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Y. P. Charles
25.9 What Should Patient andFamily Know?
Spondylolysis and low-grade spondylolisthesis are common in the population and
only symptomatic patients require treatment. High-grade spondylolisthesis represents a rarer condition that requires surgical intervention.
Further Readings
Alzakri A, Labelle H, Hresko MT, Parent S, Sucato DJ, Lenke LG, Marks MC, Mac-Thiong
JM.Restoration of normal pelvic balance from surgical reduction in high-grade spondylolis-
thesis. Eur Spine J. 2019;28(9):2087–94.
Hresko MT, Labelle H, Roussouly P, Berthonnaud E.Classication of high-grade spondylolisthe-
ses based on pelvic version and spine balance: possible rationale for reduction. Spine (Phila Pa
1976). 2007;32(20):2208–13.
Warner WC Jr, de Mendonça RGM.Adolescent spondylolysis: management and return to play.
Instr Course Lect. 2017;66:409–13.
Disc Bulging andHerniation inChildren
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andAdolescents
FedericoCanavese
26.1 Definition
A bulging disc must be differentiated from a herniated disc; in particular, a bulging
disc is a condition in which the nucleus pulposus remains contained within the
annulus brosus, unlike a herniated disc in which the nucleus pulposus extrudes
through the bers of the annulus brosus.
26.2 Natural History
Although intervertebral disk herniation is common in adults, it is relatively uncommon in children (rate in the pediatric population: 5%).
The loss of disc height with subsequent posterior bulging or herniation of the
disc into the spinal canal (cervical, thoracic, or lumbar) as well as bulging of the
ligamentum avum can lead to stenosis (dynamic or permanent) with pain that can
radiate through the back and sometimes down the arms (if the herniation is in the
cervical spine; rare) and legs (if the herniation is in the lumbar spine; more frequent).
26
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_26).
F. Canavese (*)
Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre
Hospital, Lille, France
Faculty of Medicine Henri Warembourg, Nord-de-France University, Lille, France
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_26
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F. Canavese
26.3 Physical Examination
Compared to adult patients, children (in particular) and adolescents often will have
less specic descriptions of the pain or complain of other symptoms, which leads to
a longer duration before diagnosis. Importantly, children and adolescents are less
often seen with neurological symptoms such as numbness and weakness.
History of trauma (prior back injury) or sports-related injury, activities with
repetitive or excessive axial loading, poor conditioning, decreased range of motion,
presence of spine deformity (scoliosis, transitional vertebral abnormalities, spondylolysis, and olisthesis), and obesity can be related to disc herniation.
Presentation is usually acute low-back pain and/or lower extremity radiculopathy. Pediatric patients often will have a less specic description of the pain or complain of other symptoms, which leads to a longer period before diagnosis.
Neurological examination is of paramount importance as patients with disc bulging and disc herniation can develop a broad spectrum of neurological decits, from
mild to extremely severe symptom; depending on the location of disc pathology,
radicular pain (upper or lower extremity; debilitating in some cases), progressive
neurological decit (upper or lower extremity), paresthesia (numbness or tingling;
motor decit are rare), changes in tendon reexes, loss of bladder, and bowel function (Video 26.4). Other symptoms include pain that decreases with rest; increased
pain after sitting for long periods of time, or after bending, picking up heavy objects,
or twisting; and pain that is relieved with walking or changing positions.
In children and adolescents with lumbar disc herniation, the straight-leg raising
test is positive in more than 90% of cases.
26.4 Imaging
Conventional radiographs of the whole spine represent the initial imaging and may
allow identication of narrowing of the intersomatic disc space; moreover, plain
radiographs of the spine will allow the treating surgeon to rule out other causes of
back pain (Chap. 11).
If disc pathology is suspected, magnetic resonance imaging is optimal (a) to
determine the morphological changes of the intervertebral disc and ligaments and
(b) to evaluate the soft tissue and neural constituents.
Although such degenerative changes are rare in children and adolescents, the
computed tomography (CT) can show moderate narrowing of the articular facet
space (axial bone window images) as well as subchondral sclerosis.
26.5 Differential Diagnosis
Disk disease is uncommon in the pediatric population. Therefore, other common
causes of back pain should usually be sought rst (Chap. 11).
26 Disc Bulging andHerniation inChildren andAdolescents
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26.6 Treatment Options
Accurate clinical examination and imaging are mandatory to identify the level of
disc bulging or disc herniation and to propose an adapted treatment option.
Treatment options are always conservative rst and usually include rest, physical
therapy to improve mobilization, exibility and strength, limitation of physical
activities (sports), and anti-inammatory medication. Physical therapy is of paramount importance since strengthening the paravertebral and abdominal musculature may improve spine posture and decrease pain. Bracing should be restricted to
severe symptomatology, and inltrations may be indicated if nerve root irritation
increases (rare). Bracing is also indicated to reduce pain before starting
physiotherapy.
However, pediatric patients respond less well than adults to conservative management and are more likely to require operative treatment. Because pediatric intervertebral disks are more elastic and have a higher water content than adults who
often have more dried-out or degenerative discs, surgical treatment can be more
difcult to perform; in addition, the pediatric disc does not dry up and resorb like a
degenerated adult disc might (Chaps. 42, 44, 45). As a result, open procedures (discectomy) are usually preferred to endoscopic techniques.
Surgery should only be indicated after failure of all conservative treatment
options. Indications for surgery are (1) severe pain refractory to more than 4–6weeks
of conservative treatment, (2) disabling pain affecting daily activities, (3) cauda
equina syndrome, (4) progressive neurological decits, and (5) presence of associated spinal deformities.
26.7 Expected Outcomes
Surgical treatment has a good short-term prognosis (resolution of radicular pain and
of neurological symptoms); children and teens often return to school and activities
quickly after surgery. Most patients report satisfaction and have few complications,
but in 12% to 28% of cases, repeated surgical treatment may be required later in life.
26.8 Potential Complications
A symptomatic and severely herniated disc can lead to permanent nerve damage
(rare in skeletally immature patients).
26.9 What Should Patient andFamily Know?
Although intervertebral disk herniation is common in adults, it is relatively uncommon in children. Studies have shown that between 13% and 57% of adolescents
with disc herniation have a rst-degree relative with the same disorder; herniation is
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F. Canavese
less frequent in patients younger than 10years of age but increases in the adolescent
population. Surgery has a satisfactory short-term prognosis, but up to 28% of
patients may require repeated surgical treatment later in life; moreover, degenerative changes are still possible in adulthood.
Further Readings
Dang L, Liu Z.A review of current treatment for lumbar disc herniation in children and adoles-
cents. Eur Spine J. 2010;19(2):205–14.
DeLuca PF, Mason DE, Weiand R, Howard R, Bassett GS.Excision of herniated nucleus pulposus
in children and adolescents. J Pediatr Orthop. 1994;14:318–22.
Poussa M, Schlenzka D, Maenpaa S, Merikanto J, Kinnunen P. Disc herniation in the lum-
bar spine during growth: long-term results of operative treatment in 18 patients. Eur Spine
J. 1997;6:390–2.
Schmorl’s Nodes
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27
FedericoCanavese
27.1 Definition
Schmorl’s nodes (SNs), or vertical intra-vertebral disc herniations, are protrusions
of the nucleus pulposus of the intervertebral disc through the vertebral body endplate into the adjacent vertebral body; inammation can develop if SNs contact the
bone marrow of vertebral body.
27.2 Natural History
SNs are quite common and most frequently asymptomatic. Post-mortem studies
have found SNs in around 75% of autopsies, at all ages, more frequently in males.
27.3 Physical Examination
SNs are one of the potential causes of back pain in young patients (Chap. 11)
although they often cause no symptoms (chronic SNs). Symptomatic patients complain of back pain and stiffness (acute SNs). There is a limited range of motion in
the lumbar and/or thoracolumbar area. Neurological exam should be performed
(Video 27.4).
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_27).
F. Canavese (*)
Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre
Hospital, Lille, France
Faculty of Medicine Henri Warembourg, Nord-de-France University, Lille, France
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_27
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a
Fig. 27.1 Schmorl’s node and disc degeneration (lumbar spine, L1-L2 space) (a: MRI T1,
b: MRI T2)
b
27.4 Imaging
The best imaging modality for diagnosing SNs is magnetic resonance imaging
(MRI) although plain lm radiographs of the spine (lateral view) can also detect
them. Radiographically, SNs appear as relatively small round-shaped, radio-lucent
lesions with/without sclerotic margin, involving the inferior and/or the superior
endplate of lower thoracic and lumbar vertebral bodies (Fig.27.1).
MRI best identies SNs on the sagittal sequences. SNs usually have the same
signal characteristics of the adjacent intervertebral disc, with a thin sclerotic margin.
Acute herniations usually show surrounding bone marrow edema and peripheral
enhancement.
SNs identied on computed tomography scan have the same characteristics
observed on plain radiographs.
27.5 Differential Diagnosis
In symptomatic patients, the other causes of back pain (Chap. 11) should be ruled
out, in particular infection and malignancy (different radiographic appearance).
27 Schmorl’s Nodes
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27.6 Treatment Options
Although most lesions are asymptomatic, some SNs can be symptomatic, causing
chronic back pain. Most symptoms related to SNs tend to resolve spontaneously or
respond to conservative treatment (non-steroidal anti-inammatory drugs, muscle
relaxants, and/or physiotherapy). In patients with chronic and disabling back pain
resistant to conservative treatment, fusion surgery with/without removal of the herniated disc is possible in order to alleviate the symptoms. Surgery is possible in
patients with Scheuermann’s disease (Chap. 22) with associated SNs (source
of pain).
27.7 Expected Outcomes
Most symptoms related to SNs resolve spontaneously, or following conservative
treatment (over a variable period of time, up to one year in some cases). In the very
few cases with debilitating pain, surgery can alleviate symptoms.
27.8 Potential Complications
SNs tend to occur more often in cases of Scheuermann’s disease (Chap. 22) with the
spine that has become more rigid and hypo-mobile. As a result, forces normally
distributed all over the nucleus pulposus are concentrated in a limited area causing
upper and/or lower endplates to deform in a concave manner.
27.9 What Should Patient andFamily Know?
There is a relatively strong heritability of SNs (>70%). Painful or symptomatic SNs
can lead to a signicant decrease in quality of life. Currently, there is no established
treatment modality.
Further Readings
Fahey V, Opeskin K, Silberstein M, Anderson R, Briggs C.The pathogenesis of Schmorl’s nodes in
relation to acute trauma. An autopsy study. Spine (Phila Pa 1976). 1998;23:2272–5.
Hasegawa K, Ogose A, Morita T, Hirata Y.Painful Schmorl’s node treated by lumbar interbody
fusion. Spinal Cord. 2004;42(2):124–8.
Takahashi K, Miyazaki T, Ohnari H, Takino T, Tomita K. Schmorl’s nodes and low-back pain.
Analysis of magnetic resonance imaging ndings in symptomatic and asymptomatic individu-
als. Eur Spine J. 1995;4:56–9.
Congenital Torticollis (Torticollis Not
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Related toTrauma)
FedericoCanavese
28.1 Definition
The congenital torticollis (C-TO), present from birth, is characterized by an inclination and rotation of the head in relation to the trunk, due to contracture or brosis of
the sternocleidomastoid (SCM) muscle.
Inclination occurs on the same side of the affected SCM muscle, and it is localized across the entire cervical spine while rotation of the face and chin is contralateral and it is largely localized at C1 and C2 levels.
According to the etiology and the reducibility, three types of C-TO can be identied: postural (pTO), muscular (mTO), or osseous (oTO).
28
28.2 Natural History
C-TO can lead to a malformation of the skull (plagiocephaly), and in untreated
cases, it can induce asymmetry of the face (facial scoliosis) characterized by a loss
of alignment between the eyes and the mouth (normally parallel). In older children,
C-TO is often accompanied by plagiocephaly, a difference in height of the ears and
shoulders, and facial scoliosis. The treatment done too late does not allow the correction of distorted craniofacial skeletal structures.
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_28).
F. Canavese (*)
Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre
Hospital, Lille, France
Faculty of Medicine Henri Warembourg, Nord-de-France University, Lille, France
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_28
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F. Canavese
28.3 Physical Examination
The clinical examination should look for a misalignment of the head and cervical
spine, and test the mobility of the cervical spine. The severity of the clinical picture
depends on the age of the child at the time of diagnosis; neurological examination
should be performed (Video 28.4).
As a rule of thumb, pTO is completely reducible (no muscle tightness or restriction to passive range of motion), mTO is incompletely reducible (tightness of the
sternocleidomastoid muscle and restricted passive range of motion), and oTO is
irreducible (osseous malformation; Chap. 29).
In case of mTO, the clinical examination should look for an induration or swelling on the lateral side of the sternocleidomastoid muscle, at the level of its distal
third (Fig.28.1). This swelling is rarely present at birth and appears between the
second and fourth weeks of life; it disappears a few months after birth and can be
replaced either by denitive brosis or by a complete recovery of the elasticity of
the muscle bers.
Fig. 28.1 Congenital
torticollis (untreated). Left
retraction of the
sternocleidomastoid
muscle; occiput rotates
towards the left, chin
towards the right
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