CONGENITAL ANOMALIES OF THE LUMBAR SPINE

Spondylolysis is a bony defect in the vertebral pars inter- articularis (a segment near the junction of the
pedicle with the lamina); the cause is usually a stress microfrac- ture in a congenitally abnormal segment.
It occurs in up to 6% of adolescents. The defect (usually bilateral) is best visualized on plain x-rays, CT
scan, or bone scan and is frequently asymptomatic. Symptoms may occur

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CHAPTER 9 Back and Neck Pain

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in the setting of a single injury, repeated minor injuries, or growth. Spondylolysis is the most common
cause of persistent low back pain in adolescents and is often asso- ciated with sports-related activities.

Spondylolisthesis is the anterior slippage of the vertebral body, pedicles, and superior articular facets,
leaving the posterior elements behind. Spondylolisthesis can be associ- ated with spondylolysis,
congenital anomalies, degenerative spine disease, or other causes of mechanical weakness of the pars
(e.g., infection, osteoporosis, tumor, trauma, prior surgery). The slippage may be asymptomatic or may
cause low back pain and hamstring tightness, nerve root injury (the L5 root most frequently),
symptomatic spinal stenosis, or cauda equina syndrome (CES) in severe cases. Tender- ness may be
elicited near the segment that has “slipped” forward (most often L4 on L5 or occasionally L5 on S1). A
“step” may be present on deep palpation of the poste- rior elements of the segment above the
spondylolisthetic joint. The trunk may be shortened and the abdomen pro- tuberant as a result.
Anterolisthesis or retrolisthesis can also occur at other cervical or lumbar levels in adults and be the
source of neck or low back pain. Plain x-rays with the neck or low back in flexion and extension will
reveal the movement at the abnormal spinal segment. Surgery is con- sidered for pain symptoms that do
not respond to conser- vative measures (e.g., rest, physical therapy), and in cases with progressive
neurologic deficit, postural deformity, slippage >50%, or scoliosis.

Spina bifida occulta is a failure of closure of one or sev- eral vertebral arches posteriorly; the meninges
and spinal cord are normal. A dimple or small lipoma may overlie the defect. Most cases are
asymptomatic and discovered incidentally during an evaluation for back pain.

Tethered cord syndrome usually presents as a progressive cauda equina disorder (see later), although
myelopa- thy may also be the initial manifestation. The patient is often a young adult who complains of
perineal or peri- anal pain, sometimes following minor trauma. MRI studies reveal a low-lying conus
(below L1-L2) and a short and thickened filum terminale.