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Scoliosis is an abnormal curvature of the spine with rotation of the vertebrae. This curvature often results in one shoulder appearing higher than the other or the hips appearing uneven. Since the curvature occurs with growth, it is rare for scoliosis to become evident before the age of ten years. Once detected, it should be carefully evaluated and followed. Many children have only mild curvatures and require no treatment, but others have progressive disease requiring bracing and, less frequently, surgery. Scoliosis is usually painless and detected only on examination. Pain suggests that the scoliosis has been present for a prolonged period with secondary mechanical problems.

Children are routinely screened for scoliosis at school, but the expertise and thoroughness of the examiners vary widely. Most scoliosis is idiopathic (unexplained). In rare cases, scoliosis may be the result of tumors, infections, or damage to the spinal cord. These cases may appear at an earlier age than idiopathic scoliosis and be more severe. Any child whose spine appears crooked or has an abnormal scoliosis screening should have an orthopedic evaluation.

It is easy to examine a child for scoliosis. Have the child stand in front of you with both feet together and the heels lined up with each other. Then have the child bend forward to touch the toes. Two findings suggest scoliosis. The most common is a "rib hump," which means that the ribs on one side stick up higher than the ribs on the other (Fig. 3-6). In some children, there is a prominent low back (lumbar) component that is easily felt by putting your hand on the lower part of the back. If one side of the back is lower than the other, further evaluation by an orthopedist is necessary.

Spondylolisthesis is the slippage of one vertebra over another. Most often this occurs at the junction of the lumbar and sacral spine. Some cases may be due to a congenital weakness, while other cases may be due to poor healing after an injury. Either cause results in weakness of the bone bridges (posterior elements) that hold the spine in place. Spondylolisthesis results when this weakness allows one bone segment to slide forward over another. Although mild degrees of spondylolisthesis may be asymptomatic, more severe involvement characteristically leads to low back pain that may radiate down the back of the thighs. Most children with this condition can be followed conservatively, but some require orthopedic intervention. Because the symptoms can worsen over

FIG 3-6 A positive scoliosis screen, with the ribs on the left side appearing higher than the right when the child bends over. The shoulders may also appear uneven when the child is standing up, but this is more difficult to notice.

time, all children with chronic back pain should be followed by an experienced orthopedist.

Some children have kyphosis, excessive curvature of the spine in which the spine is bent forward. If you look at the child from the side, you will see that the upper part of the back angles forward sharply (see Fig. 3-7). This abnormal forward curvature may be the result of abnormalities in the bone resulting from fractures or infections. However, most often it occurs without explanation. In severe cases the child may appear to have a hunchback.

Some children have postural kyphosis. This is usually a mild increase in the forward bend of the spine, leading to the appearance that they are always slumping over. These children often have no abnormal findings on X-ray. However, all children with this type of spinal curvature need to be investigated by an orthopedist with appropriate X-rays to find out why they have kyphosis. For children without significant abnormality, a program of exercises is often adequate.

A common cause of kyphosis in teenagers is Scheuermann's disease, thought to result from abnormalities in the growth of the vertebrae. This results in the front of the vertebrae being compressed relative to the back (see Fig. 3-7). The diagnosis is easily made with X-rays. Children with this condition may need to wear a brace to relieve their pain and prevent worsening of their condition. More severe or worsening cases may require orthopedic surgery.

Kyphosis may also be the result of damage to the bones of the spine by an infection, tumor, or poor bone formation. These conditions are all rare. Children with conditions that are known to damage the spine should be carefully monitored. Parents of children with poor bone formation or children who are taking

FIG 3-7 Appearance of the spine with wedge-shaped vertebrae in a child with kyphosis due to Scheuermann's disease.

medications that can damage the bones need to be reminded that their children should be watched carefully for spine problems. If a child has been diagnosed with an infection or a tumor in or around the spine, the family should be aware of the need to monitor the spine as the child grows.

There are a variety of infections that may damage the spine. Fortunately, none of them is common in childhood. Staphylococcal bacteria are common causes of infections that may affect the bones of the spine. Tuberculosis can also affect the bones of the spine (in which case it is sometimes called Potts' disease). Bacterial infections of the spine are usually very painful. They are easily diagnosed by either X-rays or bone scans (Chapter 22). Despite many claims to the contrary, back pain in children is not a result of Lyme disease.

Discitis is a confusing cause of back pain in younger children. Typically, it affects children under the age of ten. These children may have initial symptoms of a cold or flu-like illness. They then develop severe back pain, but in this age group they may not be able to describe it. The key to recognizing this illness in very young children is that they suddenly refuse to sit up or walk. The cause of discitis remains unclear. In some cases, a bacterium such as staphylococcus is identified and the infection is treated with antibiotics, but often no causative bacterium can be identified. This illness is usually diagnosed on the basis of the typical clinical picture with a bone scan and MRI or X-rays to be sure that no other problem is present.

The benign bone tumors called osteoid osteomas are a cause of chronic low-grade bone pain that may occur in many different locations. (See the discussion under "Knee Pain" in this chapter.) Osteoid osteomas in the spine typically come to parents' attention when a child complains of chronic back pain that comes and goes without explanation. A typical child with an osteoid osteoma reports a sense of deep aching pain, often worse at night. Untreated painful osteoid osteomas may cause major problems because the pain causes muscle spasms.

A fairly common cause of chronic back pain in adolescents is spondylolysis. This is a stress fracture of the pars interarticularis (see Fig. 3-8). It is often the result of excessive stress on the low back from dancing, running, weight lifting, or other activities. Female participants in gymnastics are prone to this injury. As with stress fractures in other locations, the complaint of pain is usually exacerbated by activity and relieved by rest. X-rays may reveal the fracture, but in some cases an MRI or bone scan may be required. Children with this type of pain

FIG 3-8 Stress fracture of the pars interarticularis (darkened segment), causing back pain.

should be carefully questioned about pain in other joints or stiffness when they arise in the morning, as these symptoms may indicate arthritis.

A common complaint among adults, disc herniation is usually the result of an excessive stress put on the spine with the resultant rupture of the cushioning material in one of the intervertebral discs. This condition is quite rare in children, though you can check for this by having the child lie on his or her back and raise one leg while keeping it straight (see Fig. 3-9). A child who has pain during this maneuver may have significant disc herniation and should be promptly evaluated.

Although an MRI of the spine is very accurate at identifying disc problems, finding minor disc problems on the MRI is not a reliable explanation for back pain; many individuals who do not experience back pain have minor disc herniation on an MRI. Although it is not impossible for a teenager to have a damaged disc, parents should be extremely skeptical about this diagnosis as the cause of back pain. Gradual onset of back pain with stiffness on awakening is more likely to be associated with a spondyloarthropathy or other illness.

Low back pain and morning stiffness are commonly due to spondyloarthropa-thies in teenagers. However, adolescents rarely come to the doctor complaining

of low back pain when they wake up in the morning. Since the onset is very gradual, most accept this stiffness as normal. The key to suspecting a spondyloarthropathy as the cause of an adolescent's back pain lies in carefully examining the teenager and finding evidence of arthritis or tendon insertion pain (enthesitis) elsewhere. A strong family history of back pain also should suggest this diagnosis. A key indication is that children with spondyloarthropathies almost never can bend over and touch their toes. See Chapter 7 for more information.

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