Back Pain in Children

Back Pain in Children

back pain?

back pain 10 ~ 30 % (up to 50 % by Questionnaire) 10 : rare (11 : 11%, 15 : 50%) : Back pain 2 ~ 8 % : (+) up to 50% if :

Significant vs. Non-significant Red flag (Fever, weight loss ) Neurologic findings Non-mechanical (night pain, rest pain) Behavior >> History taking

Significant back pain, Back pain 4 3 Night pain, sleep disturbance

LBP The cause can t be identified in most LBP pts. Psychological stress LBP : rarer LBP d/t Growing pain : (X) Activity-related LBP : (O)

Back pain (Fever, malaise, weight loss, anorexia) Bladder, bowel habit (,, )

Pain character Aggrevating or Alleviating factors Rest, activity Aspirin Coughing : mechanical pain : Ost. osteoma, osteoblastoma : HIVD, tumor Hyperextension : pars defect

Physical examination SLR Hamstring tightness Spine asymmetry Neurologic deficit F / 15

Spondylolysis, -listhesis : 33% Scheuermann s kyphosis : 33% Tumor, Infection : 18% Unknown, : 15% (Hensinger RN, 1985) Reliability??

10 tumor, infection, 10 spondylolysis, -listhesis, Scheuermann s kyphosis Tumor (6~11%)

back pain Mechanical : Strain, overuse, HIVD Developmental : Pars defect, Scheuermann s K. Infectious & inflammation : Discitis, OM Tumor : Benign & malignant Psychogenic Referred pain : from visceral disorders Idiopathic

Tumorous conditions

malignant tumors?? Leukemia 10, night-time back pain

bony malignancy?? Ewing s sarcoma Osteosarcoma

benign tumors?? Osteoid osteoma Osteoblastoma Eosinophilic granuloma

Spinal cord tumor?? Astrocytoma Ependymoma

soft tissue tumor?? Rhabdomyosarcoma

metastatic tumor?? Neuroblastoma

M/7 Back pain

F / 10 Eosinophilic granuloma

M / 14 Congenital scoliosis c.c. : Sudden paraparesis

1

Osteomyelitis & Discitis

F / 5 : Activity diminished, back pain

1

: 6 3 : Refusal to walk 3~8 : Abdominal pain 10 : HIVD - like features (SLR limitation) Fever : 28%

Organism identified : 30~60% (Staphylococcus aureus) X-ray changes : 4~5 weeks later MRI, bone scan Mostly, resolved with conservative Tx

F / 6 Back pain

2

Scheuermann s kyphosis

X-RAY 3 consecutive V.B. each > 5 wedging Thoracic kyphosis > 45 (N : 20~40 ) 65 Endplate irregularities Disc space narrowing Schmorl s node

Multiple Schmorl s node Vertebral body wedging Kyphosis & back pain

1 ~ 8% ( ) Peak incidence : 13 ~ 17 years Aseptic necrosis of verteb. ring apophysis? Scoliosis in 30% Pars defect in up to 30%

Postural kyphosis Compression fracture Congenital kyphosis Tuberculous kyphosis Neuromuscular disease

Observation & Exercises Brace treatment : 45 ~ 65 Surgery 65 persistent excessive pain neurologic deficit

Lumbar HIVD

F/15 SLR : 20 / 10

Lumbar HIVD 1~3% of all HIVD 10% Sciatica, SLR limitation, hamstring tightness ( : LBP in 98%) Variant : Apophyseal ring fracture

M / 16 : Left sciatica

2003. 5 : Left sciatica 2003. 7 : Sciatica, LBP 2003. 8 : E.S.I., E.S.I. 2004. 2 :,

2-3. 4-10..

vs

Lumbar Apophyseal Ring Fracture (LARF) Slipped vertebral ring apophysis HIVD 15% L 4-5 segment CT > > MRI

O : F/ 17, LBP & Right sciatica (for 5 years) 10

Spondylolysis & Spondylolisthesis

Spondylisthesis & Spondylolysis Active back pain up to 47% Mostly Isthmic or Dysplastic at L5-S1 Sports (hyperextension) related : 4~6 (,,, ) history in 25%( ) ~ 50%( )

Unilateral defect : 20% Incidence increasing with age 4 : very rare 6 : 4% 10 : 6% Related with increasing L. lordosis?? (30% of Scheuermann have pars defect) Racial differences : 40% of Eskimo

Natural history 30-50% slip in most patients slip, F/U further slip 10% Lytic defect : 2 High grade slip : 4

Phalen-Dickson sign : knee-bent, hip flexed gait stiff legged, short stride : Hamstring tightness Lumbosacral kyphosis

Roentgenographic parameters Translation Slip angle Sagittal rotation Sacral inclination L. index (trapezoidal L5)

parameters Slippage (or translation) L S kyphosis % Slippage Slip angle

Wiltze s guideline 25% slippage & No symptom : x-ray F/U 25 50% slippage & No symptom : F/U & 50% slippage & symptom (+) : or 50% slippage Slippage < 25% LBP (+) Slip angle : 12 :

Repair of defects Decompression In situ posterior fusion Reduction & fusion Anterior fusion L5 vertebrectomy

Reduction Improve L-S kyphosis (not translation) L4 & sacrum should be in lordotic position Normal Severe slip Reduction: unsatisfactory Reduction: satisfactory

F / 15 Low back pain

1 year follow up

O : F/ 11, severe LBP (for 2 years)

F / 15 Ankle weakness

Immediate postop.

Postop. 1 year

level approach P/E : Local or Systemic or Neurologic : 1 or

Level I II III IV P/E Findings Local Local significant (Hamstring tight, Spine asymmetry) Local significant Systemic sign Additional Neurologic sign 1mo Symtomatic treatment 1mo 1mo 1mo Management X-ray X-ray,, Bone scan add MRI

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