BACK PROBLEMS
| BACK PAIN IN CHILDREN —Robert M. Bernstein, MD, Director of Pediatric Orthopedics, Cedars-Sinai
Medical Center, Los Angeles
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| Children and adolescents: uncommon to complain of pain; up to 80% have abnormality
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| Differential diagnosis: mechanical—trauma (eg, rollerblading, inner tubing), fracture, spondylolysis, and disc herniation
(more often in adolescents); postural and overuse injuries; syrinx; developmental—Scheuermann’s disease
(abnormality of growth plate of vertebral body resulting in abnormal kyphosis); normal kyphosis in adults 45°; 50°
in 5-yr-old abnormal (normal 20°); inflammatory—rheumatologic; osteomyelitis; neoplastic—bone (uncommon);
spinal cord and canal; meningioma; neurofibromatosis; muscle; metastatic (uncommon)
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| Diagnosis: careful history and physical examination; onset (acute or insidious), location, radiation; night pain in
back or any limb consistent with infection or tumor; frequency, duration, and intensity of pain; need for medication
(nonsteroidal anti-inflammatory drugs [NSAIDs] and ibuprofen [Motrin]) might be significant; response to
NSAIDs; osteoid osteoma (benign tumor in posterior spine) causes severe night pain; interference with play;
motions that cause pain; presence of weight loss, fever, and other generalized symptoms; neurologic complaints
(eg, bowel or bladder changes, numbness, weakness, jumpy legs [hyperreflexia], gait changes [Trendelenburg
sign])
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| Physical examination: observe patient; back alignment; have patient disrobe to check for rashes, skin markings,
and midline defects; leg length discrepancies; flexion and extension of back; pain on palpation and percussion;
sensitivity to vibration; observe gait for asymmetric movement; neurologic examination—deep tendon
reflexes and abdominal reflexes; asymmetric abdominal reflex indicates intraspinal anomaly; motor examination,
sensory examination, and straight leg raise to rule out disc herniation; flexion, abduction, and external
rotation of hip (FABER) test (to stress sacroiliac joint)
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| Radiographic examination: good quality anteroposterior (AP) and lateral x-rays; oblique for spondylolysis;
bone scan for undetermined cause; magnetic resonance imaging (MRI) requires sedation
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| Laboratory studies: complete blood count; sedimentation rate; C-reactive protein; antinuclear antibody (ANA)
to rule out infection, tumor, or rheumatologic disease
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| Case: boy 6.5 yr of age with consistent complaints of thoracolumbar region pain for 5 mo; mild kyphosis; no fever
or neurologic complaints; pain with percussion; x-rays show disc space narrowing and end-plate changes;
diagnosed with discitis associated with end-plate infections; treated with intravenous and oral antibiotics and
bracing; common in age 1 to 5 yr; stiff posture
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| Normal curvatures of spine: thoracic kyphosis and lumbar lordosis; no lateral curvature in frontal plane view;
curvature indicative of problem
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| Definition: lateral rotation and translation of spine; Scoliosis Research Society—fixed lateral curvature ≥10°;
fixed lateral deformity <10° not scoliosis
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| Etiology: scoliosis is phenotype, not diagnosis; vertebral anomalies (congenital scoliosis); neurologic conditions
(eg, cerebral palsy); muscular diseases (eg, muscular dystrophy); idiopathic most common
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| History: obtain pregnancy, birth, and family history; in pediatric orthopedics, have “boys diseases” (eg, club
feet) and “girls diseases” (eg, developmental dislocation of hip [DDH], adolescent idiopathic scoliosis); some
genetic predisposition; determine when first noticed; presence of back pain; back pain not caused by scoliosis;
weakness; numbness
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| Physical examination: perform Adams forward-bending test; scoliosis 3-dimensional deformity; check leg
length with shoes off; scoliometer determines amount of rotation; refer to pediatric orthopedic surgeon if
trunk rotation ≥7°; easy to document; have patient disrobe to check for skin markings (eg, café au lait spots,
dimples, hairy patches suggest intraspinal anomaly); motor examination (lower and upper extremities), grip
strength (checks biceps and triceps); reflexes (deep tendon, abdominal)
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| Studies: start simple; good quality plain radiographs; MRI not routinely taken but useful if neurologic abnormality
found (eg, weakness, numbness, abnormal reflexes); look for progression of curve and whether atypical
(eg, left-sided); always get MRI if patient has neurofibromatosis (look for tumor inside spinal canal,
dumbbell lesions in foramen); before surgery for congenital scoliosis, get MRI of entire spine to determine
whether occiput normal, and whether malformation or tethered spinal cord present; other studies occasionally
obtained—pulmonary function tests, renal ultrasonography (US), cardiac echocardiography, and electrocardiography
(ECG); one third of children with congenital scoliosis have congenital urologic abnormalities; obtain
renal US for this population; same percentage have cardiac abnormalities; more routinely diagnosed by pediatrician
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Idiopathic Scoliosis
| Frequency: seen in 85% of children with curve; otherwise healthy; multiple causes; subclassified by age—
infantile (0-3 yr, more common in boys), juvenile (3㪢 yr), adolescent (10 yr to maturity, primarily in girls);
definitions—called infantile if during birth, child has scoliosis but no abnormalities in formation of vertebral
bodies; called congenital scoliosis if examined at age 13 yr and hemivertebrae noted; progression related to
size of curve, maturity, and location
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| Natural history: 70% do not progress or require treatment; cosmetic problem for girls; progression causes imbalance;
pulmonary and cardiac problems (eg, cor pulmonale) rare; curve in lumbar region never causes cor
pulmonale; thoracolumbar curve cosmetic; potential back pain problem, never life-threatening; before skeletal
maturity, patients progress at 2°/mo; followed by orthopedic surgeon q6mo; after skeletal maturity,
progress at 1°/yr; patients not followed as often
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| Treatment: observation; bracing (eg, Milwaukee [longest track record, but not used frequently], Boston [underarm
thoracic lumbosacral orthosis (TLSO) brace], Spinecore girdle); fusion; bracing—if patient skeletally
immature (before age 15 yr and thoracic curve 50°); generally brace if curve >25° with signs of progression;
immediately brace when skeletally immature and curve reaches 30° to 40° until growth completed; fusion—
generally if thoracic curve >50°; rapidly progressive curve despite bracing; child out of balance (cosmetic);
does not prevent back pain in adulthood; indications for both anterior and posterior spinal fusion include high
nonunion risk (eg, neurofibromatosis, curve >90°), very immature child (to prevent crankshaft phenomenon),
and significant kyphosis
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Congenital Scoliosis
| Etiology: abnormal development of vertebrae; sporadic condition, generally not familial; occurs as hemivertebra,
lack of segmentation (unilateral bar), or combination of both; progression variable
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| Associated problems: spine, kidneys, and heart form at same time (8-wk gestation); if child has one congenital
anomaly, other organ systems must be checked at same time; pulmonary abnormalities (eg, alveolar hypodevelopment);
one third of children have intraspinal anomalies (eg, Chiari malformation, syrinx, diplomyelia,
diastematomyelia); total body imaging from occiput to lower end of spinal cord
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| Progression: related to age, maturity, and structural anomaly; with hemivertebra, 1° to 2°/mo; unilateral bar
with contralateral hemivertebra, 10°/mo
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| Problems: very stiff spine; corrective spine straightening very high risk (potential severing of spinal cord); treat
before significant deformity develops; does not respond to bracing; abnormality of vertebral body growth and
fusion; some patients have constricting thoracic dystrophy and very small lung volumes; rib expander designed
by Dr. Robert Campbell opens ribs for lung development
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Neurologic and Muscular Scoliosis
| Remember: separate disease from phenotype
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| Prognosis and treatment: variable
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| Case study: quadriplegic patient with cerebral palsy (CP), long C-shaped curve; bracing generally ineffective,
but occasionally used to help patient sit and alleviate pain; position brace to prevent suffocation if head flops;
fusion performed to enable patient to sit more comfortably in alignment; CP patients have high morbidity
risk; must weigh risk against benefit of surgery
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| Duchenne’s Muscular Dystrophy: consistent presentation; diagnosed at 3 yr of age; pseudohypertrophy of
calves; wheelchair-bound by 10 to 12 yr of age; death in late teens to early 20s from pulmonary or cardiac
problems; >90% of patients develop scoliosis when wheelchair-bound; progressive; as curve worsens, pulmonary
function decreases dramatically; early surgical intervention with 10°- to 20°-curve prevents worsening
of pulmonary function and need for ventilation in future; recent advances using steroids—administering derivative
of prednisolone (deflazacort) while patient still walking enables patient to walk longer and delays onset
of scoliosis; might eliminate need for spinal fusion when patient becomes wheelchair-bound; study of patients
taking deflazacort vs those who did not showed scoliosis in 17% vs 67% in 5-yr follow-up; treatment complications
include cataracts, weight gain, osteopenia, and fractures
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| KYPHOSIS —Saul M. Bernstein, MD, Clinical Professor of Orthopaedic Surgery, Keck School of Medicine at
the University of Southern California, and Pediatric Orthopedist, Southern California Orthopedic Institute,
Los Angeles, California
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| Etiology: multiple causes; postural round back—common in adolescent girls as breasts develop, disappears with
age; patient can stand straight when asked; managed with physical therapy and exercise program; brace rarely
used; Scheuermann’s kyphosis—may result in pain at curve apex; patient cannot self-correct; present in thoracic
or lumbar area; pain most notable in lumbar area; treat with physical therapy before adding brace; for effective
bracing, child must have at least one more year of growth remaining; brace worn at night after child
reaches maturity; surgery performed if curve >70°; treatment improves patient’s self-perception; congenital
(spina bifida)—possible fusion failure of front of vertebrae or congenital fusion of multiple areas; partial or
total paralysis below waist; worsening of kyphosis due to anterior movement of posterior musculature acts as
flexor of spine; surgical resection of kyphotic segment; rods placed in sacrum for stability; sometimes segments
fused; Ehlers-Danlos syndrome—marked ligament elasticity; associated with scoliosis, kyphosis, or
both; treat with anterior and posterior fusion; trauma—eg, gunshot wounds, seatbelt injuries, compression injuries;
compression fractures treated with balloon kyphoplasty and cement in older patients; new kyphoplasty
technique uses balloon and bone to expand vertebrae in younger children; compression fracture also treated
using anterior and posterior fusion; tumors—resect vertebrae and stabilize; infection—tuberculosis with gibbous
deformity; treat with antibiotics; some people have normal kyphosis
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Educational Objectives
| The goal of this activity is to improve the care of children with back pain and scoliosis. After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. Discuss the causes and treatment of back pain in children.
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| 2. Understand the etiology of scoliosis.
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| 3. Be familiar with “boys” and “girls” diseases in pediatric orthopedics.
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| 4. List the classifications of scoliosis and discuss their treatment.
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| 5. Review the etiology and treatment of kyphosis.
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Discussed on This Program
Ibuprofen [several trade names]
Deflazacort [Calcort (not available in United States)]
Suggested Reading
El Rass G et al: Lumbar spondylolysis in pediatric and adolescent soccer players. Am J Sports Med 33:1688,
2005; Emans JB et al: Prediction of thoracic dimensions and spine length based on individual pelvic dimensions
in children and adolescents: an age-independent, individualized standard for evaluation of outcome in early onset
spinal deformity. Spine 30:2824, 2005; Emans JB et al: The treatment of spine and chest wall deformities with
fused ribs by expansion thoracostomy and insertion of vertical expandable prosthetic titanium rib: growth of thoracic
spine and improvement of lung volumes. Spine 30:S58, 2005; Fribourg D, Delgado EL: Occult spinal cord
abnormalities in children referred for orthopedic complaints. Am J Orthop 33:18, 2004; Grewal H et al: A prospective
comparison of thoracoscopic vs open anterior instrumentation and spinal fusion for idiopathic thoracic
scoliosis in children. J Pediatr Surg 40:153, 2005; Lenke LG: Kyphosis of the thoracic and thoracolumbar spine
in the pediatric patient: prevention and treatment of surgical complications. Instr Course Lect 53:501, 2004; Lerman
JA et al: The Pediatric Outcomes Data Collection Instrument (PODCI) and functional assessment in patients
with adolescent or juvenile idiopathic scoliosis and congenital scoliosis or kyphosis. Spine 27:2052, 2002;
Newton PO et al: The success of thoracoscopic anterior fusion in a consecutive series of 112 pediatric spinal deformity
cases. Spine 30:392, 2005; Parent S et al: Adolescent idiopathic scoliosis: etiology, anatomy, natural history,
and bracing. Instr Course Lect 54:529, 2005; Pizzutillo PD: Nonsurgical treatment of kyphosis. Instr Course
Lect 53:485, 2004; Smith JT et al: Simultaneous anterior-posterior approach through a costotransversectomy for
the treatment of congenital kyphosis and acquired kyphoscoliotic deformities. J Bone Joint Surg Am 87:2281,
2005; Soo CL et al: Scheuermann kyphosis: long-term follow-up. Spine J 2:49, 2002; Ugwonali OF et al: Effect
of bracing on the quality of life of adolescents with idiopathic scoliosis. Spine J 4:254, 2004; Verlaan JJ et al:
Anterior spinal column augmentation with injectable bone cements. Biomaterials 27:290, 2006; Vitale MA et al:
Comparison of the volume of scoliosis surgery between spine and pediatric orthopaedic fellowship-trained surgeons
in New York and California. J Bone Joint Surg Am 87:2687, 2005; Waicus KM, Smith BW: Back injuries
in the pediatric athlete. Curr Sports Med Rep 1:52, 2002; Wazeka AN et al: Outcome of pediatric patients with severe
restrictive lung disease following reconstructive spine surgery. Spine 29:528, 2004; Weiss HR et al: Sagittal
counter forces (SCF) in the treatment of idiopathic scoliosis: A preliminary report. Pediatr Rehabil 9:24, 2006;
Wiggins GC et al: Pediatric spinal deformities. Neurosurg Focus 14:e3, 2003; Yuan N et al: The effect of scoliosis
surgery on lung function in the immediate postoperative period. Spine 30:2182, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed.
For this issue, the faculty reported nothing to disclose.
Drs. Bernstein and Bernstein were recorded at Head to Toe: Orthopaedic Aspects of the Growing Child, held October
22, 2005, in Los Angeles, and sponsored by the Cedars-Sinai Medical Center Department of Surgery, Division
of Pediatric Orthopaedic Surgery. The Audio-Digest Foundation thanks the speakers and sponsors for
their cooperation in the production of this program.
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