Lumbar disc herniation in teenagers

Pediatric lumbar disc herniation: a report of two cases and review of the literature

BACKGROUND

Lumbar disc herniation (LDH) is not a common condition in children. Most reports on pediatric LDH concern the outcomes of surgeries performed in children in whom nonsurgical treatment failed while the outcome of nonsurgical treatment of LDH in children was rarely reported.

CASES PRESENTATION

Case 1: a 10-year-old girl presented with back pain and sciatica in her left leg for over 3 months. The physical examination revealed exacerbation of back pain by waist extension or flexion, and a positive Lasegue's sign was revealed in her left leg. Magnetic resonance imaging (MRI) revealed lumbar disc herniation at the L5/S1 level. She was diagnosed with LDH. After receiving nonsurgical treatment of traditional Chinese medicine (TCM) for 30 days, the girl had mild low back pain and sciatica and the symptoms had resolved completely at the 3-month follow-up. There was no recurrence within the following 2 years. MRI performed 30 months later revealed that the herniated disc did not shrink significantly. However, she was totally asymptomatic at the follow-up performed 30 months later. Case 2: a 13-year-old boy presented with sciatica in his left leg for over 3 months. The physical examination revealed that Lasegue's sign was positive in the left leg, the level of muscle strength in the left ankle plantar flexors was grade 4. MRI revealed a lumbar disc herniation at the L5/S1 level. He was diagnosed with LDH. The boy underwent 2 weeks of TCM treatment, and exhibited a favorable outcome: only mild pain was noticed in his left buttocks after walking for more than 15 min. He was asymptomatic at the 3-month follow-up and there was no recurrence within the next 3 years. MRI scan performed at 40 months later showed no significant resorption of the herniated disc. However, he was totally asymptomatic at the follow-up performed 40 months later.

CONCLUSIONS

For the nonsurgical treatment of pediatric LDH, resorption of herniated discs is not necessary for favorable long-term outcomes, and children with symptomatic LDH may become asymptomatic without resorption.

[Posttraumatic vertebral disc alterations after B and C type spinal injuries in childhood-Clinical and radiological 10-year results for two cases]

Pediatric traumatic vertebral injuries usually present as stable A (AOspine classification) fractures, whereas B and C injuries are relatively uncommon. In contrast to adults the appropriate treatment strategy in children remains an issue of debate.The data from two pediatric patients admitted with B and C type spinal injuries in 2007 and 2008 were retrospectively analyzed. The initial diagnostics were performed via computed tomography (CT) and an additional magnetic resonance imaging (MRI) was carried out in one case.The clinical and radiological follow-up controls were carried out after 77 and 66 months as well as 123 and 112 months, respectively. In both cases thoracolumbar MRI scans revealed degenerative alterations of the ventral half of the L1/L2 disc with a regular disc signal in the dorsal segment at the first follow-up and a progressive disc degeneration in one patient at the second follow-up.Surgical treatment of pediatric B and C type injuries via open reduction and temporary monosegmental posterior screw and rod instrumentation results in satisfactory clinical and radiological outcomes. In the absence of vertebral burst fractures, the function and stability of discoligamentous injuries in children can be restored without any additional osseous fusion.

'Progressive-onset' versus injury-associated discogenic low back pain: features of disc internal derangement in patients studied with provocation lumbar discography

Chronic low back pain (LBP) can be 'progressive onset' or injury-related. This study compares the patient-reported cause of chronic LBP to features of disc internal derangement at painful concordant discs evaluated by provocation lumbar discography. Concordant LBP was identified in 114 patients with chronic LBP studied by provocation discography. LBP cause, discogram pain response and discogram/post-discogram CT features of internal derangement were retrospectively reviewed. 'Progressive-onset' LBP was reported in 32 (28%) patients, injury-related LBP in 75 (66%) with LBP equated to non-specific causes in seven. Injury-related LBP was more commonly identified in men (52 of 63 [83%]) with women reporting near-equal frequency of 'progressive-onset' (23 of 44 [52%]) and injury-related (21 of 44 [48%]) LBP (p=0.002). In 172 concordant painful discs, near-equal frequency of severely degenerative (Dallas grade-3: 82 of 172 [47.3%]) and full-thickness radial fissure discs (Dallas grade-3: 90 of 172 [52.7%]) were identified. Women with 'progressive-onset' LBP demonstrated more frequent severely degenerative discs (24 of 37 [65%]); women with injury-related LBP demonstrated more frequent radial-defect discs (21 of 31 [68%]; p=0.01). In men with injury-related LBP, severe degeneration-only (44 of 89 [49%]) and radial defect discs (45 of 89 [51%] were seen with equal frequency. In men with 'progressive-onset' LBP, radial defects are more common (11 of 15 [73%]). 'Progressive-onset' and injury-related chronic LBP subgroups are definable. Gender-related differences in incidence and internal derangement features at concordant discs are identified at discogram/post-discogram CT. These differences may have implications related to LBP origin/treatment-response.

A review of current treatment for lumbar disc herniation in children and adolescents

Lumbar disc herniation (LDH) is a common disorder among adults with degenerated lumbar intervertebral discs. However, its occurrence in childhood and adolescence is much less frequent mostly because children and adolescents tend to have a healthier lumbar spine as compared with adults. This difference indicates that children and adolescents are far from being just little adults. Over the years, there have constantly been published studies concerning this entity where the findings suggested that pediatric LDH is, in many ways, different from that in adults. To date, the prevalence, the etiological and the diagnostic features of pediatric LDH have been fully described in the literature whereas the characteristics regarding to the treatment is yet to be reviewed in details. The aim of the present review is to provide a collective opinion on the treatment of pediatric LDH as well as its outcome. It reviewed the relevant information available in the literature and compared the results among and within various treatments. It was found that pediatric patients responded less favorably to conservative treatment as compared with adults. In addition, the outcome of surgery remained to be satisfactory for at least 10 years after the initial operation, even though it appeared to deteriorate slightly. To the best of our knowledge, this is the first literature review focusing on the treatment of pediatric LDH.