Actitud davant d'un pacient esportista amb espondilòlisi: cas clínic
Approach to an adolescent athlete with spondylolysis: A case report
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Universitat Autònoma de Barcelona. Universitat de Barcelona. Barcelona." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Serveis Mèdics FC Barcelona. Barcelona." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Approach to an adolescent athlete with spondylolysis: A case report" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "278v41n150-13093650fig02.jpg" "Alto" => 832 "Ancho" => 623 "Tamanyo" => 109972 ] ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"> Introducció</span></p><p class="elsevierStylePara"> L'espondilòlisi lumbar és una causa comuna de dolor lumbar baix en pacients adolescents esportistes<span class="elsevierStyleSup">1-5</span>. La prevalença de dolor lumbar baix en pacients esportistes entre 11-17 anys varia del 8,02 al 30,9%, segons la bibliografia consultada<span class="elsevierStyleSup">6-10</span>.</p><p class="elsevierStylePara">S'ha observat una major incidència de l'espondilòlisi en alguns esports, com la gimnàstica, aixecament de pesos, lluita, patinatge, voleibol, tennis i futbol<span class="elsevierStyleSup">2,11</span>. Es tracta d'un defecte ossi en la <span class="elsevierStyleItalic">pars interarticularis</span> de l'arc posterior vertebral i actualment aquesta lesió s'accepta com una fractura per estrès provocat per un microtrauma repetit per càrrega i descàrrega de la zona, habitualment en flexoextensió amb rotació lumbar o sense. Sol ser bilateral, i en la majoria dels casos (85-95%) afecta L5<span class="elsevierStyleSup">12,13</span>.</p><p class="elsevierStylePara">Basant-nos en les recomanacions establertes per Standaert<span class="elsevierStyleSup">5</span> i en el document de consens de la Societat Catalana de Medicina de l'Esport (SCME)<span class="elsevierStyleSup">13</span> (fig. 1), hem fet el tractament i el seguiment del cas següent.</p><p class="elsevierStylePara"><img src="278v41n150-13093650tab01.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Figura 1</span> Conducta que cal seguir davant d'un EPL en un nen adolescent. CL: clínica; DVA: esports vertebralment agressius; EPL: espondilòlisi; FD: factors displàstics; GOP: gammagrafia òssia planar; RM: ressonància magnètica.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Cas clínic</span></p><p class="elsevierStylePara">Pacient home, de 13 anys d'edat, jugador de futbol, que va acudir a consulta el setembre de 2005 manifestant dolor lumbar baix de 4 mesos d'evolució, sense irradiació a extremitats inferiors. El dolor referit és de tipus punxant al nivell L4-L5-S1 i s'accentua amb la pràctica esportiva (córrer, saltar, xutar, etc.). Igualment, minva amb repòs. En l'exploració, destacava un dolor bilateral paralumbar baix que augmentava amb la hiperextensió. Existia una disminució de la flexibilitat dels isquiosurals. Es va orientar el diagnòstic com a espondilòlisi lumbar i es va sol·licitar un estudi radiogràfic (front, perfil i oblic a 45°). Es va pautar repòs esportiu i electroteràpia antiinflamatòria. Igualment, s'acordà una visita al podòleg.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Curs clínic</span></p><p class="elsevierStylePara">En la visita següent el pacient es presenta amb radiografies que confirmen el diagnòstic d'espondilòlisi L5 unilateral dreta (figs. 1 i 2). D'acord amb el document de consens de la Societat Catalana de Medicina de l'Esport, se sol·licita una gammagrafia òssia planar (GOP) amb tomografia computaritzada per emissió de fotó simple (SPECT). Es decideix continuar amb el mateix tractament i s'assabenta el pacient que serà un tractament a llarg termini.</p><p class="elsevierStylePara"><img src="278v41n150-13093650fig02.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 2</span></p><p class="elsevierStylePara">Als 15 dies el pacient es presenta amb simptomatologia atenuada. La GOP/SPECT (figs. 3 i 4) demostra fenòmens de remodelació òssia al nivell d'ambdues <span class="elsevierStyleItalic">pars</span> d'L5. Per tant, es conclou el diagnòstic d'espondilòlisi activa L5 dreta i espondilòlisi esquerra en formació. Es continua el mateix tractament i s'hi afegeix una pauta específica d'exercicis deslordosants i ortesis plantars de correcció.</p><p class="elsevierStylePara"><img src="278v41n150-13093650fig03.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 3</span></p><p class="elsevierStylePara"><img src="278v41n150-13093650fig04.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 4</span></p><p class="elsevierStylePara">Als 2 mesos, el pacient manifesta una millora clínica significativa, per la qual cosa s'indica practicar natació per reforçar la zona lumbar, a més del tractament anterior. Se sol·licita un nou estudi radiogràfic al cap de 15 dies.</p><p class="elsevierStylePara">El nou estudi radiogràfic demostra espondilòlisi L5 dreta i persistència d'integritat de l'hemiarc esquerre (figs. 5 i 6). Igualment, l'estudi radiogràfic dinàmic demostra estabilitat completa de l'articulació lumbosacra (fig. 7). Per tot això es planteja l'alta esportiva, per bé que es recomana de continuar un mes més el tractament, i ajornar la tornada a la pràctica esportiva.</p><p class="elsevierStylePara"><img src="278v41n150-13093650fig05.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 5</span></p><p class="elsevierStylePara"><img src="278v41n150-13093650fig06.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 6</span></p><p class="elsevierStylePara"><img src="278v41n150-13093650fig07.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 7</span></p><p class="elsevierStylePara">En una visita posterior, coincidint amb el retorn a la plena activitat, es du a terme un control mitjançant GOP/SPECT, en què s'observa una lleu persistència d'activitat osteogènica al costat esquerre i nul·la al dret (fig. 8). En aquest moment es pauta un mes més de tractament i se cita l'interessat per valorar l'alta. En l'última visita el pacient es presenta completament asimptomàtic.</p><p class="elsevierStylePara"><img src="278v41n150-13093650fig08.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 8</span></p><p class="elsevierStylePara"><img src="278v41n150-13093650fig09.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 9</span></p><p class="elsevierStylePara"><img src="278v41n150-13093650fig10.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figura 10</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Discussió</span></p><p class="elsevierStylePara">Seguint les recomanacions del document de consens de l'SCME per a la sospita clínica d'espondilòlisi, hem pogut observar la història natural de dos processos d'espondilòlisi distints. D'una banda, el costat dret representa l'evolució d'una lisi activa a inactiva. D'altra banda, el costat esquerre mostra l'evolució d'una espondilòlisi inactiva, detectada precoçment i plantejada correctament, que s'autolimita en el temps sense seqüeles radiogràfiques. En el nostre cas ens ha estat de gran utilitat el fet d'orientar la lesió com de llarga evolució, ja que ens ha permès tractar el pacient amb els terminis de repòs pertinents. Igualment és molt útil el control periòdic estricte d'aquest tipus de pacients, ja que d'aquesta manera es poden introduir estratègies terapèutiques d'una manera progressiva.</p><p class="elsevierStylePara">Coincidint amb l'opinió d'Standaert<span class="elsevierStyleSup">5</span>, no ha estat necessària la col·locació d'una cotilla deslordosant, a causa del diagnòstic primerenc efectuat i pel fet que la simptomatologia va cedir als 15 dies de repòs; aquest cas demostra que col·locar-la no és estrictament necessari.</p><p class="elsevierStylePara">Finalment, quan hi ha coincidència de clínica, radiologia simple i gammagrafia òssia, no és estrictament necessari fer una tomografia computaritzada, ja que d'acord amb la nostra experiència, seguint els estudis radiogràfics periòdics, és possible el control evolutiu de la lesió.</p><hr></hr><p class="elsevierStylePara">Correspondència: Dr. Federico A. Yáñez Siller. Llorens i Braba, 45-49 B, 4-2. 08025 Barcelona.</p>" "pdfFichero" => "278v41n150a13093650pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec938127" "palabras" => array:2 [ 0 => "Espondiliosis" 1 => "Lumbalgia" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec938126" "palabras" => array:2 [ 0 => "Spondylolysis" 1 => "Low ack pain" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "La espondilòlisi lumbar és una causa comuna de dolor lumbar baix en pacients adolescents esportistes. N'hi ha diverses entitats clíniques en funció dels resultats dels exàmens complementaris, que condicionen opcions terapèutiques diferents. Presentem el cas d'un jugador de futbol de 13 anys que consulta per dolor lumbar baix. L'estudi radiogràfic inicial presenta una espondilòlisi L5 unilateral dreta. L'estudi isotòpic demostra fenòmens de remodelació òssia al nivell d'ambdues <span class="elsevierStyleItalic">pars</span> d'L5. Per tant, es conclou el diagnòstic d'espondilòlisi activa L5 dreta i espondilòlisi esquerra en formació. Es planteja un tractament conservador i el control evolutiu permet observar la història natural de dos processos d'espondilòlisi diferents. El fet d'orientar la lesió com de llarga evolució ha permès tractar el pacient amb els terminis de repòs pertinents. No ha calgut la col·locació d'una cotilla deslordosant a causa del diagnòstic primerenc i un cessament ràpid de la simptomatologia." ] "en" => array:1 [ "resumen" => "Lumbar spondylolysis is a common cause of low back pain in adolescent athletes. The results of complementary examinations can be used to distinguish among several clinical entities, whose therapeutic management will differ. We present the case of a 13-year-old football player who consulted for low back pain. Initial radiographic study showed unilateral right L5 spondylolysis. Isotopic study showed bone remodeling in both L5 pars. Therefore, a diagnosis of active right L5 spondylolysis and incipient left spondylolysis was made. Conservative treatment was provided and follow-up allowed the natural history of the two distinct processes to be observed. Viewing the lesion as a long-term process, allowed us to treat the patient with appropriate periods of rest. Due to the early diagnosis and the rapid disappearance of symptoms, the use of a brace to correct lordosis was not required." ] ] "multimedia" => array:20 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "278v41n150-13093650tab01.gif" "imagenAlto" => 232 "imagenAncho" => 700 "imagenTamanyo" => 126488 ] ] ] ] ] "descripcion" => array:1 [ "ct" => "Conducta que cal seguir davant d'un EPL en un nen adolescent. 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Documento de Consenso (octubre 2002). En: Conducta a seguir ante una espondilólisis y/o espondilolistesis en deportistas, 2002:2-7." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Societat Catalana Medicina de l'Esport." ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "ct" "url" => "/X8866581/0000004100000150/v0_201801081420/XX886658106936503/v0_201801081420/ct/main.assets" "Apartado" => array:4 [ "identificador" => "71859" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cas clínic" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/X8866581/0000004100000150/v0_201801081420/XX886658106936503/v0_201801081420/ct/278v41n150a13093650pdf001.pdf?idApp=UINPBA00004N&text.app=https://apunts.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/XX886658106936503?idApp=UINPBA00004N" ]
Article information
ISSN: X8866581Original language: Català
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| 2014 December | 21 | 11 | 32 |
| 2014 November | 30 | 8 | 38 |
| 2014 October | 42 | 10 | 52 |
| 2014 September | 24 | 8 | 32 |
| 2014 August | 21 | 14 | 35 |
| 2014 July | 19 | 14 | 33 |
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