Spine Problems in Children - ksprm.or.kr · ... 2002, 1990, 1972 by Saunders, an imprint of...
Transcript of Spine Problems in Children - ksprm.or.kr · ... 2002, 1990, 1972 by Saunders, an imprint of...
Facts !!....?
• Back pain is more common in children than we’ve thought
• Be aware of red flag !
• Bad dynamic postural abnormality is related to pain
• Effect of back pack
• Effect of computer or smart phone use
Facts ??
• Risk factors to continue to have pain in adulthood
• Biomechanical measurement
• Effect of Physical activity level
• Role of Psychosocial aspect
• Related to growth spurt?
• Bad posture leads to spinal deformity??
Spine Curvature
• Longitudinal in coronal plane
• Double ‘S’ in sagittal plane
– Primary curve
• Thoracic kyphosis
– Secondary curve
• Cervical lordosis
• Lumbar lordosis
Spinal Deformity
• Points to be noted on physical exam
• Quantitative measurement
– Cobb angle
– Debrunner kyphometer
– Inclinometer
Deformity : Cervical spines
• Congenital Torticolis
• Klippel-Feil syndrome
• Acquired Torticolis
• Cervical Kyphosis
Cervical spines
• Acquired Torticolis
– Neurogenic
– Atlanto axial rotatory displacement
– Septic lesions
– Tumor
– Disc calcification
– Juvenile Rheumatoid Arthritis
– Sandifer’s syndrome
Herring, John Anthony, MD - Tachdjian's Pediatric Orthopaedics © 2008 Copyright © 2008, 2002, 1990, 1972 by Saunders, an imprint of Elsevier Inc.
Pseudo-subluxation
Pseudosubluxation of C2-3 (most common). Possible subluxation is eliminated because of the intact spinolaminar line at C2-3. Herring, John Anthony, MD - Tachdjian's Pediatric Orthopaedics
Neck & Shoulder pain
• 6mo prevalence , pain > 1mo :
– 57 % in girls , 34 % in boys
• 1 year prevalence of pain interfering with school work in 10-17 year of age :
– 23% in girls, 14 % in boys
• Higher in girls
• Prevalence increases with age
Hakala P, BMJ 2002 Siivola SM, Spine 2004 Kujala UM, Br J Sprts Med 1999 Vikat A, Scan J Pub Health 2000 Diepenmaat AC, Pediatrics 2006
• 436 school children, 12-16 years of age
• Questionnaire on musculoskeletal symptoms
• Questionnaire on time spent using a computer
Musculoskeletal symptoms and computer use among Finnish adolescents pain intensity and inconvenience to everyday life: a cross-sectional study -Hakala PT et al, BMC Musculoskeletal Dis 2012
Symptoms Computer use time/week
< 3.6 hours 3.6 - 13.99 hours ≥ 14 hours
n* OR**(95%Cl) n OR (95%Cl) n OR (95%Cl)
Neck or shoulder
Level of inconvenience to everyday life
Severe/moderate 27 1.0 40 1.3 (0.7-2.5) 31 1.1 (0.5-2.2)
Mild 29 1.0 50 1.3 (0.7-2.3) 39 1.1 (0.6-2.1)
Pain intensity
Severe/moderate 17 1.0 42 2.6 (1.3-5.3) 35 2.9 (1.4-6.1)
Mild 26 1.0 44 1.6 (0.9-2.9) 41 1.9 (1.0-3.6)
Low back
Level of inconvenience to everyday life
Severe/moderate 15 1.0 26 1.5 (0.7-3.2) 34 2.5 (1.2-5.5)
Mild 18 1.0 39 1.8 (0.9-3.5) 33 2.1 (1.0-4.3)
Pain intensity
Severe/moderate 9 1.0 19 1.6 (0.7-3.8) 32 3.5 (1.5-8.3)
Mild 14 1.0 37 2.4 (1.2-4.8) 34 3.1 (1.5-6.7)
• Student Musculoskeletal Health Questionnaire and Computer Usage Questionnaire.
• Complete data for 3,191 questionnaires was obtained from high school students
• High prevalence (68.3%) of musculoskeletal discomfort related to using computer was reported in the past 12 months.
• Shoulder (37.7%) and neck (35.0%) were the most frequently involved body parts
• Related to longer use of computer
Computer products usage and prevalence of computer related musculoskeletal discomfort among adolescents. Siu DC et al, Work 2009
Neuromuscular Scoliosis
• In various diseases
• Mechanisms
– Congenital deformity
– Spasticity
– Paralysis
– Loss of proprioception
Other causes - Scoliosis
• Neurofibromatosis : – dystrophic vs. non-dystrophic
• Marfan’s syndrome
• Congenital Heart disease
• Thoracotomy
• Laminectomy
• Irradiation
• Hysterical
Thoracic Kyphosis
• Congenital • Postural • Scheuermann kyphosis • Traumatic • Neuromuscular • Marfan’s syndrome • Metabolic • Skeletal dysplasia • Post-infectious • Acquired
– Post laminectomy – Irradiation
Hyper lordosis of lumbar spine
• Swayback
• Due to weak or tight hip muscles
• In Neuromuscular diseases
– Cerebral palsy,
– Myelo-meningocele,
– Muscular dystrophy,
– Spinal muscular atrophy,
– Arthrogryposis
Back Pain in child & adolescent
• Incidence
– Lifetime prevalence
• At 15 years old : 50%
• At 18 years old : 85%
– 1 year period : 20-25%
– 13% : recurrent pain disabling
Burton AK, Spine 1996 Jones GT, Arthritis & Rheu 2009, Pediatrics 2003
Back Pain in child & adolescent
• Mechanical
• Developmental
• Infectious
• Inflammatory
• Neoplasm
• Psychosomatic
• Red flags
– Age , Rest pain, Night pain, Constitutional sx, Longer duration, Neurological deficits
• Age related
– < 10 years of age : • infection or neoplasm
– > 10 years of age : • trauma or overuse
Evaluation
• X-rays – AP, Lat
– Oblique
• Laboratory – CBC, ESR, CRP, UA
– RF, ANA, HLA B27
• Bone Scan, SPECT
• CT
• MRI
Back Pain in child & adolescent
• Mechanical
• Developmental
• Infectious
• Inflammatory
• Neoplasm
• Psychosomatic
• Disc Herniation
– Neurologic sign is less frequent
• Apophyseal Ring Fractures
– Acute
– postero-inferior apophysis of vertebral body , most common at L4
Back Pain in child & adolescent
• Mechanical
• Developmental
• Infectious
• Inflammatory
• Neoplasm
• Psychosomatic
• Spondylolysis & Spondylolisthesis – Dysplastic or Isthmic defect of pars
interarticularis
– Hyper-extension load
– Stork test
– X-rays of oblique view : Scotty dog sign
– SPECT : activity of lysis
• Scheuermann’s kyphosis – Anterior wedging of 3 consecutive
vertebrae
– Vertebral end-plate and intravertebral herniation (Schmorl’s nodules)
Back Pain in child & adolescent
• Mechanical
• Developmental
• Infectious
• Inflammatory
• Neoplasm
• Psychosomatic
• Diskitis
• Osteomyelitis
• Ankylosing Spondylitis
• Juvenile Rheumatoid Arthritis
Back Pain in child & adolescent
• Mechanical
• Developmental
• Infectious
• Inflammatory
• Neoplasm
• Psychosomatic
• Osteoid Osteoma
• Osteoblastoma
• Acute Lymphocytic Leukemia
• Ewing’s sarcoma
• Osteogenic sarcoma
• Metastatic tumor
• Spinal Cord tumor
Mechanical Back Pain
• Increased prevalence
• Recurrent pain in 1/3
• Lead to adulthood back pain
• Many risk factors still have inconclusive association
• Risk factors
– Anthropometry • Height
• Growth rate
• BMI
– Lifestyle factors • Physical activity
• Sedentary activity
• Mechanical load
– Psychological factors
– Social environment
Jones GT, Macfalane GJ Arch Dis Child 2005
Risk for Recurrent LBP
• Measurement
– Anthropometric measures
– Sexual Maturity
– Flexibility/ Spinal Mobility
– Abdominal muscle endurance
Br J Sports Med 2005
Prognostic indicators
• 4-year prospective cohort study
• 11-14 year old students:
– + LBP in the past 1mo & lasted for 1 day or longer
• Measurement
– information on LBP, other symptoms, lifestyle, height, weight, BMI, spine flexibility
– Outcome : persistent LBP
Arthritis & Rheum 2009
Prognostic indicators
– 25% still has LBP 4 years later
– 5 independent predictors
peer relationship problems
smaller stature
widespread body pain
long duration of LBP
radiating leg pain
Arthritis & Rheum 2009
Physical Activity
• Mixed results
– A few studies showed • Physical Inactivity associated
positively with back pain
• Physical Activity : negatively
– No association in other studies
– Sport activity • Average enjoyment : less
back pain
Physical Activity
• Measure combine the level of activity & inactivity
• Interview date of back pain
• Questionnaire data on physical activity
• Physical activity data through the use of a accelerometer
Wedderkopp N et al, Spine 2003
Posture !!
• Slouch sitting posture
• Back pack
• Lap top computer
• Hand held device
– Smart phone
– Video game
Sagittal Balance
• C7-sacral promontory line on lateral film • Imbalance:
• Strays away from the posterior superior corner of the S1 vertebral body > 2cm
• Positive vs. Negative
• Positive sagittal balance
– Pain is common – Loss of lumbar lordosis
• Most correlates with post-operative outcome of pain,
function and self image (Schwab FJ, Spine 2008, Glassman SD, Spine 2005)
C7
S1
• Sagittal Spino-Pelvic alignment
– Slight tendency for thoracic kyphosis and lumbar lordosis to increase with age
– Pelvic incidence and pelvic tilt to increase
– Sacral slope remain stable
• Global Sagittal Balance
– Linear parameters
– Angular parameters
• C7 plumb line tends to move backwards as getting older
• Global Alignment Parameters
– Pelvic Displacement angle
– Truk Lean angle
– Body Lean angle
– Craniovertebral Angle
• Spinopelvic Sagitttal Alignment Parameters
• Thoracic Kyphosis
• Lumbar Lordosis
• Pelvic Tilt
• Sacral Inclination
• Pelvic Height
Dolphens et al. Spine 2012
Low Back Pain
• Decreased Sacral Slope
• Increased Pelvic Tilt
• Decreased Lumbar Lordosis
creates compressive force contributing to disc degeneration
Due to structural 2nd to disc degeneration
Postural to decrease pain
Chaleat-Valayer & Mac-Thiong et al. Eur Spine J 2011 Jackson R, Spine 1994 Barrey C, Spine 2007 Rajinics P, Int Orthop2002
Backpack load to lumbar spine
• Standing MRI with 4, 8, 12 kg backpack load with 2 straps
• Lumbar disc height compression
• Lumbar lordosis
• Lumbar asymmetry
Postural Education
• Sitting posture
• Frequent posture change or rotatory movement
• Stooping correctly
• Arrange objects in a back pack appropriately
– Avoid a backpack heavier than 15% of body weight
• Use 2 straps for a backpack