Spondylolysis_evans - Adolescent Back Pain(Quit yer...

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Unformatted text preview: Adolescent Back Pain (Quit yer whinin’…) Amy K Evans, PGY1 Adolescent Medicine 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 Night pain Worsening pain Systemic symptoms Neuro symptoms Hx CA/TB exposure Severe disability 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: 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: 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: 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 www.Narang.com Conclusions 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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