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
Scheuermann's Disease
Scheuermann's disease was the second most common cause of back pain in children and adolescents in the King (18-20) and Turner et al(36) series. The patients usually complain of fatigue symptoms later in the day. They rarely have symptoms severe enough to halt activities. Complaints of a roundback deformity are common. Generally, radiographs of the spine show typical findings of vertebral wedging and end-plate irregularity. Further diagnostic imaging may be done for excessive symptoms. Bone scans and MR imaging studies are useful in ruling out the causes. The treatment for back pain associated with Scheuermann's disease includes modified activities, NSAIDs use, and brace immobilization. For patients with severe deformity, bracing or surgery may be needed depending on the age of the patient and curve magnitude.
Inflammatory Diskitis
Patients with inflammatory diskitis may present with severe back pain and associated fever, malaise, and signs of sepsis. In patients 3 years old and younger, the initial findings may include all of the aforementioned symptoms and signs plus a refusal to walk.(37) The radiographic evaluation usually shows disk space narrowing and sclerosis in adjacent vertebral end plates. Patients have had symptoms for several weeks before they present for evaluation.
Laboratory tests generally show elevated erythrocyte sedimentation rates and C-reactive proteins. White blood cell count may or may not be elevated. Wenger et a1(37) have shown that only 9 of 32 blood cultures were positive and were a more useful diagnostic aid in the acute period. Disk space biopsy specimens are positive in only 25% of patients.(5,32) Positive cultures usually yield Staphylococcus aureus.(5,32) Because of the low yield on disk space needle aspiration, blood cultures are obtained and patients treated as though they have S. aureus. Treatment includes brace or cast immobilization and parenteral antibiotics, especially in patients who present with high fevers and systemic symptoms. Most patients respond to brace and antibiotic treatment. Surgery is rarely indicated or required.
NEOPLASTIC DISORDERS
Turner et a1(36) and King(18) have both shown that tumors are not an uncommon cause of back pain in young people. The tumors can be primary or metastatic to the vertebral column or to the spinal cord. When the lesion is present with an associated neurologic deficit, rapid diagnosis and treatment urgency are required. Many patients present with symptoms that can be vague and nonspecific such as night pain or pain not associated with activity. Any patient who complains of painful scoliosis (not just back-ache) should be carefully evaluated for tumor. Tachdjian and Matson33 in their classic article on spinal cord tumors showed that the time to diagnosis is often quite extended because of unusual presentations that many of these patients have.