Unformatted text preview: Adolescent Back Pain
(Quit yer whinin’…) Amy K Evans, PGY1
National Naval Medical Center
August 2005 Case Presentation
Case Presentation CC: College physical HPI: 19yo WM presents for routine physical. No current concerns. Oh wait, actually my back hurts. Past 46mo. Pain low midback just above belt level, bandlike distribution but no radiation above or below. Occurs in AM after exercising day prior; gone by noon. Does not use heat, ice, or meds. No pain in buttocks or legs. No reported numbness/weakness. No specific hx trauma. PMHx: None Meds: None Case Presentation
Case Presentation HEADSS: Younger brother, good family relationships Soph at Miami of Ohio Excellent grades Government major Basketball, LAX as club sports Girlfriend x9mo, no SA Occasional EtOH, no smoking, no drug use Case Presentation
Case Presentation Physical Exam: AFVSS; Ht 75%; Wt 75% Exam unremarkable Back: symmetric, no scoliosis, no erythema/edema, no tenderness to palpation, no paraspinal spasm, FROM flex/ex Positive lumbar hyperextension test bilat LE: decreased hamstring flexibility (1/10), normal strength & sensation, FROM hips, knees, ankles Back Pain in Pediatrics
Back Pain in Pediatrics Uncommon CC, but common occurrence
7% of 12yo with >1 episode LBP
50% of 18yo F, 50% of 20yo M Most not definitively diagnosed Most benign etiologies ~Half of episodes musculoskeletal (ER)
10% infectious, 13% idiopathic, 13% SCD Remember, backpacks <1520% of weight! Back Pain in Pediatrics:
Back Pain in Pediatrics:
Differential Diagnosis Red Flags!
Red Flags! Infectious, Neoplastic, Rheumatologic Acute trauma
Hx CA/TB exposure
Young age (<4yo) RedHawk’s Films
RedHawk’s Films What does he have?
What does he have? Spondylolysis: Defect (separation) in pars interarticularis Spondylolisthesis: Anterior slippage of vertebral body over next lowest body Spondylolysis
Spondylolysis Found in 78% of general population
Found in 5% by age 6 Males>Females (2:1) Females more likely to progress to spondylolisthesis White>AfricanAmerican Most commonly at L5 (90%; 80% bilat) Often asymptomatic/incidental finding Who is at risk?
Who is at risk? Genetic predisposition Alaskans 40% adults Eskimos 54% adults Family history Spina bifida occulta? Athletes with repetitive hyperextension Gymnasts Divers Football offensive linemen Pole vaulters Weight lifters Wrestlers LAXers! Spondylolysis:
Presentation Low back pain, typically at belt line Insidious onset, may increase with activity Rarely radiating Commonly in preadolescent growth spurt Usually no hx trauma Usually no neuro deficits Spondylolysis:
Physical Findings Hyperlordosis Vertical sacrum Iliac crests high, ribs look low “Short” torso +/ “Stepoff” at L5 +/ Facet joint tenderness Hamstring spasm – classic in adolescents! PhalenDickson sign (hipflexed, kneeflexed gait) Lumbar Hyperextension Test
Lumbar Hyperextension Test Spondylolysis:
Diagnosis XRay: Firstline! SPECT: If films negative but H&P suggestive CT: If SPECT positive but dx inconsistent Bone Scan: If suspected acute pars fx MRI: If neuro involvement Plain Films
Plain Films Oblique Xray: “Collar” of Scottie dog
Greyhound sign PA/Lat Xray: Contralateral sclerosis Scottie Dog
Scottie Dog Spondylolysis:
Spondylolysis: Proposed Classification Type I: Dysplastic Type II: Developmental Type III: Traumatic
A: Acute B: Chronic Stress reaction
Stress fracture Type IV: Pathologic Treatment
Treatment Depends on SLIPPAGE and SYMPTOMS and SKELETAL MATURITY Spondylolysis and Grade I Spondylolisthesis (<25%): Regular activity. PT. Annual xrays. Grade II (2550%): Activity restriction. PT. Reeval 36mo. Grade III (5075%) Grade IV (>75%): Surgery for >50% slippage, or >30% in skeletally immature pts; progressive slippage, persistent pain, or neurological symptoms. Conservative Treatment
Conservative Treatment Activity restriction NSAIDs Physical therapy Abdominal/back strengthening
Hamstring stretching Bracing/Casting
Symptomatic Acute pars fx
Conclusions Don’t dismiss a patient with back pain Rule out Red Flags Full ortho & neuro exams Start with plain films Spondylolysis is the most commonly diagnosed organic cause of back pain, and is easily treated! References
References Behrman RE & Kliegman R. Nelson Essentials of Pediatrics. Philadelphia: WB Saunders, 1990.
Hay WW, Hayward AR, Levin MJ, & Sondheimer JM. Currents Pediatric Diagnosis and Treatment, 16th ed. New York: Lange, 2003.
Wiesel SW & Delahay JH. Essentials of Orthopaedic Surgery, 2nd ed. Philadelphia: WB Saunders, 1997.
DeWolfe C. Back pain. Pediatrics in Review 2002;23(6):221.
Nigrovic PA & Wilking AP. Overview of the causes of back pain in children and adolescents. UpToDate Online 13.2 April 2005.
Nigrovic PA & Wilking AP. Evaluation of the child with back pain. UpToDate Online 13.2 April 2005.
Smith JA & Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am 1999;30(3):487499.
Herman MJ & Pizzutillo PD. Spondylolysis and spondylolisthesis in the child and adolescent: a new classification. Clin Orthop 2005;434:4654. ...
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- Night, Spondylolisthesis, Spondylolysis, scottie dog, lumbar hyperextension test, trauma Night pain