Spine Symposium 2016 BACK PAIN IN CHILDREN & … fileHNP 9. Juvenile ankylosing spondylitis 10.Deg...

Spine Symposium 2016

BACK PAIN IN CHILDREN

& ADOLESCENTS:

More common than you think!

John P. Lubicky, MD

Department of Orthopaedic Surgery

Back Pain in Adults

• World statistics show that 60

to 80% of adults will

experience BP at least once

and it will become chronic in 5

to 10%.

Adult Office Visits 1989/90

1. Hypertension 5.5%

2. Pregnancy care 5.2%

3. General exam 4.1%

4. Acute URI 3.3%

5. Back Pain 2.8% (15

million visits, possibly

as high as 4.5%)

6. Depression,anxiety,n

eurosis 2.7%

7. Diabetes 2.6%

8. Cancer 2.2%

9. Degenerative joint

disease 2.1%

10.Acute LRI 2.0%

Hart et al 1995

Back Problem Categories NAMCS

1989 & 1990 Hart et al 1995

Herniated disc

Degen change

Spinal stenosis

Instability

Non specific

Iatrogenic

Miscellaneous

0 5,000 10,000 15,000 20,000

Estimated 1989 & 1990 Visits in 1,000s

How serious is back pain in childhood

and adolescence ?

What is its frequency?

Kids now know the pain scale!

For the vast majority of complainers no

objective abnl are ever found

Back Pain in Children

Back pain is an uncommon but serious

complaint in children and almost always has an

identifiable etiology

which is usually really serious

Old and Incorrect Textbook Teaching

Back Pain in Children NEW TEACHING

Back pain has become more & more common

as a CC w/o + findings of any kind

Body habitus – variable

Families demand million dollar W/U

Kids now know the pain scale!


• Common complaint in children and adolescents

• Increases with age and is recurrent

• True prevalence is not well recognized (20-70 lifetime%)

• Frequently either over or under investigated

• Parents/families - may be enablers or seeking reassurance

Annual Incidence of BP associated with secondary

school life during ages 11+ to 15+ yr Burton 1996

12 13 14 15 0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Child's Age (years)

11.8% 9.8%

14.6%

21.5%


• Lifetime Prevalence 13 to 51%

• Point Prevalence 1 to 33%

• Recurrent Prevalence 7 to 27%

• Sought Treatment 8 to 16%

• Interfere sch/leisure 7 to 27%

Jones 2004

Duration of LBP by Age for Boys with LBP

Taimela 1997

23%

47%

70%

30%

23%

20% 47%

30%

10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

9 10 11 12 13 14 15 16Age (years)

Recurr/chroni

c

< 1month

< 1week


1. Normal life experience (NSMLBP)

(? MusculoliNgamentous or

lordotic mechan.)

2. Pars interarticularis

pathology

3. Tumors

4. Intraspinal pathology

5. Scoliosis

6. Scheuermann’s

kyphosis (Atypical lumbar)

7. Discitis/osteomyelitis

8. HNP

9. Juvenile ankylosing

spondylitis

10.Deg Disc Disease

11.Minor fxs/anomalies

Etiology

Etiology of LBP (Turner ‘89)

• Spondylolysis 13%

• Infection 8%

• Tumor 6%

• Disc problem 6%

• NSMLBP 50%

Causes of NSMLBP

1. Anthropometry

1. Height

2. BMI

2. Lifestyle factors

1. Physical activity

2. Sedentary activity

3. Mechanical load

1. School bag

4. Psychological

a) Negative affect and psychosocial experiences Balague 1995/Brattberg 1994

b) Conduct/Emotional issues Watson 2003

c) Other psychosomatic sxs Vikat 2000/Jones 2003

Does LBP in Childhood

Predispose to LBP in Adulthood ?

BP in the growth period and familial

occurrence of back disease are

important risk factors for BP later in life,

with an observed probability of 88% if

both factors are present. No correlation

with x-ray changes as adolescents.

Non Specific Mechanical LBP

There is good evidence that children with BP

are more likely to report negative psychosocial

experiences, and there is some evidence to

support the hypothesis that such negative

experiences predict those at high risk of future

onset of LBP

Jones 2004


• Younger children have difficulty

localizing their pain

• Important information includes nature of

onset, duration, frequency, severity,

aggravating and relieving factors,

associated systemic complaints, when

does it occur and presence of leg or

buttock pain

History


• Essentially identical to that in an adult

• Stiffness or significant limitation of motion is

more problematic than in the adult

• Fever, marked tenderness, or neurological

abnormality all indicate a more serious

underlying etiology

Physical exam

Mechanical LBP

• Pain in lumbar area only

• Variably provocative

hyperextension/flexion pain

• Extension contracture of LS spine

• can’t touch toes

• secondary thoracic kyphosis

Micheli 1995

Back Strain

• Tender over the muscle

• Pain on provocative stretching

• Acute onset

Micheli 1995


• AP, lateral x-rays (obliques = ? )

• Conventional or SPECT bone scan

• MRI

• CT/myelogram

• CBC, ESR

• EMG/NCS not generally helpful

Diagnostic work up


• Abnormalities on SPECT that may be missed

with conventional bone scan

• Pedicle/pars pathology

• Spinous process pathology

• Vertebral body or endplate abnormalities

SPECT Bone Scan

SPECT vs Whole Bone Scan

Pars Interarticularis Pathology

• Stress fx

• Early fracture of a small number of trabecula in the pars, generally a hot bone scan with

normal x-ray. Probably represents the incipient state

• Spondylolysis defect

• complete pars defect w/o slippage

• Spondylolisthesis (lytic type)

• Pars defect with slippage


• Stress fx

• Acute phase (potential to heal)

• Healing phase

• Spondylolysis defect

• Acute phase (? Potential to heal)

• Chronic (no potential to heal)

• Spondylolisthesis (lytic type)

• Always chronic (no potential to heal)


• Stress fx

• Spondylolysis

• Spondylolisthesis

(lytic)

( commonly )

( uncommonly )


• Occurs only rarely before

5 yrs of age

• Probably developmental

condition with genetic

predisposition (40 %

prevalence in Eskimos)

• May represent a stress or

fatigue fx of an inherently

weak pars

• Due to repetitive stress

rather than acute injury

Etiology


• Prevalence of spondylolysis was 4.4% at

age 6 years increasing to 6% by

adolescence

• The majority of cases are asymptomatic

and require no treatment

Doubousset 1997

Fredrickson


• Onset of symptoms typically during

adolescent growth spurt, frequently

in association with basketball or

gymnastics

• Symptoms may disappear if sporting

activity is ceased

History


• Pain is in low back but may radiate to

buttocks or proximal thigh

• Symptoms are increased by activity and

decreased by rest

• Pain not present at night

History


• Lumbar tenderness

• Restricted ROM ( in high grade slips)

• Hamstring tightness ( in high grade slips )

• Neuro exam normal ( except in high grade)

• Flat or square buttock with listhetic gait ( in high

grade)

• SLR negative for sciatica

Physical exam


• Plain radiographs (+/-obliques) will usually

show lysis or slip but will not show stress

reaction or distinguish between acute and

established lysis

• Spect bone scan frequently necessary for

stress fx diagnosis and for judging state of

healing

Diagnosis


• CT scan helpful to

visualize subtle pars

defect and to

distinguish acute from

established defects

Diagnosis

MRI and Stress Fx

• MRI very helpful if

neural decompression

is contemplated

• Will also show very

early stress rx


• Avoidance of aggravating activities

• Mild anti-inflammatory medication

• Corset or TLSO ???

• Abdominal strengthening exercises ???

• Formalized physical therapy ???

Treatment


• Controversial

• Not entirely predictable

• stress reaction greater than lysis

• Need “hot” bone scan

• May not be influenced by any conservative

measure other than avoidance of aggravating

sporting activity

Healing potential of stress reaction or lysis ?


Only 2 of 29 young patients (avg. 21

yrs. range 13-31) healed an acute lysis

defect with conservative treatment

Healing potential

Daniel 1995


• CT follow up of 40 young athletes with

normal x-rays and positive bone scans

showed that 45% had chronic lysis, 40%

still with acute fx in various stages of

healing, and only 15% with healed fx

Congeni 1997


• Conservative treatment produced

healing in 73% of early defects, only

38% of intermediate, and none of the

chronic defects

Healing potential

(185 patients under age 18 yrs.)

Morita 1995


• If symptoms are not present with normal ADL,

but recur when child or adolescent returns to

sports, then adolescent and family have to

decide the relative importance of pain vs.

sports. There is no “danger” worry.

• This is a family decision

Treatment


• Surgical fusion indicated for any patient with

refractory pain occurring during routine ADL

• Surgical fusion or pars repair indicated for

any patient desiring, but unable, to return to

sporting activity

• Surgical fusion or pars repair not indicated in

asymptomatic patient, regardless of the

severity of a slip

Surgical treatment

SPONDYLOLYSIS - PLSF

SPONDYLOLYSIS – PARS

REPAIR

SPONDYLOLYSIS

PLSF + PARS REPAIR

Spinal Column Tumors

• Rare occurrence

• Primary malignant spinal column tumors

are very rare (Ewing’s , osteosarcoma)

• Most malignant lesions are metastatic

• Benign lesions are much more common

than malignant


• Osteoid osteoma

• Osteoblastoma

• Eosinophilic granuloma

• Fibrous dysplasia

• Aneurysmal bone cyst

• Osteochondroma

Benign Lesions


• Night pain relieved by

aspirin/NSAIDs

• Very hot bone scan,

sclerotic x-ray

• Usually located in

posterior element

• Natural history

unclear

Osteoid Osteoma


• Classic appearance is vertebra plana

(compression fx )

• May present before collapse

• Produces pain, occasionally neuro findings

• Spontaneous resolution of symptoms occurs,

but complete reconstitution of vertebral body

does not

Eosinophilic granuloma


• Cold bone scan possible

• Skeletal survey helpful

• May involve anterior and posterior elements

• “Vertebra plana”

• Radiation not indicated

• Needle biopsy if any question

• Surgery for neuro compression only

Eosinophilic Granuloma

Eosinophilic Granuloma

Intraspinal Pathology

• Malignant astrocytoma

• Lipoma

• Syringomyelia

• Tethered spinal cord

• Diastomatomyelia

• Chiari malformation

• Ependymoma

Intraspinal Pathology

• Pain in children under age 5 years

• Cutaneous hair patches, nevi, dermal sinus

• Neuro abnormality

• Left thoracic scoliosis

• Congenital scoliosis

• MRI is imaging method of choice

Intradural tumor

Scoliosis and Back Pain • Children frequently

complain of low grade back pain with scoliosis, especially after the diagnosis has been made

• Pain not severe, doesn’t interfere with activity

• Work up not necessary unless other factors present

Scoliosis and Back Pain

• Work up necessary if : • Curve other than right

thoracic, particularly if left thoracic, hyperkyphosis, lack of rotation or presence of any congenital anomaly

• Rapid progression

• Neurological findings present

Lumbar Scheuermann’s

Discitis/Osteomyelitis

• Variation of a single bacterial disease

with x-ray appearance dependent on

chronicity of involvement (sterile discitis

probably doesn’t exist)

• Infection probably begins in body and

traverses small vascular channels to

reach disc


• Discitis more common than osteomyelitis

• increased awareness of protean

presentation

• early use of bone scan

• recognition that disease is bacterial in

origin with earlier antibiotic coverage


• Back pain unrelieved by rest, abrupt

onset is typical

• Fever, systemic illness, malaise

• Refusal to walk, abdominal pain in the

young child

• Spasm, decreased back motion ,

reactive scoliosis

History/Physical

Discitis/Osteomyelitis • X-ray is initially normal, but bone scan will always be

hot

• Later x-ray will show disc space narrowing and end

plate erosion

• MRI may show changes in vertebral body marrow

signal even before x-ray finding of disc space

narrowing

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• Mainstay of treatment is antibiotics

• Biopsy frequently negative for bacteria

• Brace or cast probably not necessary

• Surgery not necessary for discitis, and only

infrequently necessary for osteomyelitis

Treatment

HNP in the Child

• Almost never the etiology of LBP in pre teen,

but should be considered in teenager

• LBP without classic radiculopathy is possible

but not common

• Spinal rigidity

• Pain more severe than lysis pain

• MRI is best imaging tool

• Treatment is similar to adult

HNP in the Child

HNP in the Child

• Teenagers may

present with a clinical

picture similar to HNP

but MRI confirms an

injury to the posterior

vertebral limbus- most

common at L4-5

DDD/Congenital stenosis

BACK PAIN

History,Physical Exam,

Blood Tests (CBC, ESR)

Negative X-rays

Intermittent Pain

Only

Constant,Night, Radicular,

and/or Abnor Neuro Exam

Positive X-rays

MRI

Negative

MRI

Positive

MRI

Specific

Diagnosis

Treat as

Diagnosed

Nonspecific

Back Pain

Treat with Rest,

PT, and/or NSAID

Feldman et al 2006 87 pt

21 pt 66 pt

19 pt

10 pt 9 pt

47 pt

56 pt

(64%) 31 pt (36%)

BP in the Child/Adolescent

• More common than once believed

• Usually not due to serious pathology

• Must be thoughtfully investigated to rule out the treatable etiologies

Conclusions

Back Pain in the Child/Adolescent

Need for

Surgery

should

be

Rare

Back Pain in Children in Perspective

• Annual incidence of LBP rose from 11.8% at age

12yr to 21.5% at 15+ years (Burton 1996)

• Annual incidence of migraine h/a in kids (age 11-

15 yrs) is 16% (Abu-Arefeh 1994)

• Annual incidence of migraine h/a in adults is

15% (Mounstephen 1995)

Lifetime Prevalence of LBP (%)

Burton 1996

11.6%

21.4%28.8%

38.5%

50.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

11 12 13 14 15

Child's Age (years)

Point Prevalence of LBP (%)

Burton 1996

12.9%10.0%

6.4%

3.9%3.2%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

11 12 13 14 15

Child's Age (years)

Yearly Prevalence of LBP Interfering with

School Work or Leisure Activity

Taimela 1997

1%

6%

18%18%

0%

5%

10%

15%

20%

7 10 14 16Age (years)


Psychological Factors

1. If parents have LBP more likely in child

(Balague 1995, Gunzburg 1999)

2. More BP in 9 yr olds also reporting feelings of

unhappiness, sleeplessness, and perceptions

of ill health (Gunzburg 1999)

3. Strong association between LBP and

emotional problems, conduct problems, h/a,

abdominal pain, sore throat, and daytime

tiredness (Watson 2003)

Does LBP in Childhood Predispose

to LBP in Adulthood ?

1. Up to 1/3 of children have recurrent episodes

(Salminen ‘92,Taimela97, Viry ‘99)

2. 90% of school children with BP had BP in 25yr

longitudinal f/u (Harreby ‘95)

3. BP at age 18 yr in military recruits increased

risk of BP at age 40yr (Hellsing 2000)



4. BP at age 18 y/o in military recruits increased risk of BP at age 30 y/o (Darre ‘99)

5. 13 yr f/u of BP in adolescents did not predict future BP but did predict pain in general in adulthood (Fearon 2001)

6. 26% of adolescents with more than 30 days of BP had similar pain in 8 yr f/u (Hestbaek 2006 odds ratio 4)



7. BP in the growth period and familial

occurrence of back disease are important

risk factors for BP later in life, with an

observed probability of 88% if both factors

are present. No correlation with x-ray

changes as adolescents.

Harreby 1995 ( 25 yr. prospective cohort study of 640 Danish children )


• SPECT bone scan

• Asymptomatic lysis

should have a normal

Spect scan and if a

symptomatic person

with a hot scan

becomes

asymptomatic the

scan will become

normal

Itoh 1996


• BP is common in adolescents, increases with age, is recurrent, generally does not deteriorate with time.

• Much of the symptomatology can be considered normal life experience

Conclusions



• LBP in adolescence is a significant risk factor for LBP in adulthood.

• The risk increases with increasing duration of BP in adolescence

Conclusions


• Psychosocial factors more important than mechanical factors in the reporting

of childhood LBP • Cause or effect?

• BP may be marker for somatization

Conclusions


• It is frequently not possible to provide a

definitive explanation for back pain in children

• Clinician should be knowledgeable in

diagnosis, natural history, and treatment of

the most common causes of BP

Conclusions


• Although the possibility of serious

spinal pathology must be

considered, the majority of

adolescent back trouble may be

considered a normal life experience

Conclusions

Burton 1996

1989-1990 NAMCS Groups per Hart

et al 1995

• MD FP/GP

• DO FP/GP

• General internal medicine

• Neurologists

• Orthopaedic surgeon

• Neurosurgeon

Spine Symposium 2016 BACK PAIN IN CHILDREN & … fileHNP 9. Juvenile ankylosing spondylitis 10.Deg...

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