Differential Diagnosis of Spondylolysis in a Patient with Chronic Low Back Pain

Abstract

Study Design: Resident's case problem. Background: A 26-year-old male sought physical therapy services via direct access secondary to a flare-up of a chronic low back pain condition. The patient complained of recent onset of lumbosacral joint pain, including (1) constant right-sided deep-bruise sensation, (2) intermittent right-sided sharp stabbing pain, and (3) constant bilateral aching. The patient's past medical history included a hyperextension low back injury while playing football at age 17. Physical examination revealed (1) deep pain with palpation over the right lumbosacral joint region, (2) sharp right lumbosacral joint pain with 1 repetition of active trunk backward bending, and (3) a marked increase in pain and joint hypomobility with right unilateral joint assessment at the L4 and L5 spinal levels. Diagnosis: The examining therapist referred the patient for radiographic evaluation due to strong suspicions of a pars interarticularis bony defect. Lumbar plain films, oblique views, revealed an L5 bilateral pars defect, leading to a diagnosis of a longstanding bilateral L5 spondylolysis. Discussion: Patients with low back pain often seek physical therapy services. Identification of pathology requiring examination by other health care providers, leading to patient referral to other health care practitioners, is a potential important outcome of the therapist's examination. This resident's case problem illustrates the importance of a systematic examination scheme, including a thorough medical screening component that led to a patient referral for radiographic evaluation. The resultant diagnosis, although not representing serious pathology, did impact the therapist's patient plan of care. J Orthop Sports Phys Ther 2005;35:319-326.

Red Flags: To Screen or Not to Screen?

“…6,7,10,15,20,25 In other cases, overt red flag findings were not evident; rather, a cluster of findings that were atypical for nonspecific low back pain emerged through the course of care that prompted referral. 3,6,8,14,15,21,27 Using a cluster of history and physical examination findings is also consistent with evidence-based screening strategies for serious conditions like cancer, 11 fractures, 17 and abdominal pain that is nonmusculoskeletal in nature. 24 For example, in an individual with low back pain, advanced age, corticosteroid use, or pain caused by a traumatic incident may not be concerning when each finding is considered in isolation.…”

“…11 Several published case reports have described how physical therapists have used history and physical examination findings, as well as response to intervention, in patients with signs and symptoms related to the lumbar spine to determine that physician referral was necessary. 3,[6][7][8]10,14,15,20,21,25,27 As seen in these case reports, the level of red flag screening for an individual patient may vary based on the medical complexity of the patient, emerging data from the patient history and physical examination, response to intervention, and the directions taken in the clinical decision-making process. 1 In some of these cases, red flag findings were present early in the case, which led to the initiation of early referral.…”

Utilization of mechanical diagnosis and therapy (MDT) for the treatment of lumbar pain in the presence of known lumbar transverse process fractures: a case study

“…As an example, it would not be advised to introduce repeated end-range extension exercises in the case of an acute spondylolysis. 18,19 We do recognize several limitations to this case study.…”

Lumbarspondylolysis: a review

“…Rehabilitation programmes are strongly recommended for symptomatic and post -surgical patients. It is imperative these programmes to be guided by patients' pain and toleranceand their objectives to be the promotion of bone healing, the relief of pain and the optimization of physical function (25)(26)(27) …”