Division of Sports Medicine, Department of Orthopedics and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.
Am J Sports Med. 2024 Nov;52(13):3388-3395. doi: 10.1177/03635465241283054. Epub 2024 Oct 14.
Recent studies utilizing magnetic resonance imaging (MRI) for the evaluation of symptomatic lumbar spondylolysis in pediatric and adolescent athletes have indicated that upper level lumbar involvement has a higher incidence than previously reported. There has been a paucity of literature evaluating sport-specific patterns of lumbar spondylolysis, specifically upper versus lower level involvement.
To assess the potential risk factors for upper level stress injuries of the lumbar spine in pediatric and adolescent athletes.
Cross-sectional study; Level of evidence, 3.
The medical records of 902 pediatric and adolescent athletes (364 female, 538 male; mean age, 14.5 ± 2.1 years) diagnosed with symptomatic pedicle and pars interarticularis stress injuries at 2 academic medical centers (July 2016 to June 2021) were reviewed. All patients had undergone MRI at the time of diagnosis. Only patients with pars/pedicle edema on MRI were included. Data regarding single-sport specialization, sport participation, sport category by biomechanics (axial rotation vs extension/axial loading), and vertebral level of injury over the 5-year period were analyzed. Stress reaction or active spondylolysis (SRAS) was the terminology used to designate grade 1, 2a, or 3 stress injuries according to the adapted Hollenberg classification system on MRI. Upper level vertebrae were defined as L3 or superior, whereas lower level vertebrae included L4 or inferior.
Of the 902 patients with SRAS injuries, most (n = 753 [83.5%]) had exclusively single-level lower stress injuries, while 67 (7.4%) had multilevel stress injuries. There were 82 athletes (9.1%) who had single-level upper stress injuries. Athletes with upper level pars/pedicle stress injuries were older at the time of diagnosis (15.8 ± 1.9 vs 14.3 ± 2.1 years, respectively; < .001), had a shorter duration of low back pain before presentation (2.50 ± 2.70 vs 4.14 ± 6.73 months, respectively; < .001), were more likely to specialize in a single sport (43.9% vs 32.3%, respectively; = .046), and had a lower incidence of active spondylolysis on MRI at the time of diagnosis (42.7% vs 59.8%, respectively; = .004) compared with athletes with lower level stress injuries. Athletes with lumbar stress injuries who specialized in a single sport had nearly twice the odds of having upper level involvement compared with multiple-sport athletes (adjusted odds ratio, 1.80 [95% CI, 1.06-3.04]; = .03). Athletes with active spondylolysis on MRI at the time of diagnosis had nearly half the odds of having upper level involvement (adjusted odds ratio, 0.55 [95% CI, 0.33-0.91]; = .02).
Age at the time of diagnosis, duration of low back pain, single-sport specialization, and presence/absence of active spondylolysis on MRI at the time of diagnosis were primary predictors of whether an athlete's lumbar stress injury was classified as either upper or lower level involvement. Overall, the variables included in multivariate analysis were modest predictors, explaining only 15.1% of the variance in the rates of lumbosacral stress injuries classified by spinal level. These specific biomechanical factors and other potential contributors to these findings warrant further investigation.
最近利用磁共振成像（MRI）评估儿童和青少年运动员有症状的腰椎峡部裂的研究表明，与先前报道的相比，上腰椎受累的发生率更高。文献中评估特定运动类型的腰椎峡部裂，特别是上腰椎与下腰椎受累的情况较少。
评估儿童和青少年运动员上腰椎脊柱应力损伤的潜在危险因素。
横断面研究；证据水平，3 级。
回顾了 2 所学术医疗中心（2016 年 7 月至 2021 年 6 月）诊断为有症状的椎弓根和关节突间应力损伤的 902 例儿童和青少年运动员（364 例女性，538 例男性；平均年龄 14.5 ± 2.1 岁）的病历。所有患者在诊断时均进行了 MRI 检查。仅纳入 MRI 上有椎弓根/关节突水肿的患者。分析了 5 年内单运动专业化、运动参与、按生物力学分类的运动类别（轴向旋转与伸展/轴向加载）以及损伤的椎体水平的数据。根据改良的 Hollenberg 分类系统，将应力反应或活动性脊柱裂（SRAS）定义为 MRI 上的 1 级、2a 级或 3 级应力损伤。上腰椎定义为 L3 或以上，而下腰椎包括 L4 或以下。
在 902 例有 SRAS 损伤的患者中，大多数（n=753[83.5%]）仅有下腰椎单一水平的应力损伤，而 67 例（7.4%）有多个水平的应力损伤。有 82 例（9.1%）运动员有单一水平的上腰椎应力损伤。上腰椎椎弓根/关节突应力损伤的运动员诊断时年龄较大（分别为 15.8 ± 1.9 岁和 14.3 ± 2.1 岁；<.001），腰痛前的持续时间较短（分别为 2.50 ± 2.70 个月和 4.14 ± 6.73 个月；<.001），更可能是单一运动专业化（分别为 43.9%和 32.3%；=.046），且 MRI 上的活动性脊柱裂发生率较低（分别为 42.7%和 59.8%；=.004）。与下腰椎应力损伤的运动员相比，有腰椎应力损伤且专业化的运动员上腰椎受累的可能性几乎增加了两倍（调整后的优势比，1.80[95%CI，1.06-3.04]；=.03）。MRI 诊断时存在活动性脊柱裂的运动员上腰椎受累的可能性几乎降低了一半（调整后的优势比，0.55[95%CI，0.33-0.91]；=.02）。
诊断时的年龄、腰痛持续时间、单一运动专业化以及 MRI 诊断时是否存在活动性脊柱裂是预测运动员腰椎应力损伤是上腰椎还是下腰椎受累的主要预测因素。总体而言，多变量分析中包含的变量是适度的预测因素，仅解释了脊柱水平分类的腰骶部应力损伤率的 15.1%。这些特定的生物力学因素和其他潜在的促成因素值得进一步研究。
