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Title: Factors predicting the outcome following treatment for lumbar spondylolysis
Author: Debnath, Ujjwal Kanti
Awarding Body: University of Nottingham
Current Institution: University of Nottingham
Date of Award: 2010
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Abstract:
Study 1: Study design: A non –randomised continuous retrospective cross sectional and observational study Objective 1) To evaluate the results of nonoperative treatment of symptomatic lumbar pars stress injuries or spondylolysis in sporting as well as non sporting individuals 2) To determine the factors responsible for non-operative method of managing symptomatic lumbar spondylolysis in young population 3) To evaluate the outcome in different types of sports 4) To establish the role of compulsory non-operative treatment for symptomatic lumbar spondylolysis in sporting individuals Summary of Background Data The treatment and management of symptomatic spondylolysis in sporting populations is mainly based on observation rather than experimental study. Conservative treatment in the form of bracing and avoidance of sports for at least three to six months has been recommended. Excellent or good results following bracing and physical therapy have been observed in 80% patients. Criteria for return to sport are dominated by symptom led decisions. Methods The research was carried out as a qualitative, descriptive and analytic study with a non-randomised cohort of patients investigated for spondylolysis in a single centre. A total number of 123 patients treated conservatively following confirmation by imaging studies (SPECT,CT or MRI scans) as having stress fractures of the lumbar pars interarticularis (PI) ranging in age from 8 to 35 years have been selected for the study. All patients attending the Back pain clinic has to follow a protocol of filling up the VAS, ODI and SF-36 questionnaires as a part of their assessment. At the time of the study these questionnaires along with the Back Pain & Sports Questionnaire (BPSQ) were sent to all but only 123 patients responded who were included in the study 1. The background data contains gender, age, date of onset of symptoms with current limitation in sport, pain in flexion or extension, type of sport, level of sport and length of treatment. The data also contains each subject with level, number, laterality and distribution of lumbar spondylolysis, investigations, outcome with VAS, ODI, SF-36 and Back pain and sports questionnaire (BPSQ) and return to sports. We classified the individual sports into seven types depending on the major movements of the body. Descriptive and analytical statistics was performed along with correlation testing between the outcome measures and predictive factors. Results The mean age of onset of back pain was 21.7 years (range 8-35 years). Most patients were between the ages of 15&19 years (43) followed by 20&24 years (32). The Male: Female ratio was 74:49. There were 98/123 (76.9%) sporting individuals. 35/98 (35%) were professional players, 29/98 (29.5%) were semi professional and 34/98 (34.6%) were amateur sportsmen and women. Cricket (22) followed by Football (22) were the most common type of sports played. Trunk twisting movement was the common denominator in most of the patients with pars defect. The cricketers (13) with unilateral pars defect had more commonly left sided pars defect than the right (10 left vs 3 right). Right sided pars defect was more commonly observed in soccer players (7:1). Most incomplete fractures were observed at L4 in the cricketers. The non sporting group had consulted with a delay of more than six months since the onset of pain. 60% pars lesion was observed at L5 followed by L4 (11.3%), L3 (9.7%) and L2 (2.4%). At L5 most were bilateral lesions (81%). Spina bifida was recorded in 16% patients. The mean pre and post treatment VAS score was 4.5 and 0.65 respectively (SD- 0.8,p<0.01). The mean pre and post treatment ODI was 35.5 (SD-7.8) and 6.9 (SD- 7.6) respectively (p<0.01). In the SF-36 scores, the mean score for the physical component of health improved from 34.9 (SD – 5.3) to 49.3 (SD -6.6) (p< 0.001). The mean score for the mental component of health improved from 40.2 (SD -5.2) to 52.0 (SD-6.0) (p<0.001). The mean BPSQ score was 52.5 (range 0-90). The mean pretreatment and post-treatment VAS and ODI scores were slightly better in males as compared to females. In the unilateral group, 28/36 (77%) patients had complete relief of pain by a mean time of 4.2 months (range 3-7 months). In the bilateral group, 47/59 (79%) patients had complete pain relief at a mean time of 6.5 months (3-12 months). In the unilateral pars defect group, 32/36 sporting individuals returned to active sports. In the bilateral pars defect group, 49/59 sporting individuals returned to active sports. There was significant difference between the sporting and the non-sporting group in their age (mean 20.7 vs 25.4 years, p <0.001). There was significant difference between the two groups in all pre and post treatment outcome scores. The pre treatment VAS score had most significant correlation with post treatment ODI ( =0.634, p <0.01) and post treatment VAS scores ( =0.626, p<0.01). Conclusion A treatment protocol of rest for 4-6 weeks followed by the functional restorative program has excellent or good outcome in 85% sporting individuals with symptomatic pars defect. Male sporting individuals have better outcome than females. Unilateral pars lesions have a better outcome than bilateral pars lesions. Bracing may not be required in most patients if the pain subsides on restriction of activity. Full functional recovery to previous level of activity is possible with the help of dynamic spinal stabilization exercises and physical therapy. The individuals involved in trunk twisting sports should be evaluated carefully for muscle imbalance in the lumbar spine and they should have altered techniques of sporting activity without compromising the performance in the rehabilitation phase. Study 2: Study Design: A non –randomised continuous retrospective observational study Objective 1) To identify the most significant determinant of surgical intervention in lumbar pars defect 2) To identify the independent factors that predict a successful outcome following surgery for lumbar pars defect in young sporting individuals 3) Can we establish an outcome predictive model based on these significant factors responsible for a successful outcome? Summary of Background Data Most athletes or young active professional sportsmen or women would like to return to their previous level of sports since they may be earning their livelihood through the sport. Early onset of symptoms and conservative treatment in these patients may lead to a good clinical outcome but it is difficult to predict which group or which individuals will require surgical repair of the defect. Young athletes to have returned to competitive sports after surgery have been reported only in few previous papers. The first cohort from this series was published in 2003. ODI (Oswestry Disability Index) and SF-36 (Short form) scores were used to evaluate the final outcome for the first time in lumbar spondyloysis for outcome analysis. Methods A total number of 55 patients treated operatively following confirmation by imaging studies (SPECT,CT or MRI scans) as having stress fractures of the lumbar pars interarticularis (PI) ranging in age from 8 to 35 years have been selected for the study. All patients attending the Back pain clinic has to follow a protocol of filling up the VAS, ODI and SF-36 questionnaires as a part of their assessment. At the time of the study these questionnaires along with the Back Pain & Sports Questionnaire (BPSQ) were sent to all but only 50/55 patients responded. The background data contains gender, age, date of onset of symptoms with current limitation in sport, pain in flexion or extension, type of sport, level of sport and length of treatment. The data also contains each subject with level, number, laterality and distribution of lumbar spondylolysis, investigations, outcome with VAS, ODI, SF-36 and Back pain & sports questionnaire (BPSQ) and return to sports.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID: uk.bl.ethos.588308  DOI: Not available
Keywords: WE Muscoskeletal system
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