256

[20] Sairyo K., Sakai T., Yasui N. Conservative treatment of lumbar spondylolysis in childhood and adolescence: the radiological signs which predict healing // J Bone Joint Surg Br. 2009. Vol. 91, № 2. Р. 206–9. doi: 10.1302/0301-620X.91B2.21256

[21] Mironov SP, Cykunov MB, Burmakova GM, Andreev SV. Lumbosacral pain in athletes and ballet dancers: spondylolysis and spondylolisthesis. Conservative treatment. N.N. Priorov Journal of Traumatology and Orthopedics. 2020;27(1):11–18. doi: 10.17816/vto202027111-18

[22] Миронов С.П., Цыкунов М.Б., Бурмакова Г.М., Андреев С.В. Пояснично-крестцовые боли у спортсменов и артистов балета: спондилолиз и спондилолистез. Консервативное лечение // Вестник травматологии и ортопедии им. Н.Н. Приорова. 2020. Т. 27, № 1. С. 11–18. doi: https://doi.org/10.17816/vto202027111-18

[23] Tatsumura M, Gamada H, Okuwaki S, et al. Union evaluation of lumbar spondylolysis using MRI and CT in adolescents treated conservatively. J Orthop Sci. 2022;27(2):317–322. doi: 10.1016/j.jos.2021.01.002

[24] Tatsumura M., Gamada H., Okuwaki S., et al. Union evaluation of lumbar spondylolysis using MRI and CT in adolescents treated conservatively // J Orthop Sci. 2022. Vol. 27, № 2. Р. 317–322. doi: 10.1016/j.jos.2021.01.002

[25] Nicol RO, Scott JH. Lytic spondylolysis. Repair by wiring. Spine (Phila Pa 1976). 1986;11(10):1027–30. doi: 10.1097/00007632-198612000-00011

[26] Nicol R.O., Scott J.H. Lytic spondylolysis. Repair by wiring // Spine (Phila Pa 1976). 1986. Vol. 11, № 10. Р. 1027–30. doi: 10.1097/00007632-198612000-00011

[27] Buck JE. Direct repair of the defect in spondylolisthesis. Preliminary report. J Bone Joint Surg Br. 1970;52(3):432–7.

[28] Buck J.E. Direct repair of the defect in spondylolisthesis. Preliminary report // J Bone Joint Surg Br. 1970. Vol. 52, № 3. Р. 432–7.

[29] Morscher E, Gerber B, Fasel J. Surgical treatment of spondylolisthesis by bone grafting and direct stabilization of spondylolysis by means of a hook screw. Arch Orthop Trauma Surg (1978). 1984;103(3):175–8. doi: 10.1007/BF00435550

[30] Morscher E., Gerber B., Fasel J. Surgical treatment of spondylolisthesis by bone grafting and direct stabilization of spondylolysis by means of a hook screw // Arch Orthop Trauma Surg (1978). 1984. Vol. 103, № 3. Р. 175–8. doi: 10.1007/BF00435550

[31] Gillet P, Petit M. Direct repair of spondylolysis without spondylolisthesis, using a rod-screw construct and bone grafting of the pars defect. Spine (Phila Pa 1976). 1999;24(12):1252–6. doi: 10.1097/00007632-199906150-00014

[32] Gillet P., Petit M. Direct repair of spondylolysis without spondylolisthesis, using a rod-screw construct and bone grafting of the pars defect // Spine (Phila Pa 1976). 1999. Vol. 24, № 12. Р. 1252–6. doi: 10.1097/00007632-199906150-00014

[33] Tokuhashi Y, Matsuzaki H. Repair of defects in spondylolysis by segmental pedicular screw hook fixation. A preliminary report. Spine (Phila Pa 1976). 1996;21(17):2041–5. doi: 10.1097/00007632-199609010-00023

[34] Tokuhashi Y., Matsuzaki H. Repair of defects in spondylolysis by segmental pedicular screw hook fixation. A preliminary report // Spine (Phila Pa 1976). 1996. Vol. 21, № 17. Р. 2041–5. doi: 10.1097/00007632-199609010-00023

[35] Gillis CC, Eichholz K, Thoman WJ, Fessler RG. A minimally invasive approach to defects of the pars interarticularis: Restoring function in competitive athletes. Clin Neurol Neurosurg. 2015;139:29–34. doi: 10.1016/j.clineuro.2015.08.024

[36] Gillis C.C., Eichholz K., Thoman W.J., Fessler R.G. A minimally invasive approach to defects of the pars interarticularis: Restoring function in competitive athletes // Clin Neurol Neurosurg. 2015. Vol. 139. Р. 29–34. doi: 10.1016/j.clineuro.2015.08.024

[37] Ghobrial GM, Crandall KM, Lau A, Williams SK, Levi AD. Minimally invasive direct pars repair with cannulated screws and recombinant human bone morphogenetic protein: Case series and review of the literature. Neurosurg Focus. 2017;43(2):Е6. doi: 10.3171/2017.5.FOCUS17153

[38] Ghobrial G.M., Crandall K.M., Lau A., Williams S.K., Levi A.D. Minimally invasive direct pars repair with cannulated screws and recombinant human bone morphogenetic protein: Case series and review of the literature // Neurosurg Focus. 2017. Vol. 43, № 2. Р. Е6. doi: 10.3171/2017.5.FOCUS17153

[39] Syundyukov АR, Nikolayev NS, Kuzmina VА, et al. Minimally invasive reconstruction of vertebral arch in spondylolisthesis in children and adolescents. Sovremennye Tehnologii v Medicine. 2021;13(5):62–8. doi: 10.17691/stm2021.13.5.08

[40] Syundyukov А.R., Nikolayev N.S., Kuzmina V.А., et al. Minimally invasive reconstruction of vertebral arch in spondylolisthesis in children and adolescents // Sovremennye Tehnologii v Medicine. 2021. Vol. 13, № 5. Р. 62–8. doi: 10.17691/stm2021.13.5.08

[41] Tatsumura M, Okuwaki S, Gamada H, et al. A Novel Technique for Pars Defect Direct Repair with a Modified Smiley Face Rod for Spondylolysis and Isthmic Spondylolisthesis. Spine Surg Relat Res. 2023;7(4):396–401. doi: 10.22603/ssrr.2023-0021

[42] Tatsumura M., Okuwaki S., Gamada H., et al. A Novel Technique for Pars Defect Direct Repair with a Modified Smiley Face Rod for Spondylolysis and Isthmic Spondylolisthesis // Spine Surg Relat Res. 2023. Vol. 7, № 4. Р. 396–401. doi: 10.22603/ssrr.2023-0021

[43] Urrutia J, Zamora T, Cuellar J. Does the Prevalence of Spondylolysis and Spina Bifida Occulta Observed in Pediatric Patients Remain Stable in Adults? Clin Spine Surg. 2017;30(8):E1117–E1121. doi: 10.1097/BSD.0000000000000209

[44] Urrutia J., Zamora T., Cuellar J. Does the Prevalence of Spondylolysis and Spina Bifida Occulta Observed in Pediatric Patients Remain Stable in Adults? // Clin Spine Surg. 2017. Vol. 30, № 8. Р. E1117–E1121. doi: 10.1097/BSD.0000000000000209

[45] Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am. 1984;66(5):699–707.

[46] Fredrickson B.E., Baker D., McHolick W.J., Yuan H.A., Lubicky J.P. The natural history of spondylolysis and spondylolisthesis // J Bone Joint Surg Am. 1984. Vol. 66, № 5. Р. 699–707.

[47] Kuleshov AA, Vetrile MS, Shkarubo AN, et al. Additive technologies in surgical treatment of spinal deformities. N.N. Priorov Journal of Traumatology and Orthopedics. 2018;(3–4):19–29. doi: 10.17116/vto201803-04119

[48] Кулешов А.А., Ветрилэ М.С., Шкарубо А.Н., и др. Аддитивные технологии в хирургии деформаций позвоночника // Вестник травматологии и ортопедии им. Н.Н. Приорова. 2018. № 3–4. С. 19–29. doi: 10.17116/vto201803-04119

[49] Patent RUS № 2798704 C1/ 06/23/23. IPC A61B 17/70. Kuleshov AA, Vetrile MS, Zakharin VR, et al. A method for surgical fixation of the zone of bilateral spondylolysis of the L5 vertebra using a metal fixing device. Available from: https://patents.google.com/patent/RU2798704C1/ru (In Russ.) EDN: IVKFIL

[50] Патент РФ на изобретение № 2798704 C1/ 23.06.23. МПК A61B 17/70. Кулешов А.А., Ветрилэ М.С., Захарин В.Р., и др. Способ хирургической фиксации зоны двухстороннего спондилолиза L5 позвонка с использованием металлического фиксирующего устройства. Режим доступа: https://patents.google.com/patent/RU2798704C1/ru EDN: IVKFIL

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