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Year |
2001 |
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Question Number |
99. |
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Category |
Select |
Question
A 14-year-old basketball player has had activity-related low back pain for the past 6 weeks. Plain radiographs are unremarkable. Selected coronal single-photon emission computed tomography scans are shown in Figure 27. The best course of action should be:
1. bilateral facet blocks.
2. brace immobilization for 3 to 6 months.
3. instrumented posterior spinal fusion.
4. a CT-guided needle biopsy.
5. an open incisional biopsy.
Figures
Answer (click for answer)
Preferred Response: (2)
Discussion: SPECT images provided in Figure 27 depict signal in the L4-5 or L5-1 pars (most commonly L5 level) region. This entity is as a significant cause of focal low back pain, particularly in adolescent athletes involved in sports with repetitive spinal motions. It should be suspected in any adolescent with activity-aggravated LBP with minimal physical findings. It is frequently misdiagnosed as lumbosacral muscle strain. The bony lesion is thought to be either congenital or represents a stress fracture due to cumulative repetitive stresses imposed by physical activity. The importance of identifying the lesion lies with an associated progression from pars injury to spondylolysis to spondylolisthesis.
Bone scan is more sensitive than plain XRAY, and SPECT is more sensitive and specific than PBS. Both these techniques, however, are less specific than radiography and CT. CT, when performed with a reverse gantry angle and thin sections, is the investigation of choice for identifying radiographically occult injuries. According to Harvey et al. (1998), "Advanced imaging with SPECT, CT, and MR imaging may be needed to ascertain the acuity of the lesion, assist in identifying a particular pars lesion as potentially symptomatic, and to exclude other spinal pathology that may be present. Conservative treatment, i.e. discontinuation of aggravating activity and/or bracing, is generally successful for pain relief, healing, or both; only small proportions require surgical intervention for pain or progressive spondylolisthesis (Standaert et al., 2000).
Reference: Refs: Harvey et al. 1998. Clin Rad 53(10):723-8.
Standaert et al. 2000. PM&R Clinics NA. 11(4):785-803.