Surgery for a Lower Back Stress Fracture

Rena in North Carolina, USA, asks:

"My son is a fifteen year old baseball player. He was playing the position of shortstop in the fall. His back began to hurt and he started taking anti-inflammatories. As it got worse, we decided to go to a doctor.

"He was given a bone scan which showed a lower back stress fracture. He was fitted for a custom brace which he wore for 6 weeks. It didn't get better so he wore it longer for 23 hrs a day. Despite this my son never got better and a CT scan was ordered to rule out anything else. Again a stress fracture was confirmed. He saw a sports physical therapist, but gave up on this as his pain did not settle. He tried playing with the team again this spring but the pain came back. We are now scheduled to see the surgeon for a consult on an operation.

"Is it wise to have an operation at this stage?"

Colin Natali, Consultant Spinal, Trauma and General Orthopaedic Surgeon at the back2normal back and neck clinic, London, replies:

"A stress fracture of the lumbar vertebra is known as spondylolysis. It is a common injury in keen sports participants and presents as back pain. It can also be a long standing defect that occurs as a child and remains asymptomatic until they become very active in their teenage years. The treatment requires a correct diagnosis. Based on the history and investigations you have described, spondylolysis has been confirmed.

"Conservative treatment is always attempted first and surgical treatment is seen as a last resort. It should only be considered when extensive conservative treatment has failed.

"A typical treatment protocol for this condition includes:

Rest for six weeks, as this is the usual time for bone healing. If pain is still present then the stress fracture hasn't healed and another scan may be needed. If the scan indicates there is still no healing, then a further period of rest should be considered (I personally do not immobilize as the evidence for this treatment is inconclusive).
Specialist Physiotherapy - Intensive core stability rehabilitation. Poor muscle stability in the lumbar spine has been implicated as a contributory factor in spondylolysis. Core stability exercises aim to recruit the Transversus Abdominus and Multifidus muscles. In order to understand how these exercises are effective it is necessary have a brief introduction to how the back is supported by muscles. The first muscle we are concerned with is called Transversus. This muscle arises from the middle of the tummy and goes right around the trunk, attaching itself to the spine.

The Transversus Abdominus muscle acts as a natural corset and provides stability for the lower back. The second muscle involved in this exercise programme is the Multifidus. This muscle lies deep in the spine and attaches in between each vertebra. When it contracts it increases the stability of the spinal column.

If you can contract the Transversus muscle, the Multifidus muscle is also contracted automatically. This improves spinal stability and can relieve back pain.

The most effective way to learn how to contract these muscles is to kneel on all fours. Once in position, relax and allow the stomach to sag down with gravity. To contract Transversus now, all you need to do is very gently pull in your tummy so your belly button moves closer to your spine.

It is important not to contract too hard, otherwise you will be using muscles other than the ones we are concerned with - don't contract your 'six pack' muscles. Also, don't confuse this exercise with breathing in and sucking your tummy in - you should be able to hold the contraction while continuing to breath and have a conversation.

It is difficult at first but once you have mastered the technique it should become second nature. The contraction should be held for 4 seconds and repeated 20 times. Then, as your technique improves, increase the contraction hold to 10 seconds. Eventually you should be able to hold the contraction indefinitely.

At this stage you should be able to move to different positions, such as sitting in a chair or standing up, and still be able to contract the deep stabilising muscles. Although it seems strange at first, once the muscles have been recruited, you will not have to concentrate on them and they will contract automatically - thus improving your posture and spinal stability.
Once core stability in the lumbar region has been improved, it is time to gradually resume activities under the supervision of a chartered physiotherapist.
If pain is still a problem that prevents sport and the patient considers the risks of surgery are worth taking - then surgical intervention is appropriate.

Surgery can be of the form of a screw across part of the vertebra called the Pars Inter-articularis and a bone graft is used to help healing.

Other surgical approaches include intertransverse fusion with bone graft and instrumented fusion with pedicle screws. Your doctor should explain these procedures for you in more depth, before deciding which, if any is most appropriate.