4/4/2014 Roger Saldana, MD Pediatric Orthopedic Surgeon Baptist - - PDF document

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Roger Saldana, MD Pediatric Orthopedic Surgeon Baptist Health Medical Group Approach to child with spinal/back complaints Back pain Scoliosis Spondylolysis Spondylolisthesis

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Onset Trauma Constitutional symptoms Location Neurologic history

Specifically ask about bowel and bladder

ROS Family history

Visual inspection

General appearance View from side, and back Adams forward bend test Look at feet!

Range of motion

Flexion Extension Rotation

Palpation

Point tenderness Step off

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Motor exam

Walk on toes/heels Squat Resist flexion/extension Resist shoulder abduction

Neurologic exam

Sensory C4-S1 Reflexes Babinski Clonus Abdominal reflex

• X-rays
• Trauma
• Night pain
• Fever
• Pain >6 weeks
• Age <8
• Bone Scan
• Negative x-rays
• CT
• Positive x-ray or bone scan
• MRI
• Abnormal neurologic exam
• Scoliosis in children <8
• Atypical scoliosis
• Blood work
• Night pain
• Constitutional symptoms

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Prevalence increasing Adolescent incident approaching that of adults Age

<5: tumor, discitis 5-10: Langerhans cell histiocytosis, tumor, leukemia,

discitis

10-18: Scheuermann kyphosis, disc herniation or

apophysis, spondylolyis, tumor, leukemia

Coronal curve 10 degrees or greater 80% idiopathic Rarely causes back pain

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School/community based Adams forward bend test Scoliometer

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Ask the child to slowly bend forward. The examiner

should view the child from the back with eyes at the same level as the back.

Adjust the bending position height so the deformity of

the spine is most pronounced.

Gently lay the scoliometer across the deformity at right

angles to the body, with the marking centered over the

• curve. Observe the scoliometer reading.

Generally refer if >7

There’s an app for that

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Age During growth spurts Double curves Thoracic curves More severe curves Menarche Voice change in boys Risser sign Bone age

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Pain Neurofibromatosis Neurologic abnormalities Connective tissue disorders Left curves Foot deformity 10-25 degrees 25-40 >40

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Defect in the pars interarticularis Common cause of back pain L5 most common location

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Anterior slippage of vertebral body L5 on S1 most common

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Trauma 50% Genetic predisposition Repetitive hyperextension Gait Palpation

Step off

ROM

Popliteal angles Hyperextension

Neurologic

L5

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X-rays

Obliques

Bone scan

Sensitive in acute phase Non-specific

SPECT

Gold standard

CT MRI

Becoming study of choice

Rest Brief course of anti-inflammatory medication Lumbar support

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Failed conservative treatment Neurologic symptoms Grade 3-4 slips

Thank you

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Hensinger RN: Back Pain in Children. In Bradfird Ds, Hensinger Rn (eds): The

Pediatric Spine. New York,Thieme, 1985, P 41.

James JI: Idiopathic scoliosis: The prognosis, diagnosis, related to curve pattern

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Dickson RA: Conservative treatment for idiopathic scoliosis. J Bone Joint Surg

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Izatt MT1, Bateman GR, Adam CJ. Evaluation of the iPhone with an acrylic

sleeve versus the Scoliometer for rib hump measurement in scoliosis. Scoliosis. 2012 Jul 30;7(1):14. doi: 10.1186/1748-7161-7-14.

Fredrickson BE, Baker D, McHolick WJ, et al: The natural history of

sponylolysis and spondylolisthesis. J Bone Joint Surg Am 66:699-707, 1984

Pizzutillo PD, Hummer CD III: Nonoperative treatment of pain in adolescent

spondylolysis and spondylolisthesis. J Pediatr Orthop 9:538-540, 1989

Micheli L: Low back pain in the adolescent : Differential diagnosis. Am J Sports

Med 7: 362-364, 1979