Spine and trunk Flashcards
Epidemiology of causes of back pain
(9 marks)
- LBP is common in children
- School bags have been linked
- Females
- 12 most common
- Sedentary lifestyle
- Sports injuries
- Soft tissue injuries
- obesity and poor posture
- competitive sports
Prevention of back pain in children
(5 marks)
- reduce falls risks
- spread tanbark on play area to cushion falls
- encourage regular walking / exercise
- limit TV/computer time
- teach good posture, including in a chair
LBP is more common with
(3 marks)
- High levels of psychosocial disorders
- Conduct problems
- Other somatic disorders
Causes of Acute Back Pain (3 marks)
- Herniated discs
- Fractures
- Muscle sprains
Causes of chronic back pain (3 marks)
- Developmental problems (i.e Scheuermann’s)
- Inflammatory spondyloarthropathies
- Psychological problems
Similar presentation to Herniated Disc
Slipped apophysis;
- pain radiating down legs
Physical examination essentials for child presenting with back pain
- Exclude underlying pathology
- Charting growth and neuro- development screening
- Posture, alignment and skin conditions
When should underlying disease be suspected in a child presenting with back pain?
(6 marks)
- localized tenderness
- exaggerated stiffness or any particular spinal regions
- pronounced thoracic kyphosis
- midline skin defects
- excessive hamstring tightness
- neurological abnormalities
Your patient with intermittent or recent onset of back pain has a normal physical examination, with non-specific pain. You prescribe home-based exercises or nonsteroidal anti-inflammatory drugs and reassess in 3 months.
The patient returns after the 3 months, and there is a negative improvement. What is your next step?
- Radiography AP and Lat views and possibly blood tests.
- MRI if suspected herniated disc
- CT if spondylosis is suspected
Ossification of the spine
- Begins in late fetal period and continues after birth
- Primary centre = SP TP and articular processes
- Secondary centres = vertebral body, SP, TP and ribs
Growth of the spine is not uniformly linear. When are the growth periods of the spine.
0-3 = Rapid growth
3-onset of puberty = linear growth
Adolescent growth spurts = Rapid growth
What is Scoliosis?
A 3D deformitity involving
- Rotation of verterbral body
- SP’s disappear
- Loss of spinal curves
- lateral flexion of trunk
Scoliosis is classified by?
- Age
- Cause (Idiopathic, congenital, neuromuscular)
- Type (Non-structural, structural)
Idiopathic Scoliosis in infantle, juvenile and adolescents
Infantile= Under 3 - resolves usually
Juvenile = 3-10 (high progression)
Adolescent = at puberty approx 10 - usually females
How is scoliosis named?
- side of convexity
- location
- secondary or compensatory curves
Non-structural VS Structural Scoliosis
Non-Structural
- fully corrects
- no vertebral rotation
- Non progressive usually
- LLD
Structural
- cannot be corrected
- vertebral body rotation toward convexity
- prominent ribs or para-spinal hump
Orthopaedic clinical examnination of scoliosis
- X-Ray
- Lateral & AP
- Magnitude, location & skeletal age
- Cobb Angle (magnitude)
- Measure spinal curvature, min of 10 degrees to be considered a scoliosis
- Risser’s Sign
- Determines skeletal maturity by quantifying the amount of ossification at the iliac crest
- Grades 0-5
Progression of scoliosis is defined as
Increase of 5 degrees or more on two consecutive examinations occuring at 4-6 monthly intervals
An increase risk of progression in structural curves occurs if?
- Young at diagnosis (low skeletal maturity)
- Double curves
- Large cobb angle
- female
Management considerations for scoliosis
- skeletal maturity
- growth potential
- Cobb angle magnitude over 40
- Coexisting conditions
- CP status
- psychological factors
- risks vs benefits
Measurement of scoliosis
- Adam’s test with scoliometer: an angle over 7 degrees needs referral as cobb angle is likely over 10 degrees
- Leg length
- muscle length
- balance
When to refer after you’ve confirmed scoliosis
All types and all degrees above 10
Management of non-structural
- Correct any LLD or underlying issues
- promote general fitness
- stretching and strength activity with impairments
- monitor growth of child for any progress of curves
- usually will disappear when underlying issue is treated
Structural management options
- under 25 degrees monitored
- 24-40 conservative Rx
- Over 40 surgery candidate
Neuromuscular Scoliosis develops early and is often rapidly progressive curves due to:
- Asymmetrical distribution of spasticity
- Asymmetrical paraplegia
- Asymmetrical movement patterns
- Lack of voluntary muscle control
- Asymmetrical muscle strength
Types of Neuromuscular Scoliosis
- Neuropathic (CP i.e. UMN lesion)
-
Spinal muscular dystrophy (LMN lesion) & Myopathic (Duchenne muscular
dystrophy)
Treatment of Neuromuscular Scoliosis
Non-surgical:
- observation, radiographs, orthotics, seating.
Surgical:
- fusion to sacrum is common
- greater blood loss / increased time in sx
- A and P fusion
- Anterior release for long and stiff curves
Congential Scoliosis
Anomalous vertebral development e.g hemivertebrae, spina bifida, syndromes
- Anterolateral deformity =
- Posterolateral deformity =
- Anterolateral deformity = kyphoscoliosis
- Posterolateral deformity = lordoscoliosis
Natural hx of congential scoliosis
Progression, deformority, pain and neurological deficit
Scheuermann’s Disease
A growth disorder of the spine, that involves narrowing IVD’s, wedged vertebra formation, collapse of endplates and resulting Kyphosis of the affected area.
It can occur in the thoracic, thoracolumber or lumbar level.
Diagnositc criteria of Scheuermann’s
- A thoracic kyphosis of >45°
- Thoracolumbar kyphosis of >30°
- Wedging > 5°of three adjacent vertebrae
Scheuermann’s Disease Aetiology
(5 marks)
- Mechanical
- Endogenous
- Psychological
- Posture
- Osteoporosis
Scheuermann’s Disease
Clinical features -
( 3 marks)
- Fixed kyphosis, where it cannot be corrected with movement (not flexible)
-
One Striking feature is:
Increased finger-floor distance measurement caused by contraction of the hamstrings. - Contracture of the pec muscles is always present in the thoracic form
Scheuermann’s Disease
Prognosis and Treatment
Prognosis
- Fixed thoracic <50 not an issue for adulthood
- Over 50, pain is more frequent, lung function can be compromised.
- More than 70 can be progressive into adulthood
Treatment
- Bracing (over 50)
- Surgery (over 70)
mainly for cosmetic reasons
Associated diseases of scheruermann’s disease
Scoliosis (occurs in over half)
Spondylosis - (increase incidence in thoracic)
Spondylolysis and Spondylolisthesis
- Spondylolysis is a fracture in one or more bones that make up the vertebrae
- Spondylolisthesis is a spinal condition in which all or part of a vertebra has slipped on another, with the majority involving the par’s interarticularis
Aeitiology of Congenital Malformations of the spine
Most are acquired during pregnancy
- hereditory forms usually associated with multiple anomalies
- majority the cause is assumed to be a toxic damage during pregnancy
- folate deficiency appears to play a role in the development of myelomeningocele
List 3 deformities associated with Congenital Malformations of the spine
- Fusion of the ribs
- Spinal dysraphism
- clubfoot
When describing congenital abnormalities, it is important to identify
- the type of malformation,
- the resulting deformity and
- the specific region of the spine where the malformation occurs
Malformations of the spine can be classified as:
- neural tube defects,
- defects of segmentation and
- defects of formation
Define Neural tube defects
- A condition in which the neural tube fails to completely close during the 4th week of embryonic development.
- Structures overlying these midline abnormalities are severely affected
and may be unable to form.
Failures of formation arise as a result of an absence of which structural elements of a vertebra?
Any region of the vertebral ring may be affected: anterior, anterolateral, posterior, posterolateral and lateral.
Why does the absence of structural elements occur?
Two or more vertebrae fail to fully separate and divide with concomitant partial or complete loss of a growth plate
The type of deformity depends on the area of the vertebral ring affected, which will alter normal growth patterns. Typical observable defects are?
hemivertebrae
wedge vertebrae
Hemivertebrae
bony remnants that did not complete normal development and can be fully segmented, semisegmented or nonsegmented
Difference between segmented and nonsegmented vertebrae
- Segmented hemivertebrae still have growth plates both cranially and caudally.
- A nonsegmented vertebra has not separated from either the cranial or caudal vertebra.
Classification: Segmentation defects
- ventral bar
- dorsal bar
- lateral bar (unilateral unsegemented)
- block vertebrae
These defects are classified depending on the region and quantity of vertebrae
affected. Briefly describe this classification between a block and unilateral bars.
- An entire vertebrae will create a block whereas defects of specific regions of the ring create unilateral bars that act as asymmetric rigid tether to normal growth.
- It is also possible to have a bilateral failure of segmentation and unilateral
unsegmented bars with a contralateral hemivertebra
What type of Combination defects is especially common and has a poor prognosis?
An anterolateral unsegmented bar combined with a hemivertebra on
the opposite side
Diagnosis of segmentation defects
- Primarily diagnosed during infancy,
- Chance diagnosis is based on a chest or an outwardly visible deformity
Why does the cervical spine need to be x-rayed with a thoracic or lumbar anomaly?
An x-ray of the cervical spine should always since associated malformations frequently occur in this area
The most common neural tube defect
Spina bifida
The type of Spina bifida is determined by the pattern of involvement of…?
- vertebral arch,
- spinal cord,
- meninges and
- overlying dermis.
The spinal cord defect may present at any vertebral level with the most common being the…
Lumbosacral region, which is associated with the final component of closure of the tube
Other signs of abnormalities with spinal bifida
- muscular balance,
- changes in bladder and bowel habits
- sensory loss in the lower extremities
- possibly paraplegia.
Classification of Spina bifida
- Spina bifida oculta
- Spina bifida cystica
- SB with meningocele
- SB with meningomyelocele
- myeloschisis
Spina bifida oculta
- Involves posterior elements but not the spinal cord or meninges.
- Presents with a skin indentation and a patch of hair growing in the area of the lesion
- usually asymptomatic
Spina bifida cystica
- Severe defect, which may involve the meninges as well as the spinal
cord. - several named subclasses of this defect exist.
meningocele vs meningomyelocele.
subclasses of SB cystica
Meningocele = when the cyst involves the meninges and cerebrospinal fluid
Meningomyelocele = When the cyst also contains the spinal cord.
Patients developing spina bifida with meningocele have what external manifestations?
hair growth in the area of the lesion, lipomas, cysts or hemangiomas.
Spina bifida with meningomyelocele
is more common than spina bifida with meningocele, and is considered a more severe neural tube defect because?
- the involvement of the spinal cord and meninges.
- They typically exhibit neurological symptoms such as limb paralysis, as well as bladder and bowel incontience.
- May be at risk of paralysis (flaccid, spastic or mixed) if it involves the nerve roots or entire cord.
What is considered the most severe type of spina bifida? Describe it’s characteristics
Spina Bifida Myeloschisis
- neural tube not closing properly with the
developed spinal cord being exposed to the external environment.
- Small patches of hair grow around the defect.
- not only increases risk of developing neurological symptoms and attaining paralysis, but severe infection as well.
Common aeitiology of spinal injuries in children and adolescents
Children= Traffic accidents and falls of great heights
Adolescents= sport accidents
Spinal injuries are commonly associated with neurological lesions in children, but children tend to improve more significantly than adults following correct diagnosis and prompt referral. With permanent neurological lesions, it is more likely that scoliosis will develop. What would the appropriate management strategy be for this case?
braced to avoid scoliosis developing
