Working Diagnosis:
Dysplastic spondylolysis of the L4 pars interarticularis without listhesis.

Treatment:
The patient was treated with a brace to allow physiologic lordosis for 10 weeks followed by physical therapy for stabilization and ROM. NSAIDs were stopped for optimum bone healing; vitamin D supplementation was started.

Outcome:
The patient completed a successful return to play protocol and remains symptom free throughout the remainder of the football season. He was completely pain free with normal range of motion. He returned to varsity football 10 weeks after presentation without pain or dysfunction.

Author's Comments:
The incidence of spondylolysis in athletes with spina bifida occulta (SBO) is 56% higher than in patients without. Knowledge of a history of SBO in an athlete should prompt increased attention to preventative core strengthening exercises and lower the threshold for obtaining imaging in these patients who present with low back pain. This patient had a prior spondylolysis at the L5 level, and preventive PT possibly could have avoided the recurrence.

Editor's Comments:
This is an interesting twist between a condition that we look for but often don't find (spondylolysis), and a condition that we often see but think nothing of (spina bifida occulta). The relationship gives us cause to consider the management options suggested by the author.

References:
Sairyo K et al. Biomechanical comparison of lumbar spine with or without spina bifida occulta. A finite element analysis. Spinal Cord (2006) 44, 440-444

McGrath MC. Anatomical observations related to radiological findings in spina bifida occulta of the lumbosacral spine. Journal of Osteopathic Medicine (2004) 7(2):70-78

Vannet N et al. Incidence of Symptomatic Spondylolysis Associated with Spina Bifida Occulta. The Spine Journal (2009). 10.1016/j.spinee.2009.08.315

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