Lumbar disc herniation in young children

Percutaneous endoscopic lumbar discectomy in lumbar disc herniation with posterior ring apophysis fracture: A case report in a 15-year-old child

RATIONALE

Lumbar disc herniation (LDH) with posterior ring apophysis fracture (PRAF) is rather rare in children, and in all age-stratified LDH patients, the incidence of RAF was 5.3% to 7.5%. Interestingly, the incidence of LDH with RAF in children (15%-32%) is several times higher than in adults, the mis-diagnosis of which may lead to delayed treatment.

PATIENT CONCERNS

Here, we report a 15-year-old schoolboy who suffered from sudden low back pain and radiating pain in both lower limbs after sport activities. Symptoms persisted after 3 months of conservative treatment. Computer radiography and magnetic resonance imaging indicated central disc herniation with PRAF at L4-5.

DIAGNOSIS

LDH with PRAF.

INTERVENTIONS

The herniated disc and epiphyseal fragments were successfully excised by the percutaneous endoscopic lumbar discectomy minimal-invasive technique.

OUTCOMES

Surgery was successful. Symptoms were immediately relieved postoperatively with a wound of only about 7.0 mm. Discharged on the next day. No perioperative complications occurred. Moreover, the imaging and clinical outcomes were also more satisfactory during the post-operative 15 months outpatient follow-up.

LESSONS

Pediatric LDH with PRAF is extremely uncommon, and there is a lack of training among physicians for such cases, which may lead to delayed diagnosis and treatment. Once a diagnosis for LDH with PRAF is established, percutaneous endoscopic lumbar discectomy is a safe and effective minimally invasive treatment to be considered, and we hope that this technique can provide more assistance in the future.

Pediatric lumbar disc herniation: A case series on diagnosis and management

Pediatric disc herniation is an uncommon but significant illness in children that can cause debilitating symptoms. The prevalence rate of lumbar disc herniation in this group is unknown. We present 4 rare cases of lumbar disc herniation in children. All patients complained from low back pain with radiation to the corresponding leg along with other neurological manifestations. Trauma and family history for all patients were negative. Magnetic Resonance Imaging (MRI) was performed for all patients and confirmed the diagnosis in all cases. All patients were treated conservatively without any improvement, thus surgical intervention (minimally invasive discectomy with foraminotomy) was performed. The importance of early identification and adequate care in pediatric patients with lumbar disc herniation cannot be overstated. More study is needed to better understand the risk factors, pathophysiology, and best treatments for this illness in children and adolescents.

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.

Pediatric back pain-Diagnostic algorithm

BACKGROUND

Back pain in the pediatric population is common. History and a thorough physical examination and a systematic work-up approach are key components to guide the physician in evaluating the possible causes of pain and providing appropriate treatment.

OBJECTIVE

The main aim of this review was to develop an algorithmic approach to assist physicians in the assessment of pediatric back pain. A comprehensive review of prevalence, differential diagnoses and proper management of pediatric back pain are also presented.

MATERIAL AND METHODS

An extensive literature search was performed in PubMed to gather articles on the prevalence, risk factors, diagnostic tools, differential diagnoses and appropriate management of pediatric back pain.

RESULTS

Available literature revealed that pediatric back pain is a common complaint. Although most cases are non-specific and self-limiting, there is a wide differential that should be considered including inflammatory, neoplastic, infectious and mechanical causes. Sedentary lifestyle, obesity and vigorous physical activity have been shown to increase the likelihood of developing back pain. We proposed an algorithm to guide the physician's decision about the next step in the diagnostic process.

CONCLUSION

A well-defined strategy in the diagnostic process is needed in approaching children/adolescents with back pain. This would have the benefit of minimizing costs, unnecessary tests and child/family anxiety as well as increasing the likelihood of early diagnosis and proper treatment.

Is age more than manual material handling associated with lumbar vertebral body and disc changes? A cross-sectional multicentre MRI study

OBJECTIVE

Conflicting evidence exists to what extent manual material handling (MMH) causes lumbar disc disease, lack of evidence exist that this effect takes place especially at L5-S1 level, where the greatest moment occurs. The aim was to assess if lumbar vertebral body and disc changes are more common in people whose job involves significant MMH and, if so, to evaluate if lumbar vertebral body and disc changes are more prevalent in the lower part of the lumbar spine (L4-L5 and L5-S1).

DESIGN

Observational, cross-sectional, with quasi-random recruitment.

SETTING

Outpatient radiology units of three large hospitals in northern (Bologna and Brescia) and southern (Bari) Italy.

PARTICIPANTS

183 consecutive adult subjects (89 males, 94 females) aged 20-70 years referred by the general practitioner or a specialist for MRI of the lumbar spine.

PRIMARY AND SECONDARY OUTCOME MEASURES

Neuroradiologists (blind to clinical assessment) evaluated the prevalence of intervertebral disc and vertebral body changes in standardised MRI examinations. History of personal and family musculoskeletal diseases and injuries, current and previous MMH at work and during leisure time were assessed by interview and self-administered questionnaire.

RESULTS

Participants were classified according their occupational exposure to MMH. No association was found between MMH and vertebral body and intervertebral disc changes, whereas age over 45 years was consistently associated with more disc extension beyond the interspace changes, Pfirrmann changes, osteophytes and Modic changes: the association was statistically significant at the conventional 5% level.

CONCLUSIONS

Age, and not MMH, seems to primarily affect the presence of intervertebral disc changes; prospective studies are needed to better explore the relationship between MMH and the possible presence (and level) of lumbar vertebral body and/or disc changes.

Matrix homeostasis within the immature annulus fibrosus depends on the frequency of dynamic compression: a study based on the self-developed mechanically active bioreactor

Evidence suggests that mechanical load is related to structural destruction of disk annulus fibrosus (AF) either in adult disk degeneration or in child disk acute injury. Both biochemical and biomechanical properties are different between immature and mature disks. However, the effects of mechanical compression on immature AF are not fully clear. This study was to investigate the effects of a relatively wide range of dynamic compressive frequency on matrix homeostasis within the immature AF. Immature disks from pig (3-4 months) were randomly assigned into the control group (non-compression) and compression groups (0.1, 0.5, 1.0, 3.0 and 5.0 Hz). All disks were bioreactor-cultured for 7 days. AF matrix production was evaluated by histology, gene expression, glycosaminoglycan (GAG) content, hydroxyproline (HYP) content and immunohistochemistry. Generally, no obvious difference was found in HE staining between control group and compression groups. However, alcian blue staining indicated proteoglycan content in the 5.0-Hz group was decreased compared with the control group and other compression groups. Similarly, a catabolic remodeling gene expression profile with the down-regulated matrix genes (aggrecan, collagen I and collagen II) and tissue inhibitor of metalloproteinases (TIMP-1 and TIMP-3) and the up-regulated matrix catabolic enzymes (ADAMTS-4 and MMP-3) was found in the 5.0-Hz group. Further analysis indicated that GAG content, HYP content and aggrecan protein deposition were also decreased in the 5.0-Hz group. Hence, we concluded that matrix homeostasis within the immature AF was compressive frequency dependent, and the relatively higher frequency (5.0 Hz) is unfavorable for matrix production within the immature AF. These findings will contribute to further understanding of the relationship between mechanical compression and immature AF biosynthesis.