Charles H Crawford1, Charles G T Ledonio2, Robert Shay Bess3, Jacob M Buchowski4, Douglas C Burton5, Serena S Hu6, Baron S H Lonner7, David W Polly2, Justin S Smith8, James O Sanders9. 1. Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, KY 40202, USA; Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA. Electronic address: chcraw01@gmail.com. 2. Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN 55454, USA. 3. Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, 2055 High Street, Suite 130, Denver, CO 80205, USA. 4. Department of Orthopedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110, USA. 5. Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 3017, Kansas City, KS, 66160, USA. 6. Department of Orthopaedic Surgery, Stanford School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063-6342, USA. 7. Department of Orthopaedic Surgery, New York University Langone Medical Center, 820 2nd Avenue, Suite 7A, New York, NY 10017, USA. 8. Department of Neurosurgery, University of Virginia, PO Box 800212, Charlottesville, VA 22908, USA. 9. Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
Abstract
STUDY DESIGN: Structured literature review. OBJECTIVES: To assess the current state of evidence as a first step in the development of practice guidelines for pediatric spondylolysis. SUMMARY OF BACKGROUND DATA: Progress in published medical knowledge, changes in societal expectations, and developments in health care economics have led medical organizations to develop evidence-based documents and products. METHODS: A comprehensive literature search for pediatric spondylolysis was performed with the assistance of a medical librarian. The authors reviewed citations and abstracts. Abstracts were reviewed for exclusions and data from included studies were analyzed by committee. A total of 44 articles provided the best available evidence for the questions of etiology, prevalence, natural history, and prognosis: 9 were graded as level I evidence, 23 were level II, 3 were level III, and 9 were level IV. No level V studies were included in the final list. RESULTS: There is good evidence that pediatric lumbar spondylolysis is an acquired fracture of the pars interarticularis that can occur unilaterally or bilaterally. Evidence shows that when chronic, bilateral pars defects develop, 43% to 74% of patients will progress to grade 1 or 2 spondylolisthesis. In addition, unilateral, incomplete, and early lesions can obtain bony union. With or without bony union or spondylolisthesis, short-term symptom resolution is the norm. Long-term prognosis is less clear, but there is fair evidence that most patients will have lumbar symptoms compared with the general population. There is also fair evidence that some patients will develop significant symptoms as adults and will undergo surgical treatment. There is insufficient knowledge to predict which patients will continue to do well in the long term with conservative or no treatment and which patients will develop symptoms significant enough to warrant early intervention. CONCLUSIONS: The current medical literature provides fair to good evidence for clinically relevant questions regarding the etiology, prevalence, natural history, and prognosis of pediatric spondylolysis.
STUDY DESIGN: Structured literature review. OBJECTIVES: To assess the current state of evidence as a first step in the development of practice guidelines for pediatric spondylolysis. SUMMARY OF BACKGROUND DATA: Progress in published medical knowledge, changes in societal expectations, and developments in health care economics have led medical organizations to develop evidence-based documents and products. METHODS: A comprehensive literature search for pediatric spondylolysis was performed with the assistance of a medical librarian. The authors reviewed citations and abstracts. Abstracts were reviewed for exclusions and data from included studies were analyzed by committee. A total of 44 articles provided the best available evidence for the questions of etiology, prevalence, natural history, and prognosis: 9 were graded as level I evidence, 23 were level II, 3 were level III, and 9 were level IV. No level V studies were included in the final list. RESULTS: There is good evidence that pediatric lumbar spondylolysis is an acquired fracture of the pars interarticularis that can occur unilaterally or bilaterally. Evidence shows that when chronic, bilateral pars defects develop, 43% to 74% of patients will progress to grade 1 or 2 spondylolisthesis. In addition, unilateral, incomplete, and early lesions can obtain bony union. With or without bony union or spondylolisthesis, short-term symptom resolution is the norm. Long-term prognosis is less clear, but there is fair evidence that most patients will have lumbar symptoms compared with the general population. There is also fair evidence that some patients will develop significant symptoms as adults and will undergo surgical treatment. There is insufficient knowledge to predict which patients will continue to do well in the long term with conservative or no treatment and which patients will develop symptoms significant enough to warrant early intervention. CONCLUSIONS: The current medical literature provides fair to good evidence for clinically relevant questions regarding the etiology, prevalence, natural history, and prognosis of pediatric spondylolysis.