Pediatric Annals

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Low Back Pain in Adolescents

Paul G Dyment, MD

Abstract

Low back pain (LBP) is a well-known cause of countless office visits to doctors; more than 80% of adults have had at least one episode of "lumbar strain" or "acute LBP," and many have had recurrent episodes beginning in late adolescence. The condition is a serious socioeconomic one, ranking as the most common cause of disability in patients under the age of 45, and is second only to respiratory infections as a cause of work time lost in American industry. This article describes one approach to adolescent patients with this symptom and discusses three of the common causes - lumbar strain (acute LBP), spondylolysis, and spondylolisthesis.

Backache is so rare in the prepubertal and early pubertal patient that such patients should undergo a complete work-up for a serious cause. LBP is a frequent complaint of young adults working in construction or other jobs requiring heavy lifting and of adolescent athletes. As the adult ages, degenerative changes occur in the intervertebral disc that decreases its ability to maintain the normally high intradiscal pressure necessary to buffer vertical forces on the spine. It is becoming increasingly accepted that this "natural" aging process can be associated with LBP even without evidence of actual disc protrusion. This may explain many, if not most, "mechanical" backaches in adults.

Adolescents with acute back pain are almost evenly divided between those who can relate the onset of the pain to an episode of heavy lifting or twisting of the body and those who say it just began insidiously without a history of a precipitating event. In both instances, if more specific causes cannot be elicited by a careful medical history and a complete physical examination, then it is assumed that the pain is due either to acute paraspinal muscle strain or to a chronic strain secondary to repetitive microtrauma. The term "acute low back pain" is then used, which is synonymous with "lumbar strain" and "mechanical backache." In this article, LBP when used as a diagnosis rather than as the description of a symptom will be used for all such back pain for which there is no obvious explanation, calling it acute if the duration is less than 3 weeks and chronic if longer. A practical differential diagnosis list of conditions, which either occur commonly or could be serious if the diagnosis is missed, is presented in Table 1.

LOW BACK PAIN

Whether the adolescent patient says that the LBP began acutely while lifting something or began without any precipitating events, it is generally made worse with any activity involving motion of the spine. Low back pain frequently has a history of previous occurrences that lasted from a few days to a few weeks, most of which were not cared for by a physician.

When taking a history from patients with backache, the following points should be included:

1. Severity of the pain (discitis usually produces an excruciating pain, whereas a lumbar strain produces more of a dull ache).

2. Family history of rheumatoid spondylitis.

3. Whether the pain follows the sciatic nerve distribution (typical of a posterolateral nucleus pulposus protrusion).

4. Loss of some bowel or bladder function, or history of sexual dysfunction (indicating a possible intraspinal tumor or posterior protruding nucleus pulposus).

5. What makes the pain worse (eg, movement) and what relieves the pain (eg, bed rest), treatments attempted, and doctors previously seen.

6. Athletic activity (eg, gymnastics).

7. Work history (eg, lifting).

Physical Examination

The patient should be observed getting undressed to look for an abnormal gait and evidence of pain. The patient should then be observed from the side to determine if…

Low back pain (LBP) is a well-known cause of countless office visits to doctors; more than 80% of adults have had at least one episode of "lumbar strain" or "acute LBP," and many have had recurrent episodes beginning in late adolescence. The condition is a serious socioeconomic one, ranking as the most common cause of disability in patients under the age of 45, and is second only to respiratory infections as a cause of work time lost in American industry. This article describes one approach to adolescent patients with this symptom and discusses three of the common causes - lumbar strain (acute LBP), spondylolysis, and spondylolisthesis.

Backache is so rare in the prepubertal and early pubertal patient that such patients should undergo a complete work-up for a serious cause. LBP is a frequent complaint of young adults working in construction or other jobs requiring heavy lifting and of adolescent athletes. As the adult ages, degenerative changes occur in the intervertebral disc that decreases its ability to maintain the normally high intradiscal pressure necessary to buffer vertical forces on the spine. It is becoming increasingly accepted that this "natural" aging process can be associated with LBP even without evidence of actual disc protrusion. This may explain many, if not most, "mechanical" backaches in adults.

Adolescents with acute back pain are almost evenly divided between those who can relate the onset of the pain to an episode of heavy lifting or twisting of the body and those who say it just began insidiously without a history of a precipitating event. In both instances, if more specific causes cannot be elicited by a careful medical history and a complete physical examination, then it is assumed that the pain is due either to acute paraspinal muscle strain or to a chronic strain secondary to repetitive microtrauma. The term "acute low back pain" is then used, which is synonymous with "lumbar strain" and "mechanical backache." In this article, LBP when used as a diagnosis rather than as the description of a symptom will be used for all such back pain for which there is no obvious explanation, calling it acute if the duration is less than 3 weeks and chronic if longer. A practical differential diagnosis list of conditions, which either occur commonly or could be serious if the diagnosis is missed, is presented in Table 1.

LOW BACK PAIN

Whether the adolescent patient says that the LBP began acutely while lifting something or began without any precipitating events, it is generally made worse with any activity involving motion of the spine. Low back pain frequently has a history of previous occurrences that lasted from a few days to a few weeks, most of which were not cared for by a physician.

When taking a history from patients with backache, the following points should be included:

1. Severity of the pain (discitis usually produces an excruciating pain, whereas a lumbar strain produces more of a dull ache).

2. Family history of rheumatoid spondylitis.

3. Whether the pain follows the sciatic nerve distribution (typical of a posterolateral nucleus pulposus protrusion).

4. Loss of some bowel or bladder function, or history of sexual dysfunction (indicating a possible intraspinal tumor or posterior protruding nucleus pulposus).

5. What makes the pain worse (eg, movement) and what relieves the pain (eg, bed rest), treatments attempted, and doctors previously seen.

6. Athletic activity (eg, gymnastics).

7. Work history (eg, lifting).

Physical Examination

The patient should be observed getting undressed to look for an abnormal gait and evidence of pain. The patient should then be observed from the side to determine if excessive lordosis, a cause of chronic LBP, is present, and from behind with the examiners hands placed on each of the brims of the pelvis to determine if they are level - an obliquity generally indicates a discrepancy in leg length, which could produce a "mechanical backache." The patient should be asked to bend forward "as if to touch your toes but without bending the knees" to see if this worsens the pain. Even if mild scoHosis is detected, it only rarely causes back pain. The patient should then bend sideways in each direction; this movement is frequently limited by protective muscle spasm.

The exact site of the pain must be pointed to by the patient; if the costovertebral angle is pointed to rather than the spinal column, pyelonephritis should be suspected. The physical examination may demonstrate straightening of the normal lumbar lordosis secondary to muscle spasm, as well as tenderness over the paraspinal soft tissues or the sacroiliac joints.

Table

TABLE 1Practical Differential Diagnosis of Low Back Pain in Adolescents

TABLE 1

Practical Differential Diagnosis of Low Back Pain in Adolescents

As part of the complete physical examination, the LBP patient should undergo a complete neurological examination "from the waist down." Table 2 lists the tests that should be performed on all such patients. When testing the sensory dermatomes, the author uses a wooden tongue blade that has been twisted into two pieces with one end of the splinter being sharp and the other blunt. The patient then states whether the sensation is sharp or dull. Figure 1 shows the dermatomes of the lower extremity.

If the patient has either a chronic backache that has not undergone the usual resolution after a few weeks or if the pain is a frequently recurring problem, then:

* a rectal examination should be performed looking for decreased sphincter- tone suggesting an intraspinal tumor or a posterior herniation of the nucleus pulposus and

* the circumferences of the upper and lower legs should be measured to look for signs of muscle wasting that suggest a nucleus pulposus herniating pos tero la te ral Iy and impinging on a nerve root.

The vertebral level of the disc protrusion can be deduced by the site of the muscle wasting, ie, posterior compartment of lower leg (L5-SI), anterior compartment of lower leg (L4-5), and upper leg (L.3-4).

Laboratory

In most cases of acute LBP in which the rest of the physical examination is normal, no laboratory studies are indicated- Although the author has personally cared for two adolescents whose acute lymphocytic leukemia presented as acute back pain, their examination revealed marked pallor in one case and splenomegaly in the other - both signs indicating the need for a blood count, which led to the correct diagnosis.

In chronic LBP, a complete blood count and a sedimentation rate should be obtained. If the latter is elevated or if there is neutrophilia, then an inflammatory process such as ankylosing spondylitis or discitis must be considered. If ankylosing spondylitis is suspected, the human leucocyte antigen B27 should be assayed since it is present in 90% of white Americans with ankylosing spondylitis. The test is not specific, however, because the antigen is also present in a small number of normal people who do not have and will not develop this condition. A urinalysis and a urine culture should also be obtained in patients with chronic backache.

Table

TABLE 2Pertinent Portions of the Physical Examination in Adolescents With Low Back Pain

TABLE 2

Pertinent Portions of the Physical Examination in Adolescents With Low Back Pain

Roentgenographic Studies

In the typical case of acute LBP1 roentgenograms are not indicated. Low back pain is the most frequent reason for ordering diagnostic roentgenography in office practice, with an estimated 7 million such studies done each year in the United States.1 In fact, lumbosacral radiography is the largest contributor to gonadal irradiation in this country.2 Roentgenographic studies are only indicated if there is a neurologic deficit, if the pain is chronic and has lasted longer than 3 weeks, if the problem is recurrent, if there was direct spinal trauma, or if infection or malignancy are suspected. In addition to the usual anteroposterior and lateral views, oblique views should also be requested as this is the best way to detect spondylolysis.

Management

The clinician should be aware of the natural history of acute LBR Low back pain is a self-limited disorder in which, without any treatment, 50% of patients recover within 1 week, 80% within 2 weeks, and 90% within 8 weeks.5 This spontaneous resolution rate and the subjective nature of the complaint of pain makes it difficult to demonstrate that any one of many espoused therapies for LBP is effective (Table 3).

Figure 1 . Dermatomes of lower extremities.

Figure 1 . Dermatomes of lower extremities.

Table

TABLE 3Therapies Espoused for Low Back Pain

TABLE 3

Therapies Espoused for Low Back Pain

Acute LBP should be treated for the first 3 days with cryotherapy, using a small wet towel that has been kept in the freezer long enough to become malleable and applying it to the painful area for 1 5 to 20 minutes at least four times a day. After the third day, local heat should be applied on an as-needed basis, using a heating pad or a moist hot towel. The rationale for the initial cryotherapy is to reduce microscopic bleeding believed to continue for the first few days following an acute soft-tissue injury and which contributes to the inflammatory process.4 At least one study comparing cold with heat in the management of acute ankle sprains demonstrated a marked improvement in recovery rates for those who received ice initially.5 Heat is used because it has been observed to help relieve the discomfort of backache, presumably by relieving some of the muscle spasm. Bed rest for a few days is recommended for severe episodes, but for most patients avoidance of straining, lifting, and moving excessively is sufficient.6 Some patients find more symptomatic relief continuing cryotherapy beyond the first few days of symptoms than by switching to heat application, and 1 recommend that they continue with that initial method. The only analgesics ordinarily required are acetaminophen or acetaminophen with codeine. There is no evidence that either muscle relaxants or nonsteroidal anti-inflammatory drugs are more effective than these simple analgesics.

Table

TABLE 4Advice for Low Back Pain Prevention*

TABLE 4

Advice for Low Back Pain Prevention*

If chronic low back pain persists with the use of these conservative measures, then, even if the neurologic and roentgenographic examinations are normal, referral to an orthopedic surgeon or a back pain clinic is advisable. Patients with persistent chronic LBP are notoriously refractory to most forms of treatment, and the primary care physician should use every measure available to relieve the patient's frustration with the lack of a successful outcome.

Prevention

If the adolescent recovers from his or her first episode of acute LBP, follow-up exercise programs are not usually needed. However, if the history is one of recurrent or chronic pain, then the patient needs advice about posture and how to lift heavy objects (Table 4). Patients should avoid prolonged standing and forward bending for extended periods, and they should be shown how to lift using their legs rather than with their flexed back. Work and recreational activities need to be discussed to see if certain aggravating actions can be avoided.

The effectiveness of exercise programs remains controversial, although they are generally prescribed for frequent recurrences of acute LBP in an attempt to strengthen the abdominal and pelvic extensor muscles. They are also generally prescribed following acute exacerbations in patients with chronic LBP. Figure 2 depicts a set of exercises published as a patient education brochure available for purchase by physicians from The Physician and Sportsmedicine, Sportsmedicine Service Center, 4530 W 77th St, Minneapolis, MN 55435; telephone (800) 525-4776. Unfortunately, the compliance rate for patients of any age for exercise regimens is at best only fair, and adolescents' compliance rates are less likely to reach even that level. These exercises should be prescribed for several weeks following each exacerbation.

Figure 2. Low back pain exercises regimen. Patients are instructed to repeat each exercise one to five times twice daily, gradually increasing to 10 repetitions twice daily Patients are also instructed to stop doing the exercises immediately if any pain or discomfort occurs and to contact their physician. (Reprinted with permission from The Physician and Sportsmedicine, Copyright McGraw-Hill, Ine).

Figure 2. Low back pain exercises regimen. Patients are instructed to repeat each exercise one to five times twice daily, gradually increasing to 10 repetitions twice daily Patients are also instructed to stop doing the exercises immediately if any pain or discomfort occurs and to contact their physician. (Reprinted with permission from The Physician and Sportsmedicine, Copyright McGraw-Hill, Ine).

SPONDYLOLYSIS

This defect in the pars interarticularis of the vertebral arch (Figure 3A) can be congenital in origin, and it can be seen roentgenogaphically in asymptomatic adolescents. In the active adolescent, however, it is more likely one of the "overuse syndromes" and due to a stress fracture resulting from repetitive hyperex tens ion of the lumbar spine. This occurs most frequently while participating in sports such as gymnastics and football (particularly offensive and defensive linemen) in which the spine is frequently moved quickly from the flexed position to one of extreme extension.

If spondylolysis is symptomatic, LBP that occurs after physical exertion and is relieved by rest is usually the only complaint. The physical examination can reveal a variety of signs; paravertebral muscle spasm and tenderness, hyperlumbar lordosis, loss of normal lumbar lordosis associated with pain on flexion, and pain produced by hyperex tension of the lumbar spine, especially when standing one-legged using the leg on the side of the defect. Roentgenographic studies, particularly the oblique lumbar views, will indicate the presence of the defect (Figure 4). Although a radioisotopic (technetium) hone scan will frequently also be "positive," it is rarely necessary to obtain this study.

Figure 3. A) Spondylolysis - defect is in the pars interarticularis of the vertebral arch in shaded area). B) Spondylolisthesis - the L-5 vertebra has moved forward on the sacrum with an increased pars defect evident.

Figure 3. A) Spondylolysis - defect is in the pars interarticularis of the vertebral arch in shaded area). B) Spondylolisthesis - the L-5 vertebra has moved forward on the sacrum with an increased pars defect evident.

The management of spondylolysis is essentially the same as that for idiopathic chronic LBP, which was outlined above, although a little more emphasis is placed on limiting excessive motion until the symptom has resolved. If symptoms are recurrent, then, more assertive advice about changing sports should be given.

Figure 4. Roenîgenogram (oblique) of spondylolysis showing "Scotty dog collar" (arrow).

Figure 4. Roenîgenogram (oblique) of spondylolysis showing "Scotty dog collar" (arrow).

SPONDYLOLISTHESIS

If the spondylolysis occurs in each of the vertebral arches, then forward slippage of one of the vertebrae can occur. This condition is called spondylolisthesis (Figure 3B). Spondylolisthesis is a condition primarily of adolescents and young adults and only rarely occurs after age 25.

The symptom is one of chronic LBP, generally improved but not completely relieved by rest, frequently extending into the sacroiliac joints. The pain presumably results from the vertebra slipping forward and impinging or exerting traction on a nerve root. The pain may be referred to the lower extremity, or paresthesia may occur without any pain. Unique features sometimes detected on physical examination are a palpable "ledge" felt in the external lumbar spine area and a bony mass felt anterior to the sacrum on rectal examination. The fifth lumbar vertebra is usually involved; the second most commonly involved vertebra is L-4. Spondylolisthesis, like spondylolysis, may exist throughout a patient's life without producing any symptoms and may only be detected when a lateral lumbar spine roentgenogram is obtained for an unrelated reason Figure 5).

Figure 5. Roentgenogram (lateral) of spondylohsthesis. Arrows point to distance vertebra has slipped

Figure 5. Roentgenogram (lateral) of spondylohsthesis. Arrows point to distance vertebra has slipped

Although surgery is only indicated when there are persisting neurologic deficits, it is wise to refer patients with symptomatic spondylolisthesis to an orthopedic surgeon. Conservative management with rest, an exercise regimen, and a corset or brace, however, are usually all that they recommend.

REFERENCES

1. Seave JG, Iapliew RF, Rubren GV. Use of lumber spine films-statistical evaluation at a university teaching hospital, JAMA. 1981;246;1105.1105

2. ReuleIg itS. I.nw back pam. Wesif Med 1985;143259-265

9. Quinn Ri. `ladler NM. Diagnosis and treatment of backache. Semis Airhriiis Rheranr 1979;8261.287.

4. McMaster WC. Crystherapy, Physician & Sporsmedicine. l982:10:112-119

5 Hocutt JF. JaRk K. Rvland Ct. ci al. Crvrri herapsi n iF I spr.li ns. Am i S~ns ItIH 1982;10:310.319.

6. Deyo RA. Diehl. AK. Rosethal M. How many days of bed rest for acure low back pain? N PugH Mol 1986;315:1064-1070

7. Schuchmannn JA Low back pain; accomprehensive approach, Compr Ther. 989;14:14-18

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Roach teAdjel C) G,nsensnise management si hiss hack p.c an es-:rluaiion of current meihods. lSrsigrsd Med. I 05n44 127.133.

Dew RA. Conucnaiise therapy ion Fir hack pain distinguishing useful IroriL use less iheraph JAMA. IQS ~25~i: 1057-1061.

TABLE 1

Practical Differential Diagnosis of Low Back Pain in Adolescents

TABLE 2

Pertinent Portions of the Physical Examination in Adolescents With Low Back Pain

TABLE 3

Therapies Espoused for Low Back Pain

TABLE 4

Advice for Low Back Pain Prevention*

10.3928/0090-4481-19910401-05

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