Stress Fractures in the Spine and Sacrum

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Overview of stress fractures

A stress fracture can be defined as a skeletal defect that results from repeated applications of stress of lower intensity than that required to fracture a bone in a single loading [9], [15]. Stress fractures in athletes were first described by Devas [16] in 1958. They are commonly referred to as fatigue fractures in the adolescent athletic population.

Cause

The cause of stress fractures remains controversial. Most clinicians agree that stress fractures in the lumbar spine result from a repetitive process as opposed to a single traumatic event. Two theories, the overload theory and the muscle fatigue theory, have been proposed to explain stress fractures [17]. In the overload theory, rhythmic and repetitive contractile activity of the muscles produces stress at their osseous insertions, which reduces the mechanical resistance of the bone [18].

Stress fractures in the lumbar spine

The lumbar spine consists of five lumbar vertebrae joined to the sacrum at the pelvis. Stress fractures of the lumbar vertebral column are relatively common, and the site of injury depends on the direction in which the stress is applied [17]. The main components of lumbar motion are believed to occur at the L3–L4 and L5–S1 levels [7]. Fractures of the pedicle [21], [22], [23] and sacrum [24], [25], [26], [27], [28], [29] occur, but fractures of the pars are most frequent [17], [30], [31].

Spondylolysis

Spondylolysis, a stress fracture of the pars interarticularis (the part of the lamina located between the superior and inferior articular processes of the vertebrae), is one of the most common conditions associated with lower back pain in adolescent athletes [35]. In the adolescent athlete population, the fracture of the pars interarticularis occurs at a time of spinal growth in the posterior elements, as well as anterior elements of the attached growth plate [36]. A recent study at Children's

Pedicle fractures

Pedicle stress fractures are an uncommon cause of lower back pain [60]. Of increasing interest in the pediatric literature is the development of pedicle stress fractures among athletes with spondylolysis [21], [22], [23]. Defects of the pedicle of the lumbar spine may be congenital [61]. Pedicle stress fractures also may result as a complication of posterolateral lumbar fusion, laminectomy, and surgery for idiopathic thoracolumbar scoliosis [61], [62].

Treatment

Conservative treatment includes rest and bracing. Exercises such as pelvic tilting, stretching of the thoracolumbar fascia, and strengthening of the gluteal muscles have been shown to be effective [23]. In cases in which conservative treatment fails, surgical intervention may be necessary.

Sacral stress fractures

A once uncommon cause of lower back and buttock pain, sacral stress fractures are being reported now with increasing frequency in the medical literature [6], [24], [25], [26], [27], [28], [29], [71], [72], [73], [74]. In 1989, Volpin and colleagues [75] reported the first series of sacral stress fractures among a health population. In their study, they identified three military recruits with stress fractures of the sacral wing. Since then, there have been numerous case reports of sacral stress

Summary

Stress fractures of the pars, pedicle, and sacrum are important considerations in the differential diagnosis of lower back pain in the child or adolescent athlete. A thorough history and physical examination as well as a high index of suspicion are essential when assessing a patient with lower back pain . Diagnostic imaging, including radiographs, bone scans, CT scans, and other imaging modalities are important for further narrowing the diagnosis. The early identification and proper management

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