R. W. Kerslake

Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes

We studied prospectively 22 young athletes who had undergone surgical treatment for lumbar spondylolysis. There were 15 men and seven women with a mean age of 20.2 years (15 to 34). Of these, 13 were professional footballers, four professional cricketers, three hockey players, one a tennis player and one a golfer. Preoperative assessment included plain radiography, single positron-emission CT, planar bone scanning and reverse-gantry CT. In all patients the Oswestry disability index (ODI) and in 19 the Short-Form 36 (SF-36) scores were determined preoperatively, and both were measured again after two years in all patients. Three patients had a Scotts fusion and 19 a Bucks fusion. The mean duration of back pain before surgery was 9.4 months (6 to 36). The mean size of the defect as determined by CT was 3.5 mm (1 to 8) and the mean preoperative and postoperative ODIs were 39.5 (SD 8.7) and 10.7 (SD 12.9), respectively. The mean scores for the physical component of the SF-36 improved from 27.1 (SD 5.1) to 47.8 (SD 7.7). The mean scores for the mental health component of the SF-36 improved from 39.0 (SD 3.9) to 55.4 (SD 6.3) with p < 0.001. After rehabilitation for a mean of seven months (4 to 10) 18 patients (82%) returned to their previous sporting activity.

Injury to the spinal cord without radiological abnormality (SCIWORA) in adults

Injury to the spinal cord without radiological abnormality often occurs in the skeletally immature cervical and thoracic spine. We describe four adult patients with this diagnosis involving the cervical spine with resultant quadriparesis. The relevant literature is reviewed. The implications for initial management of the injury, the role of MRI and the need for a high index of suspicion are highlighted.

An investigation into the use of MR imaging to determine the functional cross sectional area of lumbar paraspinal muscles.

The purpose of this study was to investigate the use of magnetic resonance (MR) imaging and image processing software to determine the functional cross-sectional area (FCSA) (the area of muscle isolated from fat) of the lumbar paraspinal muscles. The measurement of the morphology of the lumbar paraspinal muscles has become the focus of several recent investigations into the aetiology of low back pain. However, the reliability and validity of determining the FCSA of the lumbar paraspinal muscles using MR imaging are yet to be reported. T2 axial MR scans at the L1-S1 spinal levels of six subjects were obtained using identical MR systems and scanning parameters. Lean paraspinal muscle, vertebral body bone and intermuscular fat were manually segmented using image analysis software to assign a grey scale range to the MR signal intensity emitted by each tissue type. The resultant grey scale range for muscle was used to determine FCSA measurements for each of the paraspinal muscles, psoas, quadratus lumborum, erector spinae and lumbar multifidus on each scan slice. As various biological, instrument and measurement factors can affect MR signal intensity, a sensitivity analysis was conducted to determine the error associated in calculating FCSA for paraspinal muscle using a discrete grey scale range. Cross-sectional area and FCSA measurements were repeated three times and reliability indices for the FCSA measurements were obtained, showing excellent reliability, intra class correlation coefficient (mean=0.97, range 0.90–0.99) and %SEM (mean=2.6%, range 0.7–4.8%). In addition, the error associated with miscalculation of the grey scale range for the MR signal intensity of muscle was calculated and found to be low with an error of 20 grey scale units at the upper end of the muscle’s grey scale range resulting in a very small error in the measured muscle FCSA. The method presented in this paper has a variety of practical applications in areas such as evidence-based rehabilitation, biomechanical modelling and the determination of segmental inertial parameters.

CT imaging and three-dimensional reconstructions of shoulders with anterior glenohumeral instability.

Glenohumeral instability is a common occurrence following anterior dislocation of the shoulder joint, particularly in young men. The bony abnormalities encountered in patients with glenohumeral instability can be difficult to detect with conventional radiography, even with special views. The aim of our study was to evaluate the bony abnormalities associated with glenohumeral instability using CT imaging with 3‐D reconstruction images. We scanned 11 patients with glenohumeral instability, one with bilateral symptoms; 10 were male, one female, and their ages ranged from 18–66 years. Contiguous 3 mm axial slices of the glenohumeral joint were taken at 2 mm intervals using a Siemens Somatom CT scanner. In the 12 shoulders imaged, we identified four main abnormalities. A humeral‐head defect or Hill‐Sachs deformity was seen in 83% cases, fractures of the anterior glenoid rim in 50%, periosteal new bone formation secondary to capsular stripping in 42%, and loose bone fragments in 25%. Manipulation of the 3‐D images enabled the abnormalities to be well seen in all cases, giving a graphic visualization of the joint, and only two 3‐D images were needed to demonstrate all the necessary information. We feel that CT is the imaging modality most likely to show all the bone abnormalities associated with glenohumeral instability. These bony changes may lead to the correct inference of soft tissue abnormalities making more invasive examinations such as arthrography unnecessary. Clin. Anat. 12:326–336, 1999.

Magnetic resonance imaging of the lumbar spine in asymptomatic professional fast bowlers in cricket

Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.

The value of combining single photon emission computerised tomography and computerised tomography in the investigation of spondylolysis

The aim of this study was to assess the diagnostic value of combining single photon emission computerised tomography (SPECT) with reverse gantry computerised tomography (rg-CT) in the investigation of spondylolysis. Patient characteristics and imaging results in 118 patients, aged 8–44 years, with low back pain (LBP) were analysed. SPECT showed increased scintigraphic uptake in 80 patients, and spondylolysis was identified on rg-CT in 53. The Cohen Kappa ratio of 0.362 (95% CI: 0.198–0.526) suggests only fair agreement for the result of increased scintigraphic activity with the finding of spondylolysis on rg-CT. We conclude that these investigations give mutually exclusive information, which leads to four diagnostic categories. When there was increased scintigraphic activity on SPECT, 58.8% (95% CI: 48.0–69.5%) of patients had spondylolysis on rg-CT. With rest from provoking activities, these lesions may heal. We interpret the findings of increased scintigraphic activity, but no spondylolysis demonstrated on rg-CT as indicating a bone stress response. These also require rest from provoking activity to prevent a stress fracture developing. In this study, 84.2% (95% CI: 72.67–95.8%) of those patients without increased activity on SPECT had no spondylolysis identified on rg-CT. These patients may need further investigations such as magnetic resonance imaging (MRI) to diagnose pathology, which typically does not involve the posterior elements—but rest from sport may not be so important. There were five patients in our study, without increased scintigraphic activity, but in whom bilateral chronic-appearing (wide separation, smooth sclerotic bone margins) spondylolyses were identified at L5. These all were anticipated from previous plain radiographs or MRI. This group will almost certainly not heal, and if the spondylolyses are the cause of pain these vertebrae will need stabilisation by surgery if physiotherapy fails.

The Lumbar Paraspinal Muscle Morphometry of Fast Bowlers in Cricket

Objective:To describe the functional cross-sectional area (FCSA) of the lumbar paraspinal muscles of professional fast bowlers in cricket and to investigate the nature of any muscle asymmetry. Design:Descriptive cross-sectional between-groups study. Setting:The England and Wales Cricket Board. Participants:Forty-six asymptomatic professional fast bowlers and 17 athletic controls. Main Outcome Measurements:The magnetic resonance imaging of functional cross-sectional area (FCSA) of the lumbar paraspinal muscles, and the prevalence of asymmetry (greater than 10% difference in the FCSA between the dominant and nondominant side muscles). Results:A relatively high percentage of fast bowlers had asymmetrically larger dominant side quadratus lumborum FCSAs at L1 (47%), L3 (41%), and L4 (47%). The nondominant side psoas FCSA was larger in fast bowlers at L5, and the dominant side multifidus FCSA was larger in both the fast bowlers at L3 to S1 and in the control subjects at L4 and L5. Conclusions:There was a higher prevalence of lumbar muscle asymmetry in the fast bowler group. Paraspinal muscle asymmetry was most prevalent in the quadratus lumborum of fast bowlers, and it was also evident in the lumbar multifidus in both groups of subjects. In both muscle groups, this was consistent with hypertrophy of the dominant side muscle. This study may be used to inform prospective studies of risk factors for low back injury in athletic males and enhance the development of more accurate models of stress production in the lumbar spine during fast bowling and other asymmetrical sports.

Injuries to the lower back in elite fast bowlers: ACUTE STRESS CHANGES ON MRI PREDICT STRESS FRACTURE

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded. In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.

Single photon emission computerized tomography and reverse gantry computerized tomography findings in patients with back pain investigated for spondylolysis.

Background:Athletes with low back pain may have sustained a bone stress injury in the lumbar neural arch, including spondylolysis. Single photon emission computerized tomography (SPECT) and reverse gantry computerized tomography (rg-CT) help localize bone stress response and spondylolyses. Objectives:To describe the SPECT and rg-CT findings in those patients suspected of suffering from a spondylolysis. Study Design:Large retrospective case series. Setting:Secondary and tertiary care center in England. Patients:A total of 213 patients presenting to the Spinal Unit and Sports Medicine Clinics between 1995 and 2000 with low back pain and subsequently investigated for spondylolysis by SPECT and rg-CT. Methods:An experienced consultant musculoskeletal radiologist reported the SPECT and rg-CT, and these results along with data from the patients medical records were analyzed. Main Outcome Measures:Sites and sides of increased scintigraphic activity in the lumbar neural arch seen on SPECT and complete and incomplete spondylolyses were recorded. Results:Single photon emission computerized tomography scan showed increased scintigraphic uptake in 145 patients, mostly (42.3%) at L5. Marked increase in scintigraphic uptake was noted on the left side of the neural arch in 31 patients and on the right in 17 (χ2; P < 0.05). Spondylolysis was identified on rg-CT in 81 patients. Spondylolyses were bilateral on 44 occasions, but unilateral lesions occurred in the left pars 36 times and on the right 16 times (χ2; P < 0.01) Conclusions:Spondylolyses were a frequent finding on rg-CT in young athletes with low back pain. The sports most commonly associated with this stress response in the pars interarticularis were cricket and soccer. The lower lumbar levels are more likely to show abnormalities on SPECT and computerized tomography. Among those investigated for spondylolysis, left-sided lower lumbar pain was more common than right, and a marked increase in scintigraphic uptake was noted on the left more often than the right. Although bilateral spondylolyses were common, left-sided spondylolyses were more common than right. The asymmetric repetitive movements of certain sports may be responsible. In particular, fast bowlers developed spondylolysis on the opposite side of the body to their bowling arm.

Vertebral osteomyelitis as a complication of Crohn’s disease

Abstract Vertebral osteomyelitis arising from an enteric fistula in patients with inflammatory bowel disease is rare. We report on a patient with Crohn’s disease who developed an enteric fistula, resulting in a pre-sacral abscess and vertebral osteomyelitis involving the L4 and L5 vertebral bodies and related disc spaces. This was managed by a defunctioning colostomy with drainage of the pre-sacral abscess. The vertebral lesion was successfully managed non-operatively.