Case reportChiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report
Introduction
Although lumbar spondylolysis is generally attributed to repetitive stress imposed by physical activity resulting in fatigue fracture of the pars interarticularis,1, 2 the etiology is likely multifactorial with elements of both inherited predisposition and repetitive trauma.3, 4, 5 One study of elite athletes found a higher prevalence of lumbar spondylolysis in sports that involve elements of lumbar hyperextension, rotation, and/or torsion against resistance.6 The prevalence of lumbar spondylolysis in the general population is estimated to be between 3% and 11.5% with a male-female ratio as high as 3:1.7, 8, 9, 10, 11, 12, 13, 14 An estimated 90% of pars defects occur at L5, and most defects at L5 are bilateral.15 According to Ravichandran,16 spondylolysis of more than 1 vertebral level in the same individual is rare, with a prevalence of multiple-level lumbar spondylolysis in the general population estimated at between 0.2% and 2.8% and with a higher prevalence among Alaskan natives estimated at 5.6%.7, 16, 17, 18
There is a paucity of literature regarding the prevalence of multiple-level lumbar spondylolysis with spondylolisthesis among military and/or veteran patient populations. A single report of 6 cases out of Taiwan between 1992 and 1998 of bilateral multiple-level lumbar spondylolysis involving Republic of China Army personnel (4 infantry and 2 from an armored unit) was published in 2001.19 Each of the Republic of China Army personnel involved denied a specific history of traumatic injury during their military service, but took part in physically demanding training including a 500-m obstacle course and long-distance marches with a full pack, which were considered to be precipitating factors.19 Surgical intervention was successfully carried out in each of the 6 cases after a minimum of 6 months of failed conservative management including bed rest, medication, bracing, or rehabilitation.19
The purpose of this report is to present a case of evaluation and conservative management of mechanical low back pain (LBP) secondary to multilevel lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran treated at the chiropractic clinic at the VA of Western New York. A review of the literature pertaining to lumbar spondylolysis and spondylolisthesis among military personnel is provided.
Section snippets
Case report
A 43-year–old United States Marine Corps veteran was referred by his primary care physician to the chiropractic clinic with chronic LBP, dull in quality, rated 4/10 on a numeric rating scale upon presentation. The patient described a history of intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. The veteran patient described an over 20-year history of LBP extending back to a fall he sustained off of an amphibious vehicle during the second of
Discussion
Although many of the studies and case reports among military personnel with spondylolysis involve parachutists, reports have also been published involving nonparachutist military personnel from the Republic of China Army,19 the Israeli Defense Forces,22, 23 the United States Army Green Berets,24 and the British Army.25 As the most commonly suspected etiologic component of spondylolysis is stress (fatigue) fracture of the pars interarticularis,1 the relationship between spondylolysis and
Conclusion
A review of the literature identified a variety of studies and case reports of lumbar spondylolysis with and without spondylolisthesis in military populations, with only 1 case series reflective of involvement at multiple levels. The case presented in this report represents a unique presentation of multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran. As with certain types of athletes, military personnel involved in parachuting and related physical
Acknowledgment
This work was conducted at and supported by the VA of Western New York Healthcare System. The authors would like to thank Dr John Taylor and Carol Simolo for their contributions to this manuscript.
References (52)
- et al.
Spondylolysis
Phys Med Rehabil Clin N Am
(2000) - et al.
The radiological investigation of lumbar spondylolysis
Clin Radiol
(1998) - et al.
A comparative roentgenographic analysis of the lumbar spine in male army recruits with and without lower back pain
Clin Radiol
(2003) - et al.
Chiropractic and rehabilitative management of a patient with progressive lumbar disk injury, spondylolisthesis, and spondyloptosis
J Manipulative Physiol Ther
(2006) - et al.
Spinal reflex excitability changes after lumbar spine passive flexion mobilization
J Manipulative Physiol Ther
(2002) - et al.
Spondylolysis: a critical review
Br J Sports Med
(2000) Rehabilitation of a patient with a rare multi-level isthmic spondylolisthesis: a case report
J Can Chiropr Assoc
(2004)- et al.
Human evolution and the development of spondylolysis
Spine
(2005) - et al.
Lumbar facet anatomy changes in spondylolysis: a comparative skeletal study
Eur Spine J
(2007) - et al.
The prevalence of spondylolysis in the Spanish elite athlete
Am J Sports Med
(2000)
The incidence of separate neural arch and co-incident bone variations: a survey of 4,200 skeletons
Anat Rec
The natural history of spondylolysis and spondylolisthesis
J Bone Joint Surg Am
Lumbosacral spondylolisthesis associated with spondylolysis
Neuroradiol Clin North Am
Imaging of lumbar spondylolysis
Radiologist
The natural history of spondylolysis and spondylolisthesis: a 45-year follow-up evaluation
Spine
Spondylolisthesis and spondylolysis
Instr Course Lect
Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population
Spine
Isthmic spondylolisthesis
Neurosurg Focus
Multiple lumbar spondylolysis
Spine
Spondylolysis: a skeletal investigation of two population groups
J Bone Joint Surg
The age incidence of neurological arch defects in Alaskan natives considered from the standpoint of aetiology
J Bone Joint Surg
Management of multiple level spondylolysis of the lumbar spine in young males: a report of six cases
J Formos Med Assoc
Upper lumbar spondylolysis: report of two cases
Mil Med
Lumbar spine injuries in military parachute jumpers
Phys Sportsmed
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