Weighing the Treatment Options for Spondylolysis in Young Athletes
Spondylolysis is a stress fracture of a bone in the spine that can cause back pain in growing children and adolescents. If doctors find this injury early, it has an excellent chance of healing with rest, and young athletes can return to sports with no restrictions and little or no pain. (See When Back Pain Stops a Young Athlete, Think Spondylolysis.)
But “rest” may mean an athlete must stop sports for up to three months or the better part of a season. To avoid resting an athlete who doesn’t need it, it’s critical to know how severe the stress injury is and if the pain is actually coming from an injury that can heal.
“Advanced imaging tests can help make a precise diagnosis,” says Stan Herring, M.D., cofounder of The Sports Institute at UW Medicine and team physician to the Seattle Seahawks and Seattle Mariners. These tests can identify with reasonable certainty whether an athlete will benefit from a lot of rest or little to no rest.
But they also have a downside. Imaging tests such as computed tomography (CT) and bone scans can expose young athletes to potentially dangerous ionizing radiation at an especially vulnerable time in their lives. To make an informed decision about the right amount of rest for spondylolysis, it’s important to consider whether the benefits of advanced imaging outweigh the possible risks.
Amount of rest depends on treatment severity
When doctors who specialize in back pain examine young athletes and ask them about their symptoms, they often suspect a stress fracture after ruling out other problems. But without imaging they don’t know how recently the injury developed, how much it has weakened the bone or how much rest an athlete needs to get better.
For example, in a 2017 study that analyzed 63 children and adolescents, all very early stress reactions and the vast majority of early stress fractures healed within an average of 2 ½ months. (See table.) More complicated progressive stress fractures healed within an average of 3 ½ months. But old or chronic fractures did not benefit from rest at all, and did not heal. For these, experts often recommend just enough rest to relieve pain.
Source: Sakai 2017
Weighing radiation risks in kids
Advanced imaging isn’t necessary to decide on treatment, but it can be very helpful.
Plain x-rays and magnetic resonance imaging (MRI) often do not show the very early stress reactions and early stress fractures that have the greatest chance of healing with extended rest. Computed tomography and bone scans (also called nuclear medicine bone scans) can show these problems. When done at a hospital that adjusts its machines to deliver lower radiation doses for children, a single CT scan or bone scan exposes kids to less than the annual background radiation in Seattle.
Still, the risks of cancer from CT-induced radiation “are real,” write prominent researchers in the journal JAMA Pediatrics. Repeated exposure to large doses over time can lead to cancer. “Children are particularly vulnerable because the younger you are when you are exposed to radiation, the higher your lifetime risk of cancer… The elimination of unnecessary imaging is the ordering clinician’s obligation, and the family can play a role.”
There are other considerations in the imaging decision as well. Imaging tests can be costly. And advanced imaging increases the chance of finding something that looks abnormal but likely will never create any meaningful problems; these can lead to unnecessary treatments or more tests that may turn up still more meaningless findings.
Making a decision
In short, parents will want to talk to their child’s doctor and discuss whether the benefits of advanced imaging outweigh the risks, and decide how much imaging they want their child to receive.
Herring suggests parents have two options, each with its pros and cons:
- No advanced imaging: Physician evaluation plus x-rays (less radiation exposure than CT or bone scans) and possibly MRI (no radiation). If uncertainty about the diagnosis remains but symptoms and other factors point to a stress fracture, do no further imaging and rest the athlete for two to three months. Then rehab the athlete to return to sports.
- Pros: very likely an excellent outcome; minimal radiation; minimal cost; minimal chance of finding something that looks abnormal, leads to further testing, but likely will not cause problems.
- Cons: potentially removing an athlete from activity longer than necessary; getting out of shape; lingering uncertainty about the underlying problem.
- Advanced imaging. Pursue additional imaging if the presence or severity of a stress fracture remains unknown after physician evaluation, x-rays and possibly MRI.
- Pros: greater certainty about whether a child has a stress fracture; removing child from sports only if rest will be beneficial and for no longer than is necessary.
- Cons: increased exposure to radiation; higher costs; increased risk of finding something that looks abnormal, leads to further testing, but likely will not cause problems.
These are broad guidelines, says Herring, and they have exceptions. Every patient is different.
“We give parents the option of pursuing advanced imaging that could eliminate unnecessary removal from sports or the option to say, ‘I just want to rest this. I don’t care whether it’s an early fracture that will benefit from rest or an old, chronic fracture that won’t benefit from rest. After two or three months, it’s done,’ ” explains Herring. However, he adds, if significant back pain persists after that time frame, further tests such as MRI, CT, bone scan or others should be considered.
“We think it’s critical that parents weigh the pros and cons of their options, and participate in this shared decision with their child’s doctor. There is no one right answer.”
Key Points
- Spondylolysis is a stress fracture in the spine that can cause back pain in young athletes. Treatment requires an extended period of rest in many athletes, but not all.
- Advanced imaging tests can help determine the severity of a stress fracture and whether an athlete will benefit from a lot of rest or little to no rest.
- The downsides of advanced imaging tests are that they expose young athletes to potentially dangerous ionizing radiation, are costly, and can show other things that may be meaningless but lead to further testing or unnecessary treatment.
- Parents are advised to talk to their child’s doctor and discuss whether the benefits of advanced imaging outweigh the risks. They may choose no advanced imaging and rest the athlete for two to three months; or pursue advanced imaging and possibly eliminate unnecessary removal from sports.
- If a young athlete does not improve after proper treatment, doctors may do more tests and imaging to find the cause of the pain.