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• RECENT STUDIES- >50% children experience some back pain by 15yrs of age
HISTORYNATURE OF PAIN• ACUTE- #S,LIGAMENTOUS SPRAIN, DISC HERNIATIONS,SLIPPED VERTEBRAL APOPHYSIS.
WITHIN 24HRS• SLOW-ONSET-TUMORS,SCHEUERMANN’S KYPHOSIS• MILD PAIN FOLLOWING ACTIVITY-MUSCLE STRAIN• RECURRENT PAIN
SPONDYLOLYSIS,SPONDYLOLISTHESIS,HERNIATED DISC
• PERSISTENT,NIGHT PAIN-TUMOURS, INFECTIONS
• LOCALISED PAIN- SPONDYLOLYSIS/NEOPLASMS
• GENERALISED,DIFFUSE PAIN- INFLAMMATORY PROCESSES
• PAIN RADIATING TO LOWER LIMB- VERTEBRAL APOPHYSIS #,EPIDURAL ABSCESS,HERNIATED LUMBAR DISC, INTRASPINAL TUMOUR
CONSTITUTIONAL SYMPTOMS
• MALIGNANCY-fever, chills, malaise, anorexia, weight loss
• DISCITIS- antecedent bacterial or viral infections
Neurological symptoms-numbness,weakness, gait abnormalities
AGGRAVATING AND ALLEVIATING FACTORS
-Sport activities-increase risk of spondylolysis, spondylolisthesis
-Pain –worse at night maybe due to malignancy-Back pain due to osteoid osteoma-relieved by
NSAIDs-Rest usually alleviates pain in most cases
AGE-RELATED CONDITIONS
<4yrs –infection,neoplasms<10yrs- discitis , vertebral osteomyelitis>10yrs-spondylolysis,spondylolisthesis, disc
herniation• Teenagers-Scheuermann’s kyphosis• Tumors such as osteoid osteoma and
aneurysmal bone cysts
PSYCHOSOMATIC PAIN
• Maybe seen in Preadolescents or adolescents• diagnosis by exclusion
ASSESSMENT OF GENERAL SYMPTOMS
• GENERAL INSPECTION Neurocutaneous markers assoc with
intraspinal defects-midline skin defects Can communicate with underlying deeper
structures- indicate spinal cord abnormality or dysraphism
ASSESSMENT OF THE SPINE
• POSTURE, ALIGNMENT• SCOLIOSIS• SPINAL FLEXIBILITY ASSESSED- stiffness,
listing,dysrhythmia indicates pathological cause• STRAIGHT LEG RAISING TEST-r/o herniated
discs, apophyseal #• Hyper extending the spine while child stands on
one leg- spondyolysis, spondylolosthesis
NEUROLOGIC ASSESSMENT
Spinal cord anomaly- clonus or abnormal Babinski sign or abnormal abdominal reflex
DIAGNOSTIC STUDIES• RADIOGRAPHY VERTICAL ALIGNMENT
DISC SPACE NARROWING VERTEBRAL SCALLOPING
LYTIC OR BLASTIC LESIONS
LATERAL VIEW- PARS INTERARTICULARIS DEFECT
• BONE SCAN sensitive in infections, stress #, benign and
malignant neoplasms
• COMPUTED TOMOGRAPHY bone tumours, and fractures to assess
spondylitic lesions in lumbar spine
• SINGLE-PHOTON EMISSION CT-localizing spinal lesions, diagnosing spondylosis,stress #
• MAGNETIC RESONANCE IMAGING- evalute spinal cord and neural elements
LABORATORY TESTS
• COMPLETE BLOOD COUNT• ESR• C-REACTIVE PROTEIN• URINALYSIS
MECHANICAL DISORDERS
• MUSCLE STRAIN- adolescent athelete, no radiation on pain, neurologic findings normal
Treatment-modification of activity, application of ice first then cold, NSAIDs
• APOPHYSEAL RING FRACTURE/SLIPPED VERTEBRAL APOPHYSIS-
-posteroinferior apophysis avulses from vertebral body,displaced into spinal cord-Presents with sudden onset back pain-Treatment-surgical removal of bony fragment
with attached cartilage and disc
DEVELOPMENT DISORDERS
• SPONDYLOLYSIS –defect in pars interarticularis, caused by repetitive microtrauma
• SPONDYLOLISTHESIS-pars defect b/l at same level,fwd slippage or subluxation of upper vertebral segment on the one below.
•Caused by repititive hyperextension•Mild to mod severity-radiates to lower limb•Postural defects,shuffling,stiff legged gait
• Xray-lytic lesions pars interarticularis Scotty dog sign
• MRI detects early spondylolysis
• Treatment-modify patients activities, If a/c # TLSO can relieve pain-Surgery is indicated for slips >50% translation
SCHEUERMANN’S KYPHOSIS
• Anterior wedging of 3consecutive vertebrae →kyphotic deformity
• Intravertebral herniation of disc material (Schmorl’s nodules) seen
• Localised pain, more on sitting and standing• O/E- thoracic kyphosis ,hamstring tightness• Xray-thoracic kyphosis >50degrees• Treatment-extension exercise,Milwaukee brace surgical intervention-spinal fusion
LUMBAR SCHEUERMANN’S DISEASE
• Similar to Scheuermann’s kyphosis• Involves thoracolumbar spine• Xray –end plate irregularities,disc space
changes,Schmorl’s nodules• Orthosis- decreases pain
IDIOPATHIC SCOLIOSIS
• Painful left thoracic curves – indicate pathology
SYRINGOMYELIACavitation of spinal cord. c/o headache,neckpain,cavus foot, abnl
gait,painful thoracic scoliosis
TETHERED SPINAL CORD• Low back pain, recent onset scoliosis, ↓motor function• Bladder dysfunction, Babinski’s sign• MRI• Treatment-cord release
IDIOPATHIC JUVENILE OSTEOPOROSISLong bone pain due tocompression #s,difficulty walking
VERTEBRAL OSTEOMYELITIS• Osteomyelitis a continuation of discitis• Two disorders converge- infectious spondylitis• More significant bony change
ANKYLOSING SPONDYLITISMales, AdolescenceLoss of spinal flexibility, abnl kyphosis,limited chest expansion during sleep
inspirationMRI-inflamed sacro-iliac joint
• EOSINOPHILIC GRANULOMASeen in 10-15%Xray -lytic lesionsD/D leukemia,infectious processes
• ANEURYSMAL BONE CYST15-20%Treated by-curettage, bone grafting
MALIGNANCIES
• A/C LYMPHOCYTIC LEUKEMIACommon malignancy producing back painX ray-osteopenia,vertebral body compression,
metaphyseal leukemic linesLab investigations- ↑WBC count, ↓platelet
count ,anemia, ↑ESR
• SPINAL TUMOURS-Ewings sarcoma, osteogenic sarcoma, chondroma
CT/MRI-staging tumour
• SPINAL METASTASES- neuroblastoma
• SPINAL CORD TUMORS- astrocytomas, ependymomas
INTRAABDOMINAL AND INTRATHORACIC CAUSES OF
BACK PAIN• Inflammatory bowel d/s, hydronephrosis, UTI,ovarian cysts• More constant pain,worse at night• Pneumonia-thoracic back pain
PSYCHOSOMATIC BACK PAIN(CONVERSION REACTION)
• Diagnosis is one of exclusion, • Made only after all other possibilities ruled
out• Detailed history to be take
THANK YOU