DISORDERS OF THE SPINE

Question 1

What is back pain in infants and pre-adolescent children usually indicative of?

Answer 1

Connective tissue disorder

Scoliosis

Torticollis (if in the neck)

Question 2

What is the main cause of back muscle spasm or soft tissue pain in an adolescent?

Answer 2

Sports injury

Question 3

What are the differentials for back pain in an adolescent?

Answer 3

Sports injury

Scheuermann’s disease

Spondylolysis

Spondylolisthesis

Vertebral osteomyelitis or discitis

Tumours

Scoliosis

Spina bifida

Idiopathic

Question 4

What is the aetiology of Scheuermann’s disease?

Answer 4

Considered part of osteochondrosis family. This means that it is characterised by avascular necrosis to the epiphysis and later regrowth of the bone.

Question 5

What are the clinical features of Scheuermann’s disease?

Answer 5

Marked lower kyphosis in thoracic spine (at least 3 vertebrae must be involved)

Pain

Stiffness

Question 6

What will x-ray of someone with Scheuermann’s disease show?

Answer 6

Epiphyseal plate disturbance

Anterior wedging

Question 7

How do we treat Scheuermann’s disease?

Answer 7

Mild cases: Physio and analgesia

More severe cases: Bracing and surgical stabilisation

Question 8

What is the aetiology of spondylolysis?

Answer 8

Congenital or acquired deficiency (defect or stress fracture) of the pars interarticularis of the neural arch of of a particular vertebral body.

Question 9

What are the vertebrae most commonly affected by spondylolysis?

Answer 9

L4/L5

Almost always lumbar

Question 10

What proportion of the population are affected by a degree of spondylolysis?

Answer 10

Up to 5%, most cases are asymptomatic and therefore do not require treatment

Question 11

What is the main risk factor for acquired spondylolysis in adolescents?

Answer 11

Over-training causing a stress fracture eg during a landing in ice dance

Question 12

What are the clinical features of spondylolysis?

Answer 12

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

Question 13

What is the stork test?

Answer 13

Patient stands on one foot and then lumbar spine is extended and rotated by examiner arching them backwards

Question 14

What imaging should be done for someone with signs and symptoms consistent with spondylolysis?

Answer 14

X-ray

CT or MRI

Bone scintigraphy

Question 15

What is the gold standard in terms of imaging and diagnosing spondylolysis?

Answer 15

Bone scintigraphy

Question 16

How do we manage symptomatic spondylolysis?

Answer 16

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

Question 17

What is the aetiology of spondylolisthesis?

Answer 17

Displacement (normally anteriorly) of one vertebra relative to its immediately inferior vertebral body

Question 18

What is the most common cause of spondylolisthesis in adolescents?

Answer 18

Spondylolysis

Question 19

Is spondylolisthesis the same as a slipped disc?

Answer 19

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.

Question 20

Where is the spine is spondylolisthesis most commonly found?

Answer 20

Lumbar spine

Question 21

What are the clinical features of spondylolisthesis?

Answer 21

Generalised lower back pain - intensified on sneezing or coughing

Stiffening of the back

Leaning forwards (kyphotic) posture - compensatory change

Waddling gait

Question 22

What is the radiological sign associated with traumatic spondylolisthesis?

Answer 22

Scotty dog appearance

Question 23

How do we manage someone with spondylolisthesis?

Answer 23

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)

Question 24

What is vertebral osteomyelitis?

Answer 24

Infection of the vertebral body

Question 25

What are the clinical features of vertebral osteomyelitis or discitis?

Answer 25

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

Question 26

What are the organisms that most commonly cause vertebral osteomyelitis?

Answer 26

Staph aureus - can be MRSA

Streptococcus equisimilis

Question 27

In addition to imaging, what investigation might you do for someone in whom you suspect vertebral osteomyelitis?

Answer 27

Fine needle aspiration

Question 28

How do we manage vertebral osteomyelitis?

Answer 28

IV antibiotics for weeks to months

If severe or unresponsive to antibiotics surgery may be indicated for debridement and spinal fusion

Question 29

What is scoliosis?

Answer 29

Lateral curvature of the spine associated with rotational deformity.

Question 30

What percentage of children are affected by scoliosis?

Answer 30

4%

Question 31

What are the causes of scoliosis in children?

Answer 31

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

Question 32

Is scoliosis more common in boys or girls?

Answer 32

Girls

Question 33

What are the clinical features of idiopathic scoliosis?

Answer 33

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

Question 34

What are the possible complications of scoliosis?

Answer 34

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

Question 35

How do we manage scoliosis?

Answer 35

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

Question 36

What is the more common name for acute torticollis?

Answer 36

Wry neck

Question 37

What is wry neck or acute torticollis often associated with in children?

Answer 37

Upper respiratory tract infection

Question 38

What is the most common cause of torticollis in children?

Answer 38

Sternomastoid tumour found in the first few weeks of life

Question 39

How do we treat torticollis?

Answer 39

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.