Working Diagnosis:
Spondylolysis of left L3 in both siblings.

Treatment:
Conservative management was recommended to both patients and both elected for non-bracing. NSAIDs and acetaminophen were used as needed for pain control, as well as, home core exercises with avoidance of hyperextension, and icing or heating as needed. Avoidance of impact load, spine hyperextension exercise and axial spine load weight training were advised to both patients. Both were initially held from sport participation for 6 weeks.

Outcome:
Both returned for re-evaluation six weeks after diagnosis and reported being pain free with ADLs, rehabilitation exercises and non-impact exercise. Both were noted to have normal physical exams and encouraged to advance in a pain-free manner to full participation over the following 4-6 weeks. Both returned to full activities without recurrence of pain.

Author's Comments:
Spondylolysis is a stress fracture of the pars interarticularis, most commonly of the lumbar spine, and is a common cause of back pain in the pediatric population. The fracture usually occurs from repetitive extension, flexion, and rotation activities. Previously, there have been case reports of spondylolysis within families. This scenario begs the question of a genetic predisposition for spondylolysis, given that two siblings presented at the same age (16), after the same duration of left-sided pain (6 months) and were found to have a pars fracture at the same location (left L3). Current research indicates an autosomal dominant inheritance, but a specific gene has yet to be identified.

Editor's Comments:
Atraumatic low back pain in the young athletic population raises concern for spondylolysis. This case features siblings with spondylolysis, one being female which is less common for reported familial cases. Families with multiple children, one child presenting with spondylolysis, consider discussing warning signs for the other children and core exercises for those at increased risk given possible genetic predisposition.

There is debate about the preferred treatment protocol pertaining to brace vs non-bracing for athletes with spondylolysis. With bracing, it has been shown that athletes have been able to return to sport pain free after 4-6 weeks. Studies have not been published showing similar outcomes for return to sport without a brace in a similar time frame. Long term (i.e. one or more years after diagnosis of spondylolysis) studies show no difference in outcomes. Factors to consider for bracing include age and unilateral vs bilateral pars involvement.

References:
Yamada A, Sairyo K, Shibuya I, Kato K, Dezawa A, Sakai T. Lumbar spondylolysis in juveniles from the same family: a report of three cases and a review of the literature. Case Rep Orthop. 2013;2013:272514. doi: 10.1155/2013/272514. Epub 2013 Sep 26. PMID: 24191211; PMCID: PMC3803119.

Kato K, Hakozaki M, Mashiko R, Konno SI. Familial development of lumbar spondylolysis: a familial case report of 7- and 4-year-old brothers and their father. J Int Med Res. 2021 May;49(5):3000605211015559. doi: 10.1177/03000605211015559. PMID: 34013758; PMCID: PMC8150521.

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