DISORDERS OF THE PEDIATRIC AND ADOLESCENT SPINE
Back Pain in Children
Howard A. King, MDPage: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11
The forward bend test allows for review of frontal or sagittal plane deformities. The physician should also look at spine movement in both forward flexion and recovery to the up-right position. Lumbosacral low back pain increased by hyperextension seems to correlate well with spondylolysis and spondylolisthesis.
Careful evaluation of gait patterns, balance, and coordination should be initially addressed followed by motor, sensory, and upper and lower extremity reflex testing. Evidence of clonus and Babinski signs should be noted. Abdominal reflexes should be tested and documented. Asymmetry or absence of these reflexes may be subtle signs of syringomyelia or spinal cord tumor. Straight leg raising and crossed straight leg raising can be checked. The physician should look for evidence of radiculopathy or tension signs.
IMAGING STUDIES
Radiographic Evaluation
Every child who presents to a physician with the chief complaint of back pain should have at least an anteroposterior and lateral radiograph of the spine. Oblique lumbar spiner adiographs are not routinely ordered but are used to look for suspected spondylolysis. In a child with significant symptoms and a normal routine initial radiographic evaluation a technetium 99 bone scan can be used as a second-level diagnostic study.
On occasion, the bone scan may be negative despite a suspicious area on the radiograph. Lowe et a1(22) and Papanicolau et al(29) have both reported the use of scans in evaluating spondylolysis. Papanicolau et al believed that the scan may be useful in determining the activity and age of the pars fracture. Single-photon emission computed tomography (SPECT) links a bone scan with computed tomography (CT) to increase sensitivity and specificity of the scans. Collier et al(8) and Bellah et a1(2) have shown that SPECT imaging is more sensitive and more accurate than plain scanning techniques. Bodner et al(3) have shown the technique to be highly accurate in finding stress fractures in the lumbar spine. The author routinely uses SPECT imaging in situations in which the regular scan is negative or questionable.
Computed Tomography
The CT scan is a valuable diagnostic tool to detect spinal pathology. It can be used to define more clearly pathology located by bone scan. One-millimeter cuts in the lower lumbar spine are useful in diagnosing and evaluating spondylolytic lesions. If a brace or cast has been used to treat the spondylolysis, follow-up CT scans can determine if healing has occurred. CT scans can also be used to define more clearly a positive myelogram. The author uses magnetic resonance (MR) imaging techniques to assess abnormal clinical neurologic findings, but there are times when a myelogram or CT scan can be effective in defining better a confusing clinical picture such as in patients with neurofibromatosis.