DISORDERS OF THE SPINE Flashcards
What is back pain in infants and pre-adolescent children usually indicative of?
Connective tissue disorder
Scoliosis
Torticollis (if in the neck)
What is the main cause of back muscle spasm or soft tissue pain in an adolescent?
Sports injury
What are the differentials for back pain in an adolescent?
Sports injury
Scheuermann’s disease
Spondylolysis
Spondylolisthesis
Vertebral osteomyelitis or discitis
Tumours
Scoliosis
Spina bifida
Idiopathic
What is the aetiology of Scheuermann’s disease?
Considered part of osteochondrosis family. This means that it is characterised by avascular necrosis to the epiphysis and later regrowth of the bone.
What are the clinical features of Scheuermann’s disease?
Marked lower kyphosis in thoracic spine (at least 3 vertebrae must be involved)
Pain
Stiffness
What will x-ray of someone with Scheuermann’s disease show?
Epiphyseal plate disturbance
Anterior wedging
How do we treat Scheuermann’s disease?
Mild cases: Physio and analgesia
More severe cases: Bracing and surgical stabilisation
What is the aetiology of spondylolysis?
Congenital or acquired deficiency (defect or stress fracture) of the pars interarticularis of the neural arch of of a particular vertebral body.
What are the vertebrae most commonly affected by spondylolysis?
L4/L5
Almost always lumbar
What proportion of the population are affected by a degree of spondylolysis?
Up to 5%, most cases are asymptomatic and therefore do not require treatment
What is the main risk factor for acquired spondylolysis in adolescents?
Over-training causing a stress fracture eg during a landing in ice dance
What are the clinical features of spondylolysis?
Unilateral back pain
Pain may radiate to buttocks or legs
Restricts daily activities
Worsens with strenuous activity and lumbar hyperextension
Pain on completion of stork test - see next slide
Unilateral tenderness on palpation
What is the stork test?
Patient stands on one foot and then lumbar spine is extended and rotated by examiner arching them backwards
What imaging should be done for someone with signs and symptoms consistent with spondylolysis?
X-ray
CT or MRI
Bone scintigraphy
What is the gold standard in terms of imaging and diagnosing spondylolysis?
Bone scintigraphy
How do we manage symptomatic spondylolysis?
Activity restriction
Abdominal exercise to increase core strength and stabilise spine
Bracing - Boston brace - most common treatment of acute spondylolysis
Surgery - used especially if condition progresses to high grade spondylolisthesis
What is the aetiology of spondylolisthesis?
Displacement (normally anteriorly) of one vertebra relative to its immediately inferior vertebral body
What is the most common cause of spondylolisthesis in adolescents?
Spondylolysis
Is spondylolisthesis the same as a slipped disc?
No. A slipped disc is more correctly termed a spinal disc herniation and refers to when one of the discs in between the vertebrae has ruptured. This is not the case in spondylolisthesis where the vertebrae itself has moved.
Where is the spine is spondylolisthesis most commonly found?
Lumbar spine
What are the clinical features of spondylolisthesis?
Generalised lower back pain - intensified on sneezing or coughing
Stiffening of the back
Leaning forwards (kyphotic) posture - compensatory change
Waddling gait
What is the radiological sign associated with traumatic spondylolisthesis?
Scotty dog appearance
How do we manage someone with spondylolisthesis?
Mild: Physio and analgesia
More severe: surgery (spondylolisthesis with spinal stenosis is one of the most common indications for spine surgery (laminectomy) among older adults)
What is vertebral osteomyelitis?
Infection of the vertebral body
What are the clinical features of vertebral osteomyelitis or discitis?
Severe pain on weight bearing and walking
Local tenderness
Known for subtleness in onset
Fever
Swelling at joint
More advanced disease will present with muscle spasm
What are the organisms that most commonly cause vertebral osteomyelitis?
Staph aureus - can be MRSA
Streptococcus equisimilis
In addition to imaging, what investigation might you do for someone in whom you suspect vertebral osteomyelitis?
Fine needle aspiration
How do we manage vertebral osteomyelitis?
IV antibiotics for weeks to months
If severe or unresponsive to antibiotics surgery may be indicated for debridement and spinal fusion
What is scoliosis?
Lateral curvature of the spine associated with rotational deformity.
What percentage of children are affected by scoliosis?
4%
What are the causes of scoliosis in children?
About 65% are idiopathic - adolescent idiopathic scoliosis (AIS)
Vertebral abnormalities:
Hemivertebra
Osteogenesis imperfecta
Spina bifida
Neuromuscular disorders:
Polio
Cerebral palsy
Muscular dystrophy
Other:
Dysmorphic syndromes such as neurofibromatosis, Marfan syndrome, Prader-Willi syndrome and CHARGE syndrome
Is scoliosis more common in boys or girls?
Girls
What are the clinical features of idiopathic scoliosis?
Pain - not always a typical feature in childhood
Lateral curvature of the spine on inspection
Rotation of thoracic spine on flexion
Rib hump (prominent shoulder blade) on bending forwards
What are the possible complications of scoliosis?
Diminished lung capacity
Pressure exerted on heart
Constipation due to tightened organs from curvature
Untreated severe disease will result in later degenerative changes, pain and unwanted cosmetic appearance
How do we manage scoliosis?
Mild cases: not treated
Moderate: braced for 23 hours a day until growing has stopped
Severe (more than 40˚): requires surgery that fuses the spine and therefore termination further growth
What is the more common name for acute torticollis?
Wry neck
What is wry neck or acute torticollis often associated with in children?
Upper respiratory tract infection
What is the most common cause of torticollis in children?
Sternomastoid tumour found in the first few weeks of life
How do we treat torticollis?
The disease is self limiting and should be managed with analgesia.
If the cause is a sternomastoid tumour, physio and stretching should be encouraged. It will usually resolve within the 1st year of life.
Surgery is reserved for persistent cases.
