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"Sport Medicine Journal" No.5 - 2006

Changes 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.

Spina bifida oculta S1
Osteocondrita L3
Fractura C1-C2 operata
Noduli Schmorl
Spina bifida oculta S1
Osteocondrita L3

Fractura C1-C2 operata

Noduli Schmorl

Spondiloliza si spondilolistezis L5
Sacralizare gradul II a vtb. L5
Spondiloliza si spondilolistezis L5

Sacralizare gradul II a vtb. L5

Hernie disc posterioara L4 si L5(MRI)
CT cu reconstructie, degenerescenta discala
Hernie disc posterioara L4 si L5(MRI)

CT cu reconstructie, degenerescenta discala

Scolioza dorsală dextroconvexă

Maladie Scheuermann

Scolioza dorsală dextroconvexă
Maladie Scheuermann


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