GUIDE
ARTICLESChanges
of the vertebral column
at
sportsmen - radio-imaging aspects
Anne-Marie
Zamfir
National Institute of Sport
Medicine Bucharest
Abstract.There
are individual predisposal factors very important in the appearance
of the vertebral column changes at sportsmen-the phylogenetic
variations of the development of the column, cranial and caudal(of
which the most frequent was sacrelizing of L5 vertebra),spina bifida
oculta S1,L5 and congenital spondylolisis and spondylolistesism-which
modifying the biomechanics of the vertebral column promotes the
degenerative changes in a higher proportion than for the sportsmen
without anomalies of the vertebral column.
The changes of the vertebral column at sportsmen are
grouped into traumatic lesions (bony, ligament, disc, medullar and
those of the soft paravertebral parts),diseases due to the
micro-traumatisms(Baastroup disease, Scheuermann vertebral
epifisitis) and chronic diseases, consequences of macro- and
micro-traumatisms(diseases of the disc, traumatic spondylolisis and
spondylolistesism and changes of the vertebral statics) emphasized by
radiological images, computed tomography(CT) and magnetic resonance
imaging(MRI) of the sportsmen examined in the National Institute of
Sports Medicine.
Key
words: vertebral column, sportsmen, radio -imagery.
The variety and the multitude of sport branches, the great number of
the young who practice them and also the different requirements imposed
today, in order to obtain performances, led to the appearance of a
specific pathology for some sport disciplines.
Statistical data show a tight interdependence between the number and
the type of sport traumatisms and the features of sport discipline. The
type of the effort, its biomechanical features, the equipment and
apparatus used, the environmental and organizational conditions under
which the sports preparations and the contests are carried on are the
main reasons that make the percentage of sports traumatisms, their
localization and type vary.
There are individual predisposal factors
very important in the appearance of the vertebral column changes in the
athletes: phylogenetic variations of the column development –
cranial
or caudal, spina bifida oculta and congenital spondylolysis and
spondylolystesis.
The cranial variant includes:
- cervical
rib – long transversal apophyses
in C7,
- the 12th rib short or the lack
of it,
- LA with very short
transversal apophysis, the sacralization of L5 (sacrum with 6
vertebras),
- sacrated vertebras with
tendency to
caudalisation.
The caudal variant includes: short transversal apophyses in C7, the
12th rib long, rib or rib-shaped appendix in L1, long transversal
apophysis in L4 as well in L5, S1 lumbarisation, sacralization of the
first coccegien vertebra. It is frequently met the sacralization of L5
vertebra which represents the exaggerated development of the
transversal apophysis of L5, which take nature of sacrated little
wings: they come into contact with iliac bones or with the sacrum, and
the vertebral body can be united with the body of S1.
There are six degrees of L5 vertebra sacralization:
I
– the enlargement of the transversal
apophysis size,
II – the enlargement of the transversal apophysis size, with
possibility of coming into contact with one of the sacrated little
wings.
III – contact or articulation of the L5 transversal
apophysis,
enlarged, with the sacrated little wing
IV – intimate fusion with the sacrated little wing and as
well with the
iliac bone of L5 on the transversal apophysis and of a corresponding
part of the vertebral body. The sacralization being unilateral
establishes scoliosis.
V
– idem IV, but bilaterally. Between L5 and S1
there’s seen only
a clearer line on the disc place.
VI
– L5 incorporated in the sacrum, without having knowledge of
the
disc.
The
biomechanical consequence of the sacralization is that the efforts
and tiredness are not equally distributed anymore in two discs L5
–
S1, and LA – L5, the joint movement being in LA –
L5 disc, which
suffers degenerative changes in time. Spina bifida oculta, usually an
accidental radiological discovery represents dehiscence of the
posterior vertebral arch. 25 – 35% of adults present spina
bifida,
frequently at S1. Radiologically it is emphasized the most frequently
a median linear transparency or wider, with the vertebral blades
strayed between them or which are completely unexisting.
Spondylolisis represents a continuing solutions at the vertebral
isthmus level which establishes the separation of the vertebral body
together with the transversal apophyses and the superior joint
apophyses from the vertebral blades together with the inferior joint
apophysis and the spinal apophysis establishes rachidian pains of
static kind, being frequently unilateral. It is emphasized the best
on the radiographies of the column in the incidence ¾,
Kovacs
technique: the configuration of the posterior arch half is compared
to a “puppy”. The extensive and fractured isthmus
leads to a
image of a puppy with a neck or a puppy with a collar. Sometimes the
spondylolysis is obvious only when is complicated with the
spondylolystesis.. The subjacent vertebral disc to lesion is
narrowed, suffers degenerative changes in time, especially in
athletes, where the challenges of the column are big. The
spondylolystesis represents ahead sliding of the vertebral body which
presents the spondylolysis at level of both joint isthmuses or the
deterioration of the fixed device at the level of joint apophysis or
the association of the two reasons. The premises are at the level of
the last lumbar vertebras, 94% at L4 and L5 level. The specific
radiography of the vertebral column provides us maximum information
about the spondylolystesis and that in incidence ¾ with
double
obliqueness about the reasons. The radiographies in ortostatisms are
favorite because the vertebral sliding is emphasized. The assessment
of the vertebral dislocation degrees made according to
Ulmann’s
chart: The tracing of a spondylolysis with spondylolystesis, in an
athlete with and without clinical signs raises medical legal
problems: can he continue his sports activity, is there the danger of
some severe complications,
are the radiographies necessary at the beginning of his sports
activity, as eliminatory screening tests, who has the right to decide
the interruption of the competitive activity, under the conditions
there are precedent facts – athletes with excellent
performances,
world multiple champions who had spondylolystesis without associated
clinical signs, whose they where permitted sports of performance, is
it necessary a legislation that allows to the athlete assuming the
risk in spite of the medical directions, etc?
In order to establish
the congenital nature or the post – traumatic one of the
spondylolystesis there are necessary radiographies made at the
beginning of sports activity, in an early age. We had a case with
spondylolysis and spondylolystesis in a 7 years old gymnast, who did
not present any kind of clinical signs of vertebral suffering, the
discovering being accidental. The anterior sliding of L5 vertebral
body was small, of 4 mm, IRM confirmed. The abnormities of the
vertebral column previously enunciated were radiologically discovered
in athletes who presented lumbar disease, especially of effort. In
gymnastics and wrestling where the trainings begin in an early age,
it is identify a continuing frequency of the vertebral column
changes, however “the spine pains” appear
frequently in those
with abnormities of the vertebral column. In a small study in the
National Institute of Sports Medicine, in which there were made
radiographies lumbar spine column of a group of 18 gymnasts –
12-14
years old, for the second selection, we established: the
sacralization of L5 in a gymnast without any of them presenting
signs of lumbar suffering.
The changes of the vertebral column
specific to the sports activity include the traumatic lesions of the
column, affections due to the micro-traumatisms and chronic diseases,
after-effects of macro and micro- traumatisms. The most of lesions
associated to sports activity imply the extremities of the body
–
65% - acute or chronic lesions of the limbs. About 5%of the acute
lesions affects the vertebral column. From all the fractures the
column fracture represents around 0.5-1%. Swimming, riding and
parachutism provide the greatest percentage of column fractures.
Sports represent the fourth reason of the vertebral column fractures
and the second reason of the associated paralysis. In the National
Institute of Sports Medicine there were not seen cases of vertebral
traumatisms with fractures, specific to the emergency situation,
that’s why it will be presented only one case of cervical
vertebra
fracture
C1-C2, in a rugby player, treated surgically, with osteo-synthesis
material. As a general classification we mention among the traumatic
lesions of the column: bony lesions, ligament and disc, medullar
traumatic lesions of the para-vertebral sides. Among the vertebral
traumatisms with neurological suffering, the examination by nuclear
magnetic resonance –MRI- shows the medullar affection, the
bony
compressive or disc reason, the associated ligament lesions, the
steadiness of the lesion focus, but it does not view neither the
small bony fragments nor the dural breaches. In the emergency, the
MRI next to standard radiology are election examinations. The TC is
the favorite examinations in the realization of the bony survey,
especially in the posterior vertebral arch fractures, fractures with
vertebral body intrachannel detached and acute hematoma. The
affections due to the micro-traumatisms include lesions of
overstressing made by low intensity traumatic agents, but frequently
repeated which surpass the regeneration potential of the tissues and
which produce anatomical micro-lesions. By example, at the level of
the joints surfaces, the small compressions but frequent, produce
edema of cartilages, followed by the erosion of these and the
necrosis of subjacent spongy bony tissue. The symptomatology of these
affections consists in the appearance of the pains connected to the
physical effort, pains of progressive nature, although they also have
remission periods. The repeated micro-traumatisms represented the
traction on the shims of inter-spine ligaments and the rubbing of the
tips of the spiny apophysis by exaggerated extensions and rotations
of the vertebral column lead to an affection that debuts as an
inter-spiny apophysitis – lesions of the inter-spiny
ligaments and
of the bony insertion of these and afterward lesions of arthrosic
type at the level of inter-spiny joints surfaces, promoting Baastroup
disease inter-spiny neoarthrosis The disease affects frequently the
athletes who practice aquatic sports, especially kayak and jumping
into water. We met it in gymnasts and football players. Clinically it
manifests by pains at the level of spiny apophysis , especially in
the spine lumbar regions, pains emphasized by the extension of the
column and by palpating of the spiny apophysis. Radiologically, on
the specific radiography: the width of the spiny apophyses coming
into contact with the neighbor surfaces, on that radiography:
neo-joints with arthrosic processes, between the two spiny neighbor
apophysis, the superior apophysis having a cavity in V-down shape in
which the superior edge of the inferior apophysis tends to penetrate.
The
evolution of these diseases is slow, with periods of ingravescence
and remission, a thing that allows to the sports activity to be
continued. Also an affection due to the micro-traumatisms is the
vertebral Scheuermann epiphysitis, or the vertebral osteocondritis.
It is frequently in those athletes who practice gymnastics, athletics
and sports games. It appears in the children, during growing up, the
most frequently between 12-15 years. It especially affects the
vertebral thoracic column – classic shape of Scheuermann
disease,
located frequently at the level of T7-T10 vertebras. There is also a
spine lumbar shape of disease, associated more frequently to the
traumatisms and to the spine pains. It appears in the athletes who
practice gymnastics, football and tennis. During the growing up,
vulnerability to micro-traumatisms of the body is greater, a thing
that leads to the appearance of those diseases. The sympthoms
consists in pains at the vertebral column level, emphasized by
effort, a state stressed by tiredness and the appearance of cyphosis.
The characteristic changes are emphasized from the radiological
point of view: Schmorl nodules abnormities of conformation of the
vertebral bodies, marginal anterior listel changes the round
cyphosis.
Schmorl
nodules – intra-spongy hernias appear by prolapsing of disc
tissues
favored the continuing solutions of the cartilaginous covering plates
of the vertebral body. They establish atrophy regions by pressure
translated radiological by circumscribed cavities of the vertebral
bodies lines sometimes limited by a tender opaque liserius. Sometimes
the hernia nodules can create lacks of substance at the level of
anterior angular of the vertebral bodies or dislocations of some
portions of the body marginal ridge, with radiological aspects of
fracture routes. The vertebral body in the anterior half is easily
reduced in height, in the initial phases, then the reduction in
height can be remarkable. The vertebral plateaus are irregular,
condensed. The disease stops its evolution at the end of the growing
up process. The consequences after that period consist in the
appearance of the deformed arthrosis especially at the level of
T7-T10 vertebras. The discovery of the disease in a growing up
athletes implies the interruption of sports activity and emergency
treatment of the vertebral column stabilization. The chronic
affections in athletes are the results in time of some macro and
micro-traumatisms at the level of some
anatomical tissues and formations that present other pre-existing
affection, too. (rheumatisms, dismetabolic diseases, etc).
It cannot
be exactly said the role of the factors which interfere in the sports
activity because these affections are met in the individuals who do
not practice sports. There are a few studies concerning the
correlation sport activity – degenerative changes of the
vertebral
column. Weightlifting was associated with great degenerative changes,
especially if sports activity of that type started in an early age.
Football is charged into one of the studies by the appearance of the
degenerative lumbar column changes, prevalently inferior. The
weightlifting, football and gymnastics can establish spine
degenerative changes not only by direct traumatisms but also by the
induction of some vertebral growing up disorders. In a study with
monozigot twins, Battie and his contributors – 1995
–
demonstrated the importance of the genetic factors in the appearance
of disc degenerations in those with sports activity. We included
among the chronic affections the after-effects of macro and micro-
traumatisms of the inter-vertebral disc affections, traumatic
spondylolysis and spondylolystesis and the changes of the vertebral
statics. The disc structures, especially pulp nucleus, can suffer
disorders joined by their dislocation that can be produced towards
the body of the neighbor vertebras, intra-spongy hernias, or towards
the regions that circle the disc. The initial lesions consist in the
separation of the cartilaginous hyaline plateau out of the adjacent
vertebral body. The following stresses lead to the splitting and
weakness of the disc fiber ring. Consequently the protusion of the
pulp nucleus appears among the broken fiber of the ring, the most
frequently in the posterior lateral portion. The disc hernias, the
most frequently posterior manifest radiologically by indirect signs,
probability, making up the “Baar triad”: scoliosis,
reduction of
cervical or lumbar lordosis and the height decreasing of the
inter-vertebral space. Rarely, in one of the latest the presence of
the hernia nucleus nearby the posterior angular vertebras can produce
the demineralization or the atrophy of those by pressure. The
diagnosis of the disc hernia establishes itself certainly by CT or
MRI. The median disc hernia and/or para-median sub-ligament in
80%of the cases met in practice, MRI appears as a para-median
asymmetrical disc debord, situated in touch with the disc of origin
that can presses the nervous roots next to the going out of the dural
sack, the root having the same number as the disc. The disc
degeneration has an obvious radiological osteophytosis manifestation,
a consequence of the degeneration of the marginal fiber ring, which
suffer unusual tractions in the place of insertion of the vertebral
body, because of its solidarity with the ligament neighbor apparatus.
The osteophites produce the deformation by bone excesses of the
vertebral angulars. Their frequency is big at the level of the
regions intensely required: cervical and lumbar. The disc
degeneration is translated in some cases by the decreasing of the
height of the inter-vertebral space. In the evolutive advanced
stages, the degenerative process enlarges at the level of the
cartilaginous covering plate realizing the radiological aspect of the
vertebral osteocondrosis: the diminution in height of the
inter-vertebral space and the condensation by osteo-sclerosis of the
adjacent of vertebral plateaus, that get irregular outlines. Disc
calcification appears in rarer cases. The results of the latest
studies about the disc degenerations in athletes are contradictory:
- Tertti
sustains that there aren’t significant differences between
the disc
degeneration in athletes comparatively to normal population,
- Goldstein
shows an increasing frequency of disc degenerations in athletes
comparatively to normal population, especially in gymnasts and
swimmers,
- Sward
sustains that there is a diminution of the intensity of IRM signal at
the level of the inter-vertebral disc in gymnasts comparatively to
non-athletes,
- Hellstrom
emphasizes a diminution of the disc inter-vertebral height in
gymnasts comparatively to normal population. These non concordances
are due to the different ages of the included subjects in the studies
– during the growing up, the vulnerability at the mechanic
stress
being much greater.
The causes of the spondylolystesis can be grouped into:
-
isthmus lesions: congenital – isthmus dehiscence or isthmus
thinning, traumatic and tropho-static.
-
posterior inter-vertebral apophyses changes: bending ahead, because
of the osteomalacy of superior joint apophyses of the subjacent
vertebra that will slid more rarely, congenital agents of the joint
apophyses or their traumatic breaking.
-
the association of those two causes previously described –
the
isthmus stretching plus the bending of the joint apophyses (the
consequences of a demineralization process).
Spondylolistesis
can be also produced when the disc resistance decreases by the
generative lesions and the vertebral ligaments are getting weaker by
stretching , the most frequently because of some traumatisms. The
presence of the congenital abnormities as spina bifida or
sacralization of the last lumbar vertebra favors the appearance of
the vertebral dislocations. The spondylolistesis is frequent in the
sports in which the hyperextension and rotation movements of
weightlifting can produce fractures of “stress” or
“tiredness”
(micro fractures) at the level of the inter-joint parts, to their
separation. These aspects could explain the greater frequency of the
spondylolisis in athletes comparatively to normal population.
The
curvature changes of the vertebral column can be frontal or sagital.
Scoliosis is a bend of the vertebral column in frontal plan, larger
than 10 degrees. It is a complex deformation, evolutive which also
includes the rotation of the vertebral bodies. Ciphosis is an
anterior bending, in a sagital plan, of the column. There is a
physiological ciphosis of 20-40 degrees. It can be round , in
Scheuermann disease or angular, in the traumatisms that usually
affects the vertebral body, or more rarely in athletes, consequences
of the discitis. Scoliosis frequently appears in the sports which
require unequally some parts of the body, such as tennis, where the
superior right limb (for the right hand individuals) or the left one
(“for the left hand individuals) is more intensely required
comparatively to the others, unequal development of the muscles of
the superior limb and of the scapular girdle establishing the
asymmetrical requirements of the column with consequent static
disorders. The asymmetrical loading of the body and shoulders also
appears in the javelin throwers, scoliosis being a very frequent
change among these. In gymnastics we met frequently enough scoliosis
of the athletes, usually temperate. Some authors sustain that these
are due to the overstressing of the vertebral column in the growing
period of the body, extremely vulnerable.
Conclusions:
Traumatic accidents in the athletes present a series of features
which make them different of the rest accidents:
-they
produce in an early age, at individuals with an increasing potential
and who does not present associated affections, locally or generally.
-the
appearance mechanisms and their anatomical clinical shapes have a
certain specificity in accordance to the sports disciplines.
-
the diagnosis must be precocious, the treatment intensive and
complex, so that the recovering of the athlete to be as fast as
possible, in order to restart the competitive activity.
In
the National of Sports Medicine Institute – Bucharest it is
made
periodical examinations in the athletes. The x-ray examination is
directed every time the clinical symptomatology, imposed the most
frequently after the traumatisms or when overstressing changes
appear. At the vertebral column level we emphasized in those athletes
the different radiological changes, some of those mentioned
previously. Sometimes for the confirmation of the diagnosis or for
its completing we appealed to additional examinations of the
vertebral column: CT, MRI, mielography, etc, made in different
clinics from Bucharest. In the year of 2000 in the National Institute
of Sports Medicine they carried out the radiographies of the
vertebral column for a number of 158 athletes of those 731 who were
in need of radiographies of the different segments of the skeleton,
during medical circuits. In the year of 2001 there were 92 athletes
who made radiographies of the column of 463 whose were directed to
make radiography. It is obvious that in these years the gravity of
the vertebral column affections was 20%, respectively of 21% of all
affections which require radiological examinations. The vertebral
statics changes, the congenital abnormities of the column, the disc
degenerative changes are the most frequent (in 2001-2002 in the
National Institute of Sports Medicine the greatest frequency was in
football – 3,39%, athletics 3,1%, gymnastics 2,9% , tennis
2,6%).
Severe traumatisms with vertebral medullar important lesions are not
examined in the National Institute of Sports Medicine because of the
emergency situations that require the transportation and emergency
treatment in a hospital.