Mechanical problems are the most commonly diagnosed causes of back pain in adolescents. Some of these, such as Scheuermann's disease develop or progress during the adolescent growth spurt. Adolescent athletes are more likely to have back pain secondary to spondylolysis, spondylolisthesis, hyperlordotic mechanical back pain, or a herniated disk, especially in sports that require repetitive flexion, extension, or rotation of the spine (7) (see Chapter 11).
Although many mechanical etiologies of back pain are diagnosed on the basis of radiographs and other imaging, the significance of many of these "abnormal" findings have recently been called into question. Many studies have reported a significant frequency of abnormal radiographic spine findings in normal adults without back pain. In a review of 18 studies, for example, spondylolisthesis, spondylolysis, spina bifida occulta, transitional vertebrae, and Scheuermann-type changes were not found to be statistically associated with back pain in adults (35). There was only a weak association found between disk degeneration and nonspecific back pain, but, as most of these studies were cross-sectional, additional prospective studies are needed to better assess if there is a direct relationship (35).
Disk degeneration and herniation have also been found in asymptomatic adolescents (1,36), but some spinal changes may be more likely to be associated with back pain (37-39). A study of 439 Danish 13-year-olds found that upper lumbar disc and nucleus anomalies were associated with significant back pain in boys, while lower lumbar anomalies were associated with significant back pain in girls; endplate changes at L3 were associated with significant back pain irrespective of gender (38). In a 9-year prospective study comparing 40 adolescents with back pain to 40 without pain, disc degeneration at age 15 years was associated with a 16-fold relative risk of reporting recurrent LBP at age 23; disk protrusion and Scheuermann-type changes were also associated with an increased likelihood of recurrent back pain at 23 years (39). The frequency of spinal anomalies increases with age, and at 18 years, these spinal anomalies were less predictive of future back pain (39). Although a subset of adolescents with disc degeneration or other spinal anomalies may be more likely to have recurrent, significant back pain as adults, the majority of adolescents with these changes do not appear to be at risk for significant back pain later in life (39).
Lumbosacral Strain/Lordotic Mechanical Back Pain
Back pain may be caused by sprains or strains related to overuse. This problem is less common in adolescent athletes than in adult athletes (6% vs. 27%) (7). The activity or movement that triggered the injury aggravates pain, and there is often localized tenderness (7). There should be no associated neurological signs, although pain may be referred to the buttock or upper thigh (40). Patients improve with conservative measures over several weeks to 2 months (7,40).
Lordotic mechanical back pain has been found to be a common cause of back pain in adolescent athletes (7). Patients will have pain over the lumbar spine, and have an extension contracture of their lumbar spine that limits their ability to flex this area; there may be compensatory deformities of the thoracic spine (7). Pain is elicited by hyperextension or hyperflexion of the spine. These patients also usually improve with reduction in activities and conservative treatment.
Spondylolysis is a defect in the pars interarticularis of the L4 or L5 vertebra. If the vertebral body then slips forward, the condition is referred to as spondylolisthesis. Adolescent athletes with back pain often have the acquired traumatic form, where a fracture occurs through a normal pars interarticularis, usually at L5 (41). Sports that involve repeated lumbar hyperextension, such as gymnastics, dancing, figure skating, diving, soccer, football, hockey, and lacrosse, are particularly associated with traumatic spondylolysis and spondylolisthesis (3,36). In one study, 40% of pediatric soccer players with spondylolysis remembered maximum velocity kicking as a triggering event for their back pain (42). The high dysplastic developmental type of spondylolisthesis also often becomes symptomatic during adolescence and usually involves L5-S1 (41). This type of spondylolisthesis is more likely to be associated with bladder and bowel problems and L5 nerve radiculopathy (43).
The pain associated with spondylolisthesis and spondylolysis is typically a mild to moderate aching pain in the lower back, which is aggravated by extension and flexion, and relieved by rest. There may be paraspinal tenderness in the L5-S1 region, buttock pain, or pain radiating to the posterior thigh or buttocks (44). The onset is usually insidious unless it is precipitated by an acute fracture (1). Patients generally have tight hamstrings, which leads to a stiff legged gait with hip and knee flexion and a short stride length, also known as a "pelvic waddle" (43,44). The patient may have secondary postural changes, such as increased lumbar lordosis and a protruding abdomen. To test for this condition, the "one leg extension manoeuvre" is said to be best: the patient stands on one leg while the other hip and knee are flexed; the patient then hyperextends the lower back which elicits unilateral or bilateral LBP (1) (see Figure 11 in Chapter 11).
The oblique radiograph in a patient with spondylolysis usually shows the pars abnormality that is said to resemble a collar or broken neck of the "Scotty dog" in isthmic defects (Fig. 1), and the "greyhound sign" in dysplastic cases (44). Bone scan, single photon emission computed tomography (SPECT), and CT are all more sensitive, but bone scan and SPECT are unable to identify a chronic pars defect and cannot distinguish spondylolysis from other inflammatory problems (3,45). MRI offers the advantage of being able to detect impending spondylolysis before the actual pars breakage occurs (45). Earlier diagnosis improves the prognosis (45). Most patients respond to conservative treatment with analgesics, activity modification and/or bracing, and exercises to strengthen their abdominal and paraspinal muscles. (7,45); one study reported better results with cessation of sports activity for 3 months (42).
Scheuermann's Disease (Juvenile Kyphosis)
Scheuermann disease is a kyphotic deformity of the thoracic or thoraco-lumbar spine, which develops around 10-13 years of age and becomes more pronounced during the adolescent growth spurt (46). Adolescents may complain of aching back pain at the level of the deformity or in the lower
Figure 1 This 13-year-old girl heard a pop and had the acute onset of back pain while shoveling snow. AP view of her L spine did not show any defect, but an oblique view shows the "collar" or "broken neck" of the "Scotty dog" at L3 (white arrow), indicative of acute traumatic spondylolysis.
back, or may present with a painless thoracic kyphosis (1,47). The pain is often worse later in the day, and may be aggravated by prolonged sitting, standing or activity; those with lumbar involvement usually have more pain (3,44). About 1/3 of patients will have also have a mild to moderate scoliosis (36). AP and lateral X rays show narrowing of the intervertebral disk space, decreased vertebral height with anterior wedging of three adjacent vertebrae, irregular vertebral end plates, and sometimes Schmorl nodes (46). Patients with a mild degree of kyphosis can be monitored, treated with thoracic-extension and abdominal strengthening exercises, and will generally improve when their growth is finished (44). Patients with more severe kyphosis require bracing prior to skeletal maturity, and possibly surgery (44).
Although disk herniation is commonly associated with adult back pain, only 1% to 4% of all documented cases of disk herniation occur during adolescence (36). Adolescent males, athletes, and those with a positive family history of lumbar disk herniation appear to be at increased risk (44,48). In contrast to the adult, where degenerative changes in the lumbar disk predispose the tissue to herniation, during adolescence herniation is usually secondary to a fracture (44).
Most herniations occur at L4-L5 or L5-S1 (36). As discussed above, the relationship between disc herniation and back pain is not clear, since herniation is a common finding in MRIs of asymptomatic adolescents and adults (1,36,38). Those that have significant, symptomatic disk herniation with actual disk protrusion and not just bulging, will have severe back pain and lumbar tenderness, and can have sciatica (3,49). If neurological signs are present, they rarely involve bladder or bowel changes; more common signs are gait abnormalities, abnormal reflexes, sensory deficits, and motor weakness (44,49,50). Most will have a positive straight leg raise sign (44).
Apophyseal ring injuries were found to be associated with back pain in a 3-year longitudinal study of adolescent athletes (37). The apophyseal ring fuses with the vertebral body between the ages of 17 and 20 years, and is subject to injury from traction or compression prior to fusion. Ring injuries are associated with figure skating and gymnastics, and can be detected by MRI (37).
Apophyseal ring fracture is an injury related problem that occurs in adolescent boys who participate in heavy weight lifting or similar activities. The onset of pain is usually acute; the pain is often described as constant and burning, and aggravated by activity and Valsalva maneuver. Pain is usually bilateral, and can be associated with sciatica and back stiffness (44). The posterior portion of the lumbar apophysis fractures, followed by partial disk herniation into the spinal canal, most commonly at L4. The condition may be visualized on a lateral X ray or by CT scan. If there are no neurological symptoms, patients can be treated conservatively with reduced activities, analgesics, and physical therapy. For those with neurological symptoms, excision of the bone fragment and lamina should be done (44).
Scoliosis is relatively common during adolescence, but most cases are idio-pathic and should not cause pain: the frequency of back pain in children with and without idiopathic scoliosis is similar (51). However, adolescents with idiopathic scoliosis need to have the magnitude of their curvature monitored as it can worsen during growth spurts, and those with rapidly progressive scoliosis or with 25 or more degrees of curvature may need bracing or surgery. Such patients should be referred to a pediatric orthopedist for further evaluation and management (52).
Scoliosis associated with severe pain should be regarded as a red flag, as it could represent pathologic osseous lesions such as a tumor (i.e., osteoid osteoma, osteoblastoma, eosinophilic granuloma, aneurysmal bone cyst) or infection (3). Other signs suggestive of intraspinal pathology include abnormal neurological findings, a left rather than right thoracic curve, very rigid scoliosis, rapid progression, and lack of compensatory curves above or below the lesion (3,51,53,54). Patients with these findings need a thorough evaluation.
Idiopathic juvenile osteoporosis is a rare cause of back pain in otherwise healthy adolescents. Patients will develop growth arrest, and some may present with an abnormal gait or progressive kyphosis (55). X rays show osteopenia, multiple growth arrest lines, progressive loss of height of the vertebrae, and often compression fractures of the long bones, especially around the joints. Other disorders that cause osteoporosis, such as leukemia, juvenile idiopathic arthritis (especially with chronic corticosteriod use), Cushing disease, thyroid disease, diabetes mellitus, growth hormone deficiency, homocystinuria, osteogenesis imperfecta, and dietary deficiencies (calcium, vitamin D, vitamin C) need to be excluded. Adolescent girls with behavioral eating disorders are also at increased risk for osteopenia (55) (see Chapter 12).
Adolescents may have back pain associated with congenital anomalies of their L5 or S1 vertebrae. The L5 vertebrae can become sacralized or the S1 vertebrae can be lumbarized; these changes can be unilateral or bilateral. Pain is more likely with the unilateral asymmetrical form, and there may be sciatic pain down the leg opposite to the side of sacralization (56). Symptomatic transitional vertebrae may best be detected by SPECT scans. Adolescents with lumbar disk herniation are more likely to have transitional vertebrae, but again since transitional vertebrae can be found in many asymptomatic subjects, it is not clear if these radiographic findings are actually the cause of the back pain. (35).
Adolescents with a tethered cord can present with painful scoliosis and neurological signs such as bladder dysfunction, motor weakness, atrophy of one limb, or a Babinski sign (40,44). Other associated physical findings include a cavovarus foot, lumbosacral hair patch, dermal cyst, or heman-gioma. Radiographs can show spina bifida occulta or diastematomyelia (44); MRI will define this problem, which will require neurosurgical intervention.
About 25% of patients with syringomyelia, or spinal cord cysts, will present with painful scoliosis. Other associated symptoms include headache, neck pain, pes cavus, and neurological signs such as abnormal gait, loss of abdominal reflexes, and change in sensation for pain or temperature (44). When syringomyelia is present, it is recommended that the entire spine of these patients be examined by MRI to look for other anomalies (44).
The child that has back pain who has had unusual or suspicious trauma should be evaluated for signs of nonaccidental injury. These signs could include multiple fractures, bruises, skin scars suggestive of burns or other unusual traumas, frequent school absences, and signs of neglect. This problem is more likely to be found in the younger child than in the adolescent.
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