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
Patients with symptomatic spondylolysis usually complain of mechanical-type back pain with strenuous sports or activities. The symptoms can be acute but generally are insidious in onset. Some patients present with back pain and complain of tight hamstrings and buttock pain. The symptoms may be mild without any change in activity or more severe causing abandonment of sports and strenuous activities.
The diagnosis can frequently be made on radiographs by obtaining anteroposterior, lateral, and oblique views. In those instances in which radiographs do not reveal the defect, bone scan with SPECT imaging can be useful. In instances in which bone scan and radiographs are equivocal, fine cut CT images can locate the lesion. MR imaging scans are generally not helpful in the diagnosis of pars defects.
The initial treatment for symptomatic spondylolysis is usually based on activity modification, rest, and use of NSAIDs. In patients with severe symptoms, the use of a thoracolumbosacral orthosis (TLSO) brace may be effective in resting the back. The author frequently recommends the use of a brace for 6 to 12 weeks. Morita et al(21) have shown that in patients with early defects, about 73% heal with brace immobilization. In the more chronic defects, healing was less likely. Healing has not been consistent in the author's experience, but brace immobilization has been useful in the cessation of symptoms with subsequent return to activities.
Surgical treatment for spondylolysis has been reserved for patients who have failed to improve with a compliant nonoperative program. In L5-S1 level spondylolysis, a posterolateral fusion is generally recommended. For lesions at L4-5 and above, a pars defect repair is considered. Surgery is rarely needed, and most patients improve with nonoperative treatment.
Wiltse38 has categorized spondylolisthesis into five basic types: (1) isthmic, the most common type in children and adolescents; (2) dysplastic; (3) traumatic; (4) degenerative; and (5) pathologic. Wiltse has categorized displacements based on the forward slippage of one vertebra on another: grade I, 0 to 25% slip; grade II, 25% to 50%; grade III, 50% to 75%; and grade IV, 75% to 100%. Spondylolisthesis symptoms generally mimic the symptoms of spondylolysis. For grade 1-11 slips, modified activity and brace immobilization may reduce symptoms and allow the patient to resume normal activities. In patients with radiographic documentation of progressive slippage, a slip greater than 50% in a growing child, or in patients with back pain not relieved by conservative treatment, posterolateral fusion may be beneficial. Controversy exists about the need for reduction and the use of instrumentation.