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David R. Chandler, MDOrthopaedic Spine Surgery and Rehabilitation

Andrews Institute

� Epidemiolgy

� Evaluation◦ History

◦ Physical Findings

◦ Diagnostic Studies

� Diagnoses/Patho-Antomical Entities

� Treatments/Interventions◦ Nonoperative

◦ Surgical

� Return to Play

� Does back pain in children indicate a serious underlying abnormality?

� Formerly thought that back pain in children/youth had a underlying patho-anatomical abnormality 80 – 90% of cases.

� Currently appreciated that the incidence of back pain in children and adolescents is 1% to 30%.

� Age

� Family History

� Male / Female

� Training Intensity

� Frequency of Activity

� Technique

� Sport Played◦ Adolescent Athletes 46% v Controls 18%

◦ Wrestlers 59% v Controls 31%

◦ Gymnasts 79% v Controls 38%

� Incidence per 100◦ Overall 7

◦ Football 17

◦ Gymnastics 11

◦ Basketball 6

◦ Wrestling 6

◦ Baseball 2

Keene et al J Spinal Disord 1989

� Nature of Injury◦ Acute 59%

◦ Overuse 12%

◦ Aggravation of Preexisting Injury 29%

� Place of Occurrence◦ Competition 6%

◦ Practice 80%

◦ Preseason Conditioning 14%

Keene et al J Spinal Disord 1989

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� Back Pain is a symptom not a specific diagnosis

� Non-Spinal causes◦ Intrapelvic/Gynecologic Conditions

� Ovarian Cysts

� Endometriosis

◦ Renal Disease

� Urinary Tract Infection

� Nephrolithiasis

� Spinal Causes◦ Muscle strains /Ligament Strains◦ Spondylolysis◦ Spondylolisthesis◦ Facet Syndrome◦ Ring Apophyseal Injury◦ Sacral Stress Fracture◦ Herniated Nucleus Pulposis◦ Sacralization L5 / Transverse Process Impingement◦ Fractures◦ Infection◦ Tumors

� Young Athletes with Low Back Pain◦ Definable Cause 62%

◦ Spondylolysis 47%

◦ Discogenic

◦ Musculotendinous Strain

� Adult Patients with Low Back Pain◦ Discogenic Pain 48%

◦ Musculotendionous Stain 27%

◦ Osteoarthrosis / Spinal Stenosis 10%

◦ Spondylosis 5%

Micheli LJ, Wood R Arch Pediatr Adolesc Med 1995

� Standard History◦ Context

◦ Location – back v. leg

◦ Quality

◦ Severity – VAS 1 - 10

◦ Duration

◦ Timing

◦ Modifying factors – Exacerbation / Alleviation

◦ Associated factors

� Numbness/Tingling, Weakness, Sphincter, Recumbency

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� Serious Conditions◦ Spinal Fracture◦ Spinal Infection◦ Spinal Tumor◦ Cauda Equina Syndrome

� Red Flags◦ High energy trauma

◦ Pain increased by or precluding recumbency

◦ Paresthesias/Neurologic deficits

◦ Loss of Bowel and/or Bladder Control

� Tidbits◦ Location

� Localized v Generalized

◦ Radiating Pain

◦ Sports Activity Association

� After Activity and with Extension - spondylolysis

◦ Night Pain

◦ Pain Constant Duration and Increasing Intensity

◦ Analgesic Response

◦ Parents More Focused on the Pain than the Patient

� Trunk & Lower Extremities

� Inspection◦ Coronal/Sagittal Alignment, Pelvis, Waist, Adams

� Palpation

� Stability◦ FABER, Femoral Compression, Gaenslen

� ROM

� Muscle Tone

� Tests / Signs◦ SLR, Flip, Single Limb Stance Extension

� Skin◦ Hemangioms, Sacral Dimples, Café-au-lait

� Limited Forward Flexion◦ Hamstrings?

� Pain with Forward Flexion

� Pain with Extension◦ Facet Joint, Spondylolysis

� FABER, Femoral Compression, Gaenslen

� Scoliosis◦ Structural / Functional

� Kyphosis◦ Scheuerman’s (spondylolysis)

� X-Rays◦ When?◦ AP + Lateral + Cone Down◦ Obliques?◦ Flexion/Extension?

� Advance Imaging◦ Bone Scan - SPECT◦ CT◦ MRI

� EMG / NCV

� Laboratories◦ CBC, ESR, C Reactive Protein

�Musculo-Ligamentous Strains�Degenerative Disc�Herniated Nucleus Pulposis� Spondylolysis� Spondylolisthesis� Sacral Stress Fractures� Fractures� Lumbar Scheurmans’

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� Nonoperative◦ Prevention

◦ Medications

◦ Bracing

◦ Physical Exercises

� Operative◦ Injections

◦ Decompression

◦ Stabilization

� Repair

� Fusion

� Clinical Considerations◦ Pain

◦ Strength and Flexibility

◦ Radiographic Findings

� Spine Disorder

� Treatment ◦ Nonoperative

◦ Surgery – type of surgery

� Specific Sport / Position

� 20% of Back Pain in Adolescent Athletes� Most Common Back Injury in College Athletes◦ Acute 59%◦ Overuse 12%

� Stretching or Disruption of Tendon or Ligament Fibers

� Symptoms / Findings◦ Acute Pain 24-48hrs◦ Spasm / Trigger Point◦ Recurrent / Chronic

Keene JS, Drummond DS Compr Ther 1985

� Rest

� Ice

� NSAID’s

� Physical Therapy◦ Core Strengthening

◦ Hamstring Stretching

◦ Conditioning

◦ Sport Related Training

� Uncommon in Adolescents� Athletes have a higher prevalence◦ Athletes 30-75%◦ Non-Athletes 14-30%

� Location is Sport Dependent◦ Upper lumbar in weight lifting◦ Lower lumbar in soccer

� Prevalence may be Technique Dependent◦ 21% good technique – 62% poor technique

� Controversial as a Pain Generator� Treatment is Symptom Management

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� Skeletally Immature

� Open Ring Apophysis

� Anterior Herniation◦ Rest & Symptom Management

� Central◦ Schmorl’s Node

◦ Rest & Symptom Management

� Posterior◦ MRI

◦ Surgical Excision

� Presentation◦ Trauma Association 30-60%

◦ LBP 88%

◦ Radiating pain 35%

� Anatomic Localization◦ 90% at L4-5 and L5-S1

� Apophyseal Fracture◦ 28% of adolescent disc herniations

◦ Higher rate of surgical interventions

� MRI / CT (visualize ring apophysis fragment)

� Pediatric HNP do not respond as well to nonsurgical management

� Nonsurgical Management◦ Rest / Activity Curtailment◦ NSAID’s◦ PT◦ Epidural

� Surgical Management◦ More difficult than in adults – disc hydration, bone◦ 90% positive short term results (1% recurrence 1st yr)

� Long Term Prognosis◦ 20 – 30% additional surgery within 20 years

� Defect in the pars interarticularis

� General prevalence 3-6%◦ Males 2-3X > females

� Young athlete prevalence 8-15%

� Associated with spondylolisthesis 25%

� Natural history of spondylolysis on the whole appears to be benign

� Dramatic progression of spondylolisthesis is generally uncommon

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� Associated with Hyperextension Sports◦ Divers 43%

◦ Wrestlers 30%

◦ Throwing Athletes 27%

◦ Weight Lifters 23%

◦ Gymnasts 17%

◦ Crew 17%

� Fredrickson et. al.– 500 1st graders 1955 -1957

– Prevalence at age 6 = 4%

– Prevalence 6% in adulthood

–Males 2x

– Pain not associated with defect development

– 15% progressed to spondylolisthesis

– Slip progression during growth spurt

–Minimal progression after age 16

– Progression to slip did not cause pain

JBJS 1984; 66A:699-707

� Beutler et. al.◦ 500 1st graders in 1955◦ 22 (4.4%) had pars defects + 8 +30◦ Followed for 45 years – no loss to f/u◦ Only 3 had surgery & only 1 at the defect level◦ Clinical course similar to general population� SF-36 scores

◦ Slowing of slip progression with each decade� Unilaterals did not slip� No patient reached 40% slip

◦ No association of slip progression with LBP

Spine 2003;28:1027-35

� Kalichman et al– CT unselected community based population

– 3529 Patients, Framingham Heart Study

– 11.5% spondylolysis/listhesis (2x xray studies)

– No significant association between spondylolysis, isthmic spondylolisthesis, or degenerative spondylolisthesis and the occurrence of LBP

Spine 2009; 34:199-205.

� 506 football players over 8 year period

� Low back pain 135 (27%)

� 58 had x-rays persistent symptoms

� 12 cases of spondylolysis

� No significant difference in time loss comparing the athletes with spondylolysis to a control group with back pain only

Semon, RL, Spengler, D. Spine. 1981; 6: 172-174.

� History◦ Back pain

� Acute or Chronic

◦ Sclerotomal Referral

� Physical Examination◦ No pathognomonic findings

◦ Pain with extension

◦ One-legged hyperextension maneuver?

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� Plain radiography◦ Visualization may be difficult

� Radionuclide Imaging◦ SPECT is highly sensitive (not specific)

� CT scan◦ More sensitive than plain radiography◦ More specific than bone scan◦ Assessment of healing of pars defect

� MRI◦ No ionizing radiation◦ Detects other relevant pathology◦ Poor bone visualization◦ Predictive value?

� Non-Operative Treatment◦ Activity Restriction

◦ Brace Treatment

� Anti-Lordotic 0, 15, and 30 degrees

◦ Electrical Stimulation

◦ Ultrasound – no spondylolyis studies

◦ Platelet Rich Plasma - no spondylolyis studies

� Surgery◦ Repair

◦ Fusion

� Morita et. al.◦ Radiographic stage of pars lesion� Early� Progressive� Terminal

◦ Non-rigid bracing & sport avoidance◦ PT & extension limiting corsette◦ 75% early lesions healed◦ 30% progressive lesions healed◦ 0% terminal lesions healed◦ No clinical outcomes reported

JBJS 1995; 77B:620-25

� Katoh et. al. ◦ CT staging of lesions

◦ Early stage 62% healing

◦ Late stage 0%

◦ No SPECT or clinical outcomes

Proc NASS Mtg New York, 1997: 222

� Steiner & Micheli◦ 67 patients low grade spondylolisthesis

◦ Diagnosis by xray + bone scan ?defects

◦ 6 month Boston brace, 23 hours/day with 6 month weaning

◦ PT stretching & abdominal strengthening

◦ 78% Excellent/Good Outcome

◦ 23% Evidence of Bony Healing

Spine. 1985; 10:937-43

� Blanda et. al.◦ Diagnosis by xray and/or bone scan

◦ Lumbar brace to maintain lordosis 2-6months

◦ PT stretching & abdominal strengthening

◦ 82% Excellent/Good in Spondylolysis

◦ 38% Evidence of Bony Healing

J Spinal Disord 1993;6:406-11

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� d’Hemecourt PA et al◦ 56 patients

◦ Brace alone v. brace with e-stim

◦ Brace 0 degree Boston overlap 23hr/day

◦ E-stim group 3hrs/day

◦ Brace only – bony union 13/26

◦ Brace + E-stim – bony union 20/30

◦ E-stim

� Stimulation of angiogenesis

� Upregulation of TGF B-1, BMP’s 2,4,6 & 7

� AP & Lateral Plain Radiographs (obliques?)

� SPECT

� CT – confirm & stage the lesion◦ Densely sclerotic on either side of a well defined gap?

◦ Sclerosis without separation or minimal separation with non-corticated or cystic margins?

� F/U Radiographs◦ Not needed to confirm healing

◦ Need to observe for spondylosithesis

� Slips can progress painlessly

� Densely sclerotic on either side of a well defined gap◦ Rest (activity restriction) for symptom relief

◦ Bracing for additional activity restriction if not asymptomatic after 2-4 weeks

◦ Progressive return to play when asymptomatic

� Sclerosis without separation or minimal separation with non-corticated or cystic margins◦ Rest (activity restriction) 12 weeks

◦ Bracing for additional activity restriction if not asymptomatic after 2-4 weeks

◦ Progressive return to play at 12 weeks

◦ Electrical Stimulation?

◦ Ultrasound?

◦ PRP?

� Indication◦ Unsuccessful relief of LBP despite conservative treatment for at least 3-4 months

� Direct Repair ◦ Preferred in order to preserve motion segment

◦ Most often at L3 and L4

◦ No spondlylolisthesis

◦ MRI shows no adjacent disc degeneration -> fusion

� Direct Repair Techniques◦ Debridement of fibrous tissue in pars defect

◦ Grafting with autogenous bone from iliac crest

◦ Fixation – 3 techniques

� Buck – intralaminar screw stabilization

� 90% healing

� Scott – transverse and spinous process wiring

� Least stable – 77% healing

� Pedicle screws and infralaminar hooks

� Most stable but bulkier

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� Fusion◦ Most commonly at L5-S1

◦ Required in the presence of spondylisthesis or degenerative disc at that level

◦ Posterior or posterolateral

◦ Autogenous iliac crest bone graft

◦ Instrumentation with pedicle screws preferred

� Pars Defect with Anterior Displacement

� Meyerding Classification◦ Grade 1 – to <25%◦ Grade 2 – 25% to <50%◦ Grade 3 – 50% to < 75%◦ Grade 4 – 75% to < 100%◦ Grade 5 – 100+% - Spondyloptosis

� Progression Risk Related to Skeletal Maturity

� Treatment in Skeletally Immature◦ Grades 1 and 2 – try non-operative◦ Surgery for persistent pain, progressive slip, progressive hamstring tightness◦ Grade 3 and more – surgical intervention required

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� In Situ Fusion v Reduction & Fusion◦ Iatrogenic neurologic injury 5-10%◦ Neural Monitoring

� Posterolateral

� Interbody� Combined◦ Preferred in higher grade slips

� Fusion to L4◦ Preferred in higher grade slips

� Instrumentation◦ Pedicle screws and rods

� Spine Disorder?

� Sport Played?

� Surgical Treatment Required?

� Specific Surgical Procedure Performed

� Not Currently EBMG Supported

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� Nonsurgical Treatment◦ 100 (72M/28F) Consecutive 9/1993-10/2009

◦ Mean age 23

◦ Discontinue sport c/s meds

◦ After 80% symptom reduction, began individual training to RTP

◦ 79% returned after mean 4.8 months (1-12m)

◦ Able to sustain for 6 months

◦ Not influence by sport intensity

◦ Severity of symptoms prior to rx was the key determinate in RTP

Iwamoto J. OAJSM 2011; 2: 25-31.

� Surgical Treatment

� Done for the season!

� Surgical Treatment◦ 14 NCAA athletes

◦ 10 one level, 3 two level, 1 perc disc

◦ Mean age 20.7y

◦ Followed mean 3.1 years; SF-36

◦ All had resolution of radicular pain, took less pain meds and returned to recreational sport

◦ 9 (all single level) returned to varsity sport

◦ 5 retired compared to age/sport matched controls -had significantly lower SF-36 in bodily pain, physical role, general health and social function

Wang et al. Spine 1999; 24:570-3

� 137 NFL athletes with a LDH requiring treatment

� 96 underwent lumbar discectomy

� 34 were treated nonoperatively

� Performance score base on a modified scoring system of Carey

Hsu WK. Spine 2010; 35: 1247-1251.

� 78% of the surgical treatment returned to play at least one NFL game v 59% (nss)

� Surgically treatment group averaged 36 regular season games over 3.1 years v nonoperative group - 18 games over 2.0 years (p<0.03)

� In the operative group there were 8 (8.3%) recurrent LDH requiring surgery

Hsu WK. Spine 2010; 35: 1247-1251.

� Performance outcomes measured both pre and post treatment through the percentage of games started and the Performance Score

� Op and non-op groups no statistically significant difference in these measures

� In each group, there was no difference in pre and post treatment performance measures

Hsu WK. Spine 2010; 35: 1247-1251.

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� No association of performance based outcomes in relationship to age, height, weight, BMI, position played, NFL experience, and Pro Bowl appearances.

� In patients 30 years and older, 22/30 (73%) in the op group and 9/17 (59%) nonop group returned to play which was not statistically different than those under 30.

Hsu WK. Spine 2010; 35: 1247-1251.

� Nonsurgical Treatment◦ 80% return to sport at 6 weeks

◦ Worst Outcomes

� High-risk sports(Football)

� Acute onset of symptoms

� Hamstring tightness

Iwamoto J et al Scand J Med Sci Sports 2004 14: 346-351

� Surgical Treatment

� Done for the season!

� Debnath et al.◦ 22 young athletes

◦ Fusion for spondylolysis

◦ Average 9 months duration of symptoms

◦ 82% returned to previous sport after a rehab program of 7 months (mean) duration

◦ Buck interlaminar screw technique better results than Scott wiring

Debnath et al JBJS Br 2003; 85: 244-249

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� Blanda, J, Bethem, D, Moats, W, et al. Defects of pars interarticularis in athletes: A protocol for nonoperative treatment. J Spinal Disord....1993;6:406-11.

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