Spine Problems in Children

: pain and deformity

건국대학병원, 재활의학과

정희연

Spine Problems in children

3. Back Pain

Possible Combination

1 2 3

1+2 1+3 2+3

1+2+3

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

Spine Curvature

• Scoliosis

• Cervical Lordosis

• Thoracic Kyphosis

• 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.

• Cervical Kyphosis

– Developmental

– Acquired

• Cervical Lordosis

– Previous post fusion

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

• Finland Birth cohort 1987

Auvinen J et al. Spine 2007

Scoliosis

Congenital Scoliosis

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

Feldman DS et al, J Ped Ortho 2006

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

Physical activity

Physical Inactivity

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 Spinopelvic Balance

• Pelvic parameters

– Sacral Slope

– Pelvic Incidence

– Pelvic Tilt

• 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

Postural compensation due to backpack loads

Kistner F et al, Ped Phy Ther 2013

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

What will be the effective way for postural education to children??