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
MECHANICAL DISORDERS
Disk Herniation
In adults, disk herniation is a frequent cause of back and leg pain. Disk herniation in adolescents accounts only for 1 % to 4 % of all disk herniations.(10) DeLuca et a1(9) noted that 98% of children with disk herniations presented with back pain with or without sciatica. Others have also noted that back and leg pain may be the presenting Symptoms. (4,6,10,14) Epstein et al(10) reported that about 50% of the patients in their series had symptoms after trauma. All patients had positive straight leg raising, and more than half had positive cross leg raising tests. Epstein et al noted a high incidence of associated spinal anomalies, such as transitional vertebra, spondylolisthesis, spinal stenosis, and narrowed lateral recesses. Experience suggests that MR imaging scans and CT-enhanced myelograms are the optimal ways to document disk herniation. DeLuca et al(9) have shown that most herniations occur at the L4-5 or L5-S1 levels.
The treatment for adolescent disk herniation begins with conservative treatment. Limited activity, NSAIDs, and brace immobilization can be used as the initial form of treatment. If symptoms persist or worsen, documentation with imaging studies, either MR imaging or CT and myelogram, should be done and disk excision completed. Approximately 90% of patients with surgical disk excision report good-to-excellent short-term results. (9)
A fracture with posterior displacement of the vertebral apophysis can occur in growing patients. These injuries follow trauma and present similar to a ruptured disk. CT and MR imaging studies identify the displacement of the apophysis and adjacent piece of bone. These displaced fragments can be quite large and represent a surgical challenge.
Developmental Spondylolysis and Spondylolisthesis
The studies by Turner et a1(36) and King (18) demonstrate that spondylolysis and spondylolisthesis are the most common causes of back pain in children and adolescents older than age 10. Spondylolysis is rare in children younger than 5 and is much more likely to be seen in patients older than 10. Spondylolysis is believed to be a stress fracture of the pars interarticularis .38 Popular theory suggests that accentuation of lumbar lordosis with activities is the predisposing cause of stress in the pars leading to a fatigue fracture. Jackson et a1(17) have demonstrated an 1 1 % incidence of spondylolysis in young gymnasts. Kono et a1(21) reported a 10.9% incidence of spondylolisthesis in athletic Japanese boys. Ferguson et a1(21) have shown an increased incidence of spondylolysis in college football linemen. Teitz(34) reported a 15% to 20% incidence of spondylolysis in dancers who complain of back pain. These studies suggest that certain activities which demand lumbar hyperextension carry a high incidence of spondylolysis. Spondylolysis has been shown to have a heritable association .(26,27,38)