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Chapter 24 Outcomes of Nonsurgical and Surgical Treatment of Chronic Sacroiliac Joint Pain 413
46. Sachs D, Capobianco R. One year successful outcomes for
novel sacroiliac joint arthrodesis system. Ann Surg Innov Res.
2012;6(1):13.
47. Sachs D, Capobianco R. Minimally invasive sacroiliac joint
fusion: one-year outcomes in 40 patients. Adv Orthop.
2013;2013:536128.
48. Cummings J Jr, Capobianco RA. Minimally invasive sacroiliac
joint fusion: one-year outcomes in 18 patients. Ann Surg Innov
Res. 2013;7(1):12.
49. Gaetani P, Miotti D, Risso A, et al. Percutaneous arthrodesis of
sacro-iliac joint: a pilot study. J Neurosurg Sci. 2013;57(4):
297-301.
50. Schroeder JE, Cunningham ME, Ross T, Boachie-Adjei O. Early
results of sacro-iliac joint xation following long fusion to the
sacrum in adult spine deformity. HSS J. 2013;10(1):30-35.
51. Sachs D, Capobianco R, Cher D, et al. One-year outcomes
aer minimally invasive sacroiliac joint fusion with a series of
triangular implants: a multicenter, patient-level analysis. Med
Devices (Auckl). 2014;7:299-304.
52. Vanaclocha-Vanaclocha V, Verdú-López F, Sánchez-Pardo M,
et al. Minimally invasive sacroiliac joint arthrodesis: experience
in a prospective series with 24 patients. J Spine. 2014;3:185.
53. Sachs D, Kovalsky D, Redmond A, et al. Durable intermediateto long-term outcomes aer minimally invasive transiliac
sacroiliac joint fusion using triangular titanium implants. Med
Devices (Auckl). 2016;9:213-222.
54. Ledonio CGT, Polly DW Jr, Swiontkowski M, Cummings JT.
Comparative eectiveness of open versus minimally invasive
sacroiliac joint fusion. Med Devices (Auckl). 2014;7:187-193.
55. Smith AG, Capobianco R, Cher D, et al. Open versus
minimally invasive sacroiliac joint fusion: a multi-center
comparison of perioperative measures and clinical outcomes.
Ann Surg Innov Res. 2013;7(1):14.
56. Vanaclocha V, Herrera JM, Sáiz-Sapena N, Rivera-Paz M,
Verdú-López F. Minimally invasive sacroiliac joint fusion,
radiofrequency denervation, and conservative management
for sacroiliac joint pain: 6-year comparative case series.
Neurosurgery. 2017. [Epub ahead of print].
57. Al-Khayer A, Hegarty J, Hahn D, Grevitt MP. Percutaneous
sacroiliac joint arthrodesis: a novel technique. J Spinal Disord
Tech . 2008;21(5):359-363.
58. Khurana A, Guha AR, Mohanty K, Ahuja S. Percutaneous
fusion of the sacroiliac joint with hollow modular anchorage
screws: clinical and radiological outcome. J Bone Joint Surg Br.
2009;91(5):627-631.
59. Kancherla VK, McGowan SM, Audley BN, Sokunbi G, Puccio
ST. Patient reported outcomes from sacroiliac joint fusion.
Asian Spine J. 2017;11(1):120-126.
60. Kube RA, Muir JM. Sacroiliac joint fusion: one year clinical
and radiographic results following minimally invasive sacroiliac
joint fusion surgery. Open Orthop J. 2016;10(1):30.
61. Rappoport LH, Luna IY, Joshua G. Minimally invasive
sacroiliac joint fusion using a novel hydroxyapatite-coated
screw: preliminary 1-year clinical and radiographic results of a
2-year prospective study. World Neurosurg. 2017;101:493-497.
62. Spain K, Holt T. Surgical revision aer sacroiliac joint xation
or fusion. Int J Spine Surg. 2017;11:5.
63. Miller L, Reckling WC, Block JE. Analysis of postmarket
complaints database for the iFuse SI Joint Fusion System: a
minimally invasive treatment for degenerative sacroiliitis
and sacroiliac joint disruption. Med Devices (Auckl). 2013;6:
77-84.
64. Cher DJ, Reckling WC, Capobianco RA. Implant survivorship
analysis aer minimally invasive sacroiliac joint fusion using
the iFuse Implant System. Med Devices (Auckl). 2015;8:485-492.
65. Martin BI, Mirza SK, Comstock BA, et al. Reoperation rates
following lumbar spine surgery and the inuence of spinal
fusion procedures. Spine. 2007;32(3):382-387.
66. Martin BI, Mirza SK, Flum DR, et al. Repeat surgery aer
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67. Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic
recognition of the sacral alar slope for optimal placement
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Trauma. 1996;10:171-177.
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III
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IV
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PEDIATRICS
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25
Back Pain in Children and Adolescents
CHAPTER
Introduction
e prevalence of back pain in children and adolescents is
1-3
rising.
more than 50% of children note episodes of back pain by 15
years of age.
teenagers complain of low back pain, few actually present for
medical evaluation.8 While the incidence of back pain in
adolescents was previously reported to be around 18% to
30%,
self-reported back pain in a prospective cohort study of 1348
students ages 11 to 13 years, which increased to 89% at 2-year
follow-up.
the classically held belief that back pain in children and adolescents is due to serious pathology is no longer thought to be
true.13 In 1985, Hensinger found a specic diagnosis in 84%
of children presenting for treatment of back pain.14 In a more
recent analysis, however, Yang and colleagues found that over
80% of adolescents had no identiable etiology for their back
pain within 1 year of presenting to a physician.3 In this cohort,
the most common etiology of back pain in ages 10 to 19 years
was muscle strain or sprain. A similar study of patients
screened by single photon emission computed tomography
(SPECT) scans found a cause for back pain in only 22% of 217
children.15 Based on this, it is up to the evaluating surgeon to
identify which children are most likely to have an underlying
musculoskeletal condition and require a comprehensive evaluation to identify the etiology of their back pain.
worrisome, while adolescent pain is more likely to pattern
aer adult complaints, especially when the complaint is
chronic.16 e thought that a pathologic abnormality can
nearly always be identied as the cause of the symptoms is
evolving as more studies demonstrate fewer pathologic ndings.
less likely to yield a diagnosis.18 As the radiologic armamentarium grows, the treating physician has more choices in the
evaluation of these patients, yet every child who presents to
the physician does not need to undergo a comprehensive
While it is assumed that pediatric back pain is rare,
4-7
In 2001, it was reported that, although 39% of
9-11
a recent Danish study reported an 86% incidence of
12
As complaints of back pain in young adults continue to rise,
Studies suggest that back pain in younger children is more
16,17
As children reach adolescence, diagnostic imaging is
Lori A. Karol
Lauren LaMont
Megan Mignemi
workup. erefore, a complete understanding of the potential
causes of back pain will enable treating physicians to properly
evaluate the pediatric patient who complains of back pain.
History
e initial step in distinguishing which children require
symptomatic treatment from those who merit a complete
radiographic evaluation is obtaining a detailed history. e
characteristics of the pain are most helpful. Acute pain following trauma is seen with fractures, disc herniations, and
apophyseal ring separations. Insidious pain without a specic
antecedent event is characteristic of developmental conditions
such as Scheuermann kyphosis and benign neoplasms.
However, in adolescent patients, pain without a specic event
may also be attributable to mechanical back pain, as is seen in
adults with similar complaints. Recurrent pain associated with
athletics and relieved by rest leads to suspicion of overuse
injuries, such as spondylolysis, or may also be mechanical in
nature. Unremitting pain, especially if it is worse at night or
wakes the child from sleep, is most worrisome, as this type of
pain can be seen in malignancies and infection.
e location of the pain is very helpful in narrowing down
the dierential diagnosis. Localized bony pain may indicate
either benign or malignant neoplasms. Lumbar pain may be
produced by spondylolysis or spondylolisthesis, while pain in
the thoracic area may be due to Scheuermann kyphosis. It is
important to note whether pain in each region is bony tenderness elicited while palpating spinous processes or paraspinal
soreness, which may point more to muscle strain or mechanical pain. When pain radiates into either the buttocks or legs,
there is concern for a disc herniation, apophyseal fracture, and
spinal cord or vertebral tumors. As with all examinations,
when pain radiates down into the leg or groin, it is important
to rule out hip pathology, especially in the adolescent female,
who may suer from unrecognized hip dysplasia.
e presence or absence of constitutional symptoms is
useful in deciding the potential severity of the underlying
condition. Fever in a child with acute back pain points to an
19,20
IV
417
418 PEDIATRICS
infectious or neoplastic etiology. It is important to question
the parents about malaise, anorexia, and the presence of a rash
or abnormal bruising, as back pain can be the presenting
complaint in children with leukemia. ese concerns call for
more emergent blood work and imaging to conrm the
diagnosis.
Next, a detailed neurologic history must be obtained. e
presence of numbness, weakness, decreased ability to walk,
and changes in coordination require prompt imaging of the
spinal cord. Questioning the patient and parents as to how
much these neurologic symptoms have altered activity level
can also be helpful to determine their severity. e treating
physician should ask specically about changes in bowel or
bladder function, as adolescents are hesitant to admit to these
symptoms.
e patient’s age is also very helpful in directing the evaluation of back pain. Back pain in children younger than 4 years
is usually due to either infection or malignancy. A history of
fever, limp, and malaise should be sought, and an immediate
diagnostic evaluation should be performed. Children in the
rst decade of life commonly present with discitis and/or
osteomyelitis and malignant neoplasms, but also may present
with benign conditions such as eosinophilic granuloma.20
Patients older than 10 years are most likely to have back pain
secondary to trauma or overuse, resulting in spondylolysis,
disc herniations, or apophyseal fractures.21 Scheuermann
kyphosis typically presents in adolescence. Patients older than
10 years are also more likely to have pain attributable to
overuse, strain, or mechanical low back pain without abnormal imaging.3 While more common in younger children,
teenagers can present with malignancies. us, the evaluating
physician should weigh the relative frequency of conditions
based on age, but always remain cautious.
A family history should be taken regarding back pain.
Adolescents with ill-dened pain, no constitutional symptoms,
no history of excessive athletic activity, no anatomically consistent neurologic complaints, and a positive family history
oen do not have a musculoskeletal etiology for their pain.
5,20
Psychosomatic pain does occur in this age group, but remains
a diagnosis of exclusion. History of sleep habits, school performance, changes in weight, mood, and mental health
problems can also help identify patients in whom pain is
associated with a psychiatric diagnosis that at times may
require urgent referral.
Finally, a complete review of systems should be obtained.
Back pain associated with menses is rarely orthopaedic in
nature. Flank pain may be renal in origin. A recent study
showed that 5% of children presenting to an emergency
department for evaluation of back pain had urinary tract
infections.
22
inability to walk can be due to infection or spinal cord compromise. Specic gait abnormalities, such as increased poste-
rior pelvic tilt and decreased hip exion, may be seen in
spondylolisthesis. Examination of the skin for dysraphic
lesions, such as hairy patches or deep sinuses, as well as for
café-au-lait spots, is also required. Palpation of the spine can
identify the location of the pathologic abnormality.
e spine should be inspected for sagittal and coronal
alignment. e Adams forward bend test identies patients
with scoliosis, but the presence of scoliosis is more likely to be
a symptom of underlying pathology rather than a cause of
pain. Trunk lean and decompensation may indicate such
pathology as benign or malignant neoplasms, or irritating
lesions such as herniated discs. Stiness of the spine should
be noted. oracic kyphosis typically increases and lumbar
lordosis reverses as a child bends forward. In the presence of
signicant pain, the child will not allow the spine to move, and
will bend the knees to touch the oor rather than ex the
spine. Pain with hyperextension of the spine is oen seen in
patients with spondylolysis and is oen worsened with onelegged hyperextension on the aected side if unilateral. is
can be further exacerbated by twisting during hyperextension.
e Lasegue sign is nearly always positive in patients with
herniated discs or fractured apophyses. e straight-leg raise
is also diminished in patients with tight hamstrings due to
spondylolisthesis, and popliteal angles will also be increased.
Next, a thorough neurologic examination is critical in the
evaluation of the child with back pain. Motor and sensory
function and deep tendon reexes should be tested. Long tract
signs, such as clonus and the Babinski reex, must be evaluated to rule out spinal cord compression or abnormality. e
abdominal reex is tested by lightly stroking the four quadrants
around the umbilicus in the supine child. While an absent
abdominal reex is not abnormal, an asymmetric response
may indicate spinal cord abnormalities.
Diagnostic Studies
With the information obtained from the history and physical,
a focused approach to diagnostic studies can be taken. If the
patient is aged 10 years or younger, has had pain for 2 months
or longer, has night pain, had traumatic injury, or if there are
constitutional symptoms, standard radiographs of the spine
should be obtained at once. If the patient is older, the pain is
of short duration with no major traumatic event, and the
physical examination is completely normal, the patient may
be observed for a short period of time. Most patients fall
between these two groups; thus, the extent of the radiographic
evaluation should be decided on an individual basis.
Physical Examination
e general appearance of the child should be noted. If the
child appears systemically ill, immediate evaluation for infection or malignancy is warranted. Whether the child can walk
and the characteristics of the child’s gait are important, as the
Radiographs
Plain radiographs are the best screening examination for the
child with back pain.
views of the spine should be obtained without pelvic shielding, as the shield hides the sacrum, sacroiliac (SI) joints, and
pelvis. e physician should carefully examine the lms for
19,23
Anteroposterior (AP) and lateral
Chapter 25 Back Pain in Children and Adolescents 419
alignment, disc space narrowing, endplate irregularities, and
lytic or blastic lesions. Each pedicle should be identied on the
AP view. If a question of a lesion arises, a focused coned-down
view taken with the patient supine provides better bony detail.
e lateral lm should be reviewed for the presence of
spondylolysis or spondylolisthesis. As on the AP view, if there
is a question of lysis on the lateral view, a spot lateral of the
lumbosacral junction better visualizes the pars interarticularis.
Oblique views of the lumbosacral spine can also show the lysis;
however, recent studies demonstrate that, in the majority of
cases, oblique lms do not improve the rate of diagnosis of
spondylolysis.
e identication of scoliosis on screening lms of a child
with back pain should not lead to the conclusion that the
curve is the cause of the pain. Although up to 33% of adolescents diagnosed with scoliosis complain of some back pain, it
is usually located over the rib prominence and is rarely a
presenting complaint.23 e apex of the curve should be care-
fully inspected for bony lesions in the child with painful
scoliosis.
18
Bone Scan
If plain radiographs are normal, the neurologic examination
is normal, but the symptoms of the patient are suggestive of
bony pathology, a triphasic technetium bone scan is recommended. Scintigraphy is a highly sensitive but nonspecic tool
to localize bony processes. Infection, most benign and malignant bony lesions, and stress fractures will have increased
bone turnover, which is visualized as increased tracer uptake
on scintigraphic images. Pinhole collimation is helpful in
localizing the increased uptake. e study should include the
SI joints and pelvis, as pathology in these areas oen presents
as back pain.
SPECT scanning combines the physiology of a bone scan
with the ability to precisely localize lesions within the vertebra,
similar to a CT scan. Increased uptake can be seen in the
posterior elements in stress fractures; therefore, SPECT is
particularly helpful in diagnosing spondylolysis.
study of children younger than 10 years with back pain found
SPECT to be highly sensitive for identifying injury to the
pars.28 Another study of 100 patients aged 2 to 18 years presenting with low back pain found that a negative SPECT scan
was most helpful in ruling out an organic cause for back pain
of less than 6 weeks’ duration.
29
24–27
A recent
Computed Tomography
Computed tomography (CT) provides the best imaging of
the vertebral anatomy. It is not used as a screening tool, but
it is useful when a lesion is seen on plain radiography or
when plain radiography is negative but bone scintigraphy
shows increased uptake. It can be used to assess the status
of the pars interarticularis in patients with spondylolysis or
to better delineate the extent of bony tumors. Although bone
lesions can be seen on magnetic resonance imaging (MRI),
surrounding edema may overestimate the extent of skeletal
involvement.
Magnetic Resonance Imaging
MRI is used to image the neural axis in all children who have
an abnormal neurologic examination. MRI is able to identify
spinal neoplasms, cord abnormalities such as syringomyelia
and tethers, discitis, and herniated discs, among other conditions. Auerbach and coworkers29 recommend MRI as the best
imaging modality for patients with low back pain of greater
than 6 weeks’ duration. In support of this, a recent study of
pediatric patients found the incidence of abnormal pathology
on MRI to be 34% in patients with constant pain, night pain,
radicular pain, and abnormal neurologic examination.
30
Laboratory Tests
Laboratory tests should be obtained at presentation in all
young children with back pain and those with night pain,
fever, malaise, or easy bruising. A complete blood count with
dierential should be obtained. e peripheral smear should
be ordered to look for abnormal cell lines consistent with
leukemia. e erythrocyte sedimentation rate and C-reactive
protein should also routinely be studied because they are
elevated in infection and malignancy. Urinalysis should be
used to screen for renal conditions.
Dierential Diagnosis
Muscle Strain
A very common cause of back pain, especially in athletic
adolescents, is muscular strain, which can be up to 3 to 5 times
more prevalent in elite athletes.31 Pain can oen be attributed
to changes in amount and level of training, ill-tting equipment, or poor technique. Poor strength of the back extensor
and abdominal musculature, as well as tight hamstrings and
hip exor muscles, may be found in patients with muscular
strain.32 Absence of concerning history, such as night pain or
radicular pain, and relation to activity can be helpful in
excluding other more concerning diagnoses.
Treatment consisting of temporary activity modication,
application of ice in the acute phase and heat later for spasm,
in combination with nonsteroidal antiinammatory drugs
(NSAIDs), is oen sucient for most young adults. In patients
who have failed these measures, a home physical therapy
program for core and back strengthening, as well as hamstring
stretching, may be prescribed. Important in the counseling of
these patients is the emphasis that without regularly performing these exercises, there will be no signicant improvement
in pain. Return to activity is based on resolution of symptoms
while continuing a core strengthening program as part of
athletic training.
Disc Herniation
Intervertebral disc herniation occasionally occurs in older
children and teens. e onset of symptoms is usually related
to acute or repetitive trauma.33 Of aected patients, 82% complain of back pain with radiation into the legs.34 is radicular
SECTION
IV
420 PEDIATRICS
FIG. 25.1 Magnetic resonance image of a 16-year-old female with back
and right leg pain demonstrates a herniated L4–L5 disc (arrowhead).
pain is exacerbated by activity and relieved by rest. As in the
adult population, the pain is worsened by sneezing, coughing, or straining. Recent studies have demonstrated a higher
incidence of disc herniation in female patients and support
that leg pain is the most common presenting complaint.
35
Physical examination reveals decreased spinal exibility,
with inability to touch the toes. On bending toward the oor,
the patient oen lists to one side. e straight-leg raise test
(Lasegue sign) is positive in 85% of children with herniated
discs, while objective neurologic ndings—such as absent
reexes, motor weakness, and decreased sensation—are less
common in pediatric patients than in adults.36 Hamstring
tightness is oen present and has been found to persist even
aer treatment of disc hernation.
37
Radiographs are generally normal, although if suciently
symptomatic, lms may show an olisthetic scoliosis or trunk
lean away from the side of herniation. ere is an increased
incidence of concomitant spinal abnormalities in patients with
herniated discs. In particular, congenital spinal stenosis is
frequently seen. Other ndings include transitional vertebrae
or spondylolisthesis.
38
Disc herniation is seen best on MRI (Fig. 25.1). e
involved disc is readily appreciated, and other processes that
might produce sciatica, such as epidural abscess and spinal
cord tumor, can be ruled out.20 Herniation of the disc can be
dierentiated from an avulsed vertebral apophysis on either
MRI or CT scan. Correlation of the MRI ndings with the
history and clinical examination is necessary, as mild disc
bulging can exist as a normal variant.
Treatment is initially conservative, consisting of antiinammatory medication and bed rest. Prolonged nonoperative
management may lead to persistent pain, however; if the
patient does not respond to symptomatic treatment, disc excision should be oered.36 More urgent surgical intervention is
indicated when a progressive neurologic decit develops.
Short-term results are very encouraging, with 95% good and
excellent results and nearly universal resolution of back and
leg pain.36 Long-term follow-up, however, shows a deterioration in results, with a 24% reoperation rate aer 30 years.39
Outcome studies demonstrate that patients treated with discectomy as adolescents function better than adults following
the same surgery.40 Surgical technique is similar to that in
adult patients.
Apophyseal Ring Fracture/Slipped Vertebral Apophysis
e apophyseal ring fracture, also known as a slipped vertebral
apophysis, occurs in adolescents and young adults prior to
fusion of the vertebral body to the cartilaginous ring apophysis. e etiology is either acute trauma resulting in rapid
exion and axial compression, or cumulative microtrauma.
e fracture typically develops at the junction of the posteroinferior vertebral body and the cartilaginous ring apophysis,
with posterior displacement of the fragment into the spinal
canal.41 CT can demonstrate the size and location of the bony
fragment, with large central fragments being both most
common and most likely to result in signicant pain if le
untreated.
42
e symptoms are very similar to those of a herniated disc,
with the sudden onset of severe back pain radiating into the
leg. Physical examination will show a positive straight-leg
raise test, but, as is the case with disc herniations, neurologic
signs are infrequently present.
e diagnosis is made radiographically. High-quality lateral
radiographs may show an arc-shaped rim of cartilage, cartilage
with attached underlying bone, or a small triangular bony
fragment lying posterior to the vertebral body. e fragment
is best visualized on CT scan.41 e levels most frequently
injured are L4 or S1. Treatment is surgical excision of the
avulsed fragment.
Vertebral Fractures
Pediatric patients with spine fractures present with back pain.
If the energy of injury is sucient enough that fracture is
possible, radiographs should be obtained at once. When
compression fractures are seen in children without highenergy trauma, an immediate evaluation should be performed
for underlying malignancy. When patients have undergone
high-energy trauma and fracture has been ruled out, however,
the patient still complains of severe back pain, MRI may be
indicated to rule out ligamentous injury, which can lead to
instability in one or more of the spinal columns, especially in
younger children.
43
Developmental Disorders
Spondylolysis and Spondylolisthesis
Spondylolysis refers to a stress fracture of the pars interarticularis, occurring predominantly in the lower lumbar spine. e
most frequent level is L5, followed by L4. It is extremely rare
to have more than one vertebral level involved. Spondylolysis
is bilateral in 80% of cases, and unilateral in 20%, although in
certain athlete groups unilateral spondylolysis is more
prevalent.
back pain have injuries to the pars interarticularis.45 e
mechanism of injury is repetitive microtrauma in hyperextension, overloading the pars interarticularis and over time
leading to stress fracture. Sports linked to a high incidence of
spondylolysis are gymnastics, diving, ballet, and football.
Gymnasts and football linemen have a fourfold increase in
incidence of spondylolysis compared with the general pediatric population.
by athletic activity and at least partly relieved by rest. e pain
is present in the lower back, but can radiate into the legs.
loss of normal lumbar mobility. e ability to bend forward to
the oor may be diminished. In hyperexible patients (e.g.,
gymnasts and ballerinas), motion may appear normal. e
patient is usually tender to palpation about the lumbar spine.
Hyperextension usually reproduces the back pain, and axial
rotation in hyperextension exacerbates that pain.
ticularis, and oblique radiographs can be helpful in less
obvious cases (Fig. 25.2). e appearance of a collar on the
“Scottie dog” suggests stress fracture. Oen, plain radiographs
are nondiagnostic. In these cases, scintigraphy can reveal
increased tracer uptake at the involved level. e use of the
SPECT scan is particularly helpful in localizing increased
uptake in the pars interarticularis
scintigraphic pattern, seen as a triangle of increased signal
with increased uptake in the pedicles, has been described.48
Positive bone scans and SPECT imaging are generally seen in
the prefracture state and in relatively acute injuries.49 e bone
scan may not be “hot” in chronic spondylolysis.
false-positive scans do occur.50 Better bony denition of the
fracture is obtained using CT scans. Additionally, CT is superior to MRI in the assessment of incomplete fractures and in
establishing healing in patients with spondylolysis.51 e pars
is best imaged by using a reverse gantry angle and obtaining
thin slices on the CT.
Curves due to these conditions are usually described as olisthetic, are associated with oblique take-o of the spine from
the pelvis, are small in degree, and have little rotation. Spondylolysis and spondylolisthesis occur in patients with idiopathic scoliosis more frequently than in the general population
but are usually asymptomatic.
44
Up to 50% of young athletes presenting for evaluation of
46
Symptoms consist of low back pain, which is exacerbated
Physical examination may reveal hamstring tightness and
Lateral radiographs may show lysis across the pars interar-
25,26,47
(Fig. 25.3). A specic
26
MRI has also been used to diagnose spondylolysis, but
52
Spondylolysis and spondylolisthesis can produce scoliosis.
Chapter 25 Back Pain in Children and Adolescents 421
SECTION
IV
FIG. 25.2 Lateral radiograph of the lumbar spine shows spondylolysis of L5
in a 16-year-old volleyball player.
FIG. 25.3 Increased uptake in the pars interarticularis (arrow) of an
adolescent ballerina with spondylolysis.
Treatment of spondylolysis is initially nonoperative and
rst involves modifying the patient’s level of athletic activity.53
Cessation of sport until the resolution of symptoms is combined with a concomitant exercise program to stretch the
hamstrings and strengthen the paraspinal and abdominal
musculature. Resumption of activities is gradual. Modication
of the patient’s technique or training should be made to minimize recurrent fractures. Use of an antilordotic lumbar
orthosis increases the success of nonoperative treatment,
422 PEDIATRICS
A B
FIG. 25.4 (A) Scoliosis in a 13-year-old male with low back and leg pain of 6 months’ duration. (B) Lateral
radiograph shows spondylolisthesis at L5–S1.
particularly in patients with acute injuries and “hot” bone
54,55
scans.
A recent study found resolution of symptoms following bracing correlated with initial increased activity on
SPECT scans and decreased uptake on follow-up scans, while
SPECT scans for patients whose pain did not improve showed
no signicant decrease in activity following bracing.56 e
overall success rate of nonoperative treatment ranges from
73% to 100%.55 A recent multicenter study of 436 children and
adolescents with CT-proven spondylolysis found 95% excellent results and 100% return to sport without surgery following
3 months of cessation of activity with use of a thoracolumbar
orthosis.57 Patients who have normal radiographs but are
found to have a stress reaction without fracture on further
imaging are highly likely to improve (and not progress to
radiographic fracture) with conservative treatment.
58,59
Surgery is typically reserved for the few patients whose symptoms are refractory to 6 months of conservative measures and
whose pain recurs with activity following initial nonoperative
success.
60
Spondylolisthesis is a related condition in which anterior
slippage of a vertebral body occurs on the more distal vertebra.
Most oen it is due to bilateral spondylolysis, with the portion
of the vertebra anterior to the pars fracture slipping anteriorly.
Dysplastic spondylolisthesis occurs in teens who have an
elongated but intact pars interarticularis, which allows for the
anterior translation without pars fracture.
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Patients with spondylolisthesis oen present with com-
plaints of low back pain. e pain may radiate into the legs.
Physical ndings mimic those of spondylolysis, with the
addition of a possible palpable step-o at the area of listhesis.
In severe spondylolisthesis, the buttocks may appear “heart
shaped.” If there is signicant hamstring tightness, gait altera-
tions are seen where the teen appears to be shuing with
posterior pelvic tilt. Patients may have a painful, or olisthetic,
scoliosis (Fig. 25.4).
Plain radiographs establish the diagnosis. e slip is easily
seen on a spot lateral radiograph of the lumbosacral junction,
and the severity of the spondylolisthesis can be classied as
the percentage of forward translation of L5 on the sacrum.
Abnormal kyphosis is also seen as the cephalad vertebra tips
forward on the caudal segment. A characteristic nding on the
AP radiograph, which is the appearance of “Napoleon’s hat,”
can be seen as L5 moves forward on the sacrum and is seen
in a nearly axial view.
Treatment is initially conservative in mild spondylolisthesis, and surgical as the magnitude of the slip increases. Surgical
treatment of high-grade spondylolisthesis is recommended,
but preferred techniques vary among surgeons and reduction
remains controversial.
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Scheuermann Kyphosis
Scheuermann kyphosis is a developmental condition occurring in adolescence characterized by increased thoracic
kyphosis accompanied by lumbar hyperlordosis. Males are
aected slightly more frequently than females.
Presenting symptoms are those of back pain, which is
usually located at the apex of the thoracic kyphosis, and also
may be present in the lower lumbar spine. e pain is usually
described as aching in nature, does not wake the patient from