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脊椎分離症、脊椎分離すべり症

著者: 酒井紀典1) 徳島大学大学院医歯薬学研究部 地域運動器・スポーツ医学分野

著者: 西良浩一2) 徳島大学整形外科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2022/03/30
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
酒井紀典 : 企業などが提供する寄付講座(吉野川医療センター)[2022年]
西良浩一 : 講演料(株式会社エリクエンスインターナショナル,泉工医科工業株式会社,第一三共株式会社),研究費・助成金など(ジンマー・バイオメット合同会社),奨学(奨励)寄付など(日本ストライカー株式会社,スミス・アンド・ネフュー株式会社,旭化成ファーマ株式会社,メドトロニックソファモアダネック株式会社,株式会社日本エム・ディ・エム,京セラ株式会社,ニューベイシブジャパン株式会社),企業などが提供する寄付講座(地域運動器・スポーツ医学(併任))[2022年]
監修:酒井昭典 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 腰椎分離症は椎弓の関節突起間部の骨性の非連続性を指す。
 
腰椎分離症

a:椎間関節部(矢印)の両側性欠損を伴う脊椎分離症
b:L5~S1の脊椎分離すべり症につながったL5(矢印)の脊椎分離症

 
  1. スポーツ愛好者に多くみられることなどから、疲労骨折の1つと考えられている。
  1. 一般的には小学生~高校生で発生する。
  1. 約6%の頻度で認められる。人種差・性差などもあるが一般日本人成人においては5.9%(男性7.9%、女性3.9%)の頻度で認められる。
  1. ひとたび分離が完成すれば、その後椎体すべりや楔状椎など、生涯にわたる変形を残す症例もある。
  1. 分離部周囲に生じるfibrocartilage massやbony ragged edgeは、青壮年期以降に神経根性疼痛の原因になる。
問診・診察のポイント  
問診:
  1. 発症時期を確認する。

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文献 

Koichi Sairyo, Toshinori Sakai, Natsuo Yasui
Minimally invasive technique for direct repair of pars interarticularis defects in adults using a percutaneous pedicle screw and hook-rod system.
J Neurosurg Spine. 2009 May;10(5):492-5. doi: 10.3171/2009.2.SPINE08594.
Abstract/Text In this report, the authors described a new minimally invasive technique to repair pars interarticularis defects in adults. The well-established technique using the pedicle screw (PS) and hook-rod system was modified. First, bilateral PSs were inserted percutaneuosly using the Sextant system. Then, through a small skin incision (3-4 cm), an illuminated tubular retractor (Quadrant system; Medtronic Sofamore Danek) was inserted into the pars defect. When this system is used, it is not necessary to detach all the back muscles to access the lytic part. The bursa and fibrocartilaginous mass near the defects were removed. After decortication of the pseudarthrosis at the spondylolytic level, bone grafts were implanted. Finally, the hook part of a hook-rod system was attached to the lamina and the rod was secured at the tulip head of the PSs. The authors performed this procedure in 2 adult patients, 32 and 24 years of age. Immediately after surgery both patients' low-back pain disappeared, and by 3 months postoperatively both had returned to their original work or sports activities.

PMID 19442013
K Higashino, K Sairyo, S Katoh, T Sakai, H Kosaka, N Yasui
Minimally invasive technique for direct repair of the pars defects in young adults using a spinal endoscope: a technical note.
Minim Invasive Neurosurg. 2007 Jun;50(3):182-6. doi: 10.1055/s-2007-982511.
Abstract/Text Pars defect (spondylolysis) of the lumbar spine can cause chronic low back pain, and it sometimes requires surgical intervention. Direct repair is selected for the surgery if young adult patients do not present significant disc degeneration and lumbar instability. In order to lessen damages of back muscles during surgery, we added the use of a spinal endoscope to the "Buck's screwing procedure" the direct repair. There are four steps in this procedure: 1) identification of the defect, 2) curettage (refresh) of the defect, 3) percutaneous insertion of the annulated screws and 4) cancellous bone grafting. All these steps can be done endoscopically. We treated 3 young adults--a baseball player, a professional cycle-racer and a sculptor--using this endoscopic procedure. There were no complications during or after the operation. Union was obtained in all defects within 3 months, and they returned to their previous activities within 6 months after the surgery.

PMID 17882757
Koichi Sairyo, Shinsuke Katoh, Tadanori Sakamaki, Shinji Komatsubara, Natsuo Yasui
A new endoscopic technique to decompress lumbar nerve roots affected by spondylolysis. Technical note.
J Neurosurg. 2003 Apr;98(3 Suppl):290-3.
Abstract/Text The authors describe a new endoscopic technique to decompress lumbar nerve roots affected by spondylolysis. Short-term clinical outcome was evaluated. Surgery-related indications were: 1) radiculopathy without low-back pain; 2) no spinal instability demonstrated on dynamic radiographs; and 3) age older than 40 years. Seven patients, four men and three women, fulfilled these criteria and underwent endoscopic decompressive surgery. Their mean age was 60.9 years (range 42-70 years). No subluxation was present in four patients, whereas Meyerding Grade I slippage was demonstrated in three. For endoscopic decompression, a skin incision of 16 to 18 mm in length was made, and fenestration was performed to identify the affected nerve root. The proximal stump of the ragged edge of the spondylotic lesion, and the fibrocartilaginous mass compressing the nerve root were removed. The follow-up period ranged from 6 to 22 months (mean 11.7 months). Clinical outcome was evaluated using Gill criteria; in three patients the outcome was excellent, and in four it was good. This new endoscopic technique was useful in the decompression of nerve roots affected by spondylolysis, the technique was minimally invasive, and the clinical results were acceptable.

PMID 12691388
K Sairyo, S Katoh, T Ikata, K Fujii, K Kajiura, V K Goel
Development of spondylolytic olisthesis in adolescents.
Spine J. 2001 May-Jun;1(3):171-5.
Abstract/Text BACKGROUND CONTEXT: Although it has been well documented that slippage in patients with spondylolysis is most prevalent during the growth period, the exact time when slippage initiates and halts during the growth period is still unknown. Moreover, the contribution of spinal deformities, such as wedging of the vertebral body to the slippage, remains controversial.
PURPOSE: To clarify when slippage in pediatric spondylolysis initiates and halts.
STUDY DESIGN: Retrospective study.
PATIENT SAMPLE: We radiographically examined 46 athletes under 18 years of age with spondylolysis at the fifth lumbar vertebra (L5). The mean age at the first consultation was 13.3 years. The average follow-up period was 6.0 years.
OUTCOME MEASURES: Longitudinal observation of slippage at L5 on radiogram in correlation with the maturity of the lumbar spine.
METHODS: From a lateral radiogram of each patient, percent slippage, lumbar index (LI), and skeletal age of the affected vertebra were measured. Changes in the percent slippage over time were investigated, and the correlation between the percent slippage and LI was analyzed.
RESULTS: From the cartilaginous stage to the apophyseal stage, the slippage increased in 80.0% of the patients (16 of 20). From the cartilaginous stage to the epiphyseal stage, slippage increased in 11.1% of the patients (3 of 27). None of the patients (0 of 22) showed an increase after the epiphyseal stage. In 20 patients in whom slippage increased during the follow-up period, the percent slippage at the final consultation and the LI at the first consultation showed no significant correlation; however, the percent slippage and the LI at the final consultation were significantly (p<.01) correlated.
CONCLUSION: In conclusion, slippage was more prevalent in individuals of a younger skeletal age whose lumbar spine was immature, and it halted during the epiphyseal stage when the growth period was over and the vertebra matured. Furthermore, the results suggest that wedge deformity of an affected vertebra might be the result rather than the cause of slippage.

PMID 14588344
Shoichiro Takao, Toshinori Sakai, Koichi Sairyo, Tadashi Kondo, Junji Ueno, Natsuo Yasui, Hiromu Nishitani
Radiographic comparison between male and female patients with lumbar spondylolysis.
J Med Invest. 2010 Feb;57(1-2):133-7.
Abstract/Text We studied the lumbar spines of 117 adults (39 women and 78 men) with spondylolysis unrelated to low back pain using multidetector computed tomography (CT). Of the 117 subjects with spondylolysis, including five with multiple-level spondylolysis, there were 124 vertebrae with spondylolysis. In adult lumbar spines with unilateral spondylolysis, there was no significant difference between the incidence of spondylolisthesis in female and male subjects. However, in those with bilateral spondylolysis, there was a significantly higher incidence of spondylolisthesis in female subjects (90.9%) than in males (66.2%). Furthermore, females with bilateral spondylolysis had significant more slippage than males. Lumbar index and lumbar lordosis were not significantly different between male and female subjects, and did not significantly correlate with slippage. In conclusion, to treat acute spondylolysis in adolescents, it is important to obtain bony union at least unilaterally, especially in female subjects, to prevent further slippage.

PMID 20299752
Koichi Sairyo, Toshinori Sakai, Natsuo Yasui, Ali Kiapour, Ashok Biyani, Nabil Ebraheim, Vijay K Goel
Newly occurred L4 spondylolysis in the lumbar spine with pre-existence L5 spondylolysis among sports players: case reports and biomechanical analysis.
Arch Orthop Trauma Surg. 2009 Oct;129(10):1433-9. doi: 10.1007/s00402-008-0795-3. Epub 2008 Dec 16.
Abstract/Text STUDY DESIGN: Case series and a biomechanical study using a finite element (FE) analysis.
OBJECTIVES: To report three cases with multi-level spondylolysis and to understand the mechanism biomechanically.
BACKGROUND: Multi-level spondylolysis is a very rare condition. There have been few reports in the literature on multi-level spondylolysis among sports players.
METHODS: We reviewed three cases of the condition, clinically. These patients were very active young sports players and had newly developed fresh L4 spondylolysis and pre-existing L5 terminal stage spondylolysis. Thus, we assumed that L5 spondylolysis may have increased the pars stress at the cranial adjacent levels, leading to newly developed spondylolysis at these levels. Biomechanically, we investigated pars stress at L4 with or without spondylolysis at L5 using the finite element technique.
RESULTS: L4 pars stress decreased in the presence of L5 spondylolysis, which does not support our first hypothesis.
CONCLUSIONS: It seems that multi-level spondylolysis may occur due to genetic and not biomechanical reasons.

PMID 19084979

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