Lumbar disc disease in children

Evaluation and management of paediatric and adolescent back pain: Epidemiology, presentation, investigation, and clinical management: A narrative review

This narrative review will summarise a clinical approach to the investigation of back pain in children and adolescent patients, including a discussion of the epidemiology, presentation, investigation and clinical management of back pain in children and adolescents. This will assist the prompt and accurate diagnosis of spinal disorders that require significant medical intervention. Existing evidence suggests a relatively high incidence of non-specific back pain among young people; 27-48% of presentations of back pain in children and adolescents are attributed to non-specific back pain. Low back pain among schoolchildren is often linked to psychosocial factors and only occasionally requires medical attention, as pain is benign and self-limiting. Nonetheless, those young patients who seek medical assistance exhibit a higher incidence of organic conditions underlying the major symptom of spinal pain. A cautious and comprehensive strategy - including a detailed history, examination, radiographic imaging and diagnostic laboratory studies - should be employed, which must be accurate, reliable, consistent and reproducible in identifying spinal pathologies. A specific diagnosis can be reached in 52-73% of the cases. For cases in which a specific diagnosis cannot be made, re-evaluation after a period of observation is recommended. At this later stage, minor symptoms unrelated to underlying pathology will resolve spontaneously, whereas serious pathologies will advance and become easily identified.

Percutaneous endoscopic discectomy in adolescent lumbar disc herniation: a 3- to 5-year study

OBJECTIVEThe authors sought to investigate the efficiency of percutaneous endoscopic discectomy (PED) in adolescent patients with lumbar disc herniation (LDH), compare PED outcomes in adolescent patients with those in young adult LDH patients as controls, and discuss relevant technical notes.METHODSThis was a retrospective study involving 19 adolescent LDH patients (age > 13 and < 18 years, 20 discectomies) and 38 young adults (age < 40 years, 38 discectomies) who also had LDH and were matched to the adolescent group for sex and body mass index. The combined cohort included 51 male patients (89.5%) and 6 female patients (10.5%), with an average age of 26.7 years (range 14-39 years). The operated levels included L3-4 in 1 patient (1.7%), L4-5 in 22 patients (37.9%), and L5-S1 in 35 patients (60.4%). Two adolescents (10.5%) exhibited apophyseal ring separation and one (5.3%) had had previous PED. All patients underwent PED under local anesthesia. Outcomes were evaluated through a visual analog scale (VAS), the Japanese Orthopaedic Association (JOA) scoring system, and the modified MacNab grading system.RESULTSThe mean duration of follow-up was 41.7 months (range 36-65 months). The outcomes in adolescents were satisfactory and comparable with previously reported outcomes of microsurgical discectomy (MD) and conventional open discectomy (COD). The adolescent patients had a faster and better recovery course than the adult patients (p < 0.01). One adolescent patient (5.3%) exhibited recurrence and 2 adults (5.3%) experienced transient dysesthesia; the complication rates were comparable in the 2 age groups (p = 0.47). Prolonged duration of symptoms (p < 0.01) and disc degeneration (p = 0.01) were correlated with lower postoperative JOA values; patients with extrusions had higher postoperative JOA values than those with protrusions (p = 0.01).CONCLUSIONSPED may yield favorable results in the treatment of adolescent LDH in terms of short- to medium-term follow-up; restricted discectomy and a conservative rehabilitation program might be advisable. Further long-term studies are warranted to address this rare disease entity.

Lumbar Disk Herniation in Children and Adolescents: The Significance of Configurations of the Lumbar Spine

BACKGROUND

Lumbar disk herniation in adults is thought to be caused by repetitive overloading and age-rated degenerative changes. However, these causes are absent in children and adolescent patients. We assume that structural malformations in the lumbar spine could predispose intervertebral disks to early degeneration and hence need to be surgically fused. This issue has never been raised before.

OBJECTIVE

To investigate the assumption that structural malformations in the lumbar spine could predispose intervertebral disks to early degeneration and hence need to be surgically fused.

METHODS

Lumbar spine configurations, including the height of the intercrestal line, the length of L5 transverse processes, and the presence of transitional vertebrae, were recorded from anteroposterior radiographs taken from 63 consecutive pediatric patients with lumbar disk herniation admitted to our hospital over a period of 8 years. Each configuration was compared in relation to the level of disk herniation. Diskectomy alone was performed in 36 cases; arthrodesis was added in the remaining 27 cases. Patients' back and leg pain visual analog scale scores and frequency and their Oswestry Disability Index scores were recorded before surgery and at follow-up. The results were compared for assessment of outcome.

RESULTS

Patients with high intercrestal lines and long L5 transverse processes had a significantly higher incidence of L4/5 disk herniation, whereas low intercrestal line and lumbarization were associated with L5/S1 disk herniation. Patients' visual analog scale scores, pain frequency, and Oswestry Disability Index score all improved significantly after surgery, but there was no significant difference with or without arthrodesis.

CONCLUSION

Pediatric lumbar disk herniation is significantly associated with structural malformations of the lumbar spine, but arthrodesis does not improve the clinical outcome.

ABBREVIATIONS

ICL, intercrestal lineLDH, lumbar disk herniationL5TP, L5 transverse processODI, Oswestry Disability IndexTV, transitional vertebraeVAS, visual analog scale.

Prevalence and geographic distribution of herniated intervertebral disc in Korean 19-year-old male from 2008 to 2009: a study based on Korean conscription -national and geographic prevalence of herniated intervertebral disc in Korean 19YO male-

PURPOSE

This study was to determine the prevalence of herniated intervertebral disc (HIVD) among Korean 19-year-old male in a large national sample and to compare the prevalence across geographic regions based on the data of conscription.

MATERIALS AND METHODS

We analyzed the conscription data of 615508 cases who were 19-year-old male, given an examination for conscription at nationwide Korean Military Manpower Administration from January 2008 to December 2009. Prevalence was determined by dividing the number of cases by the number of persons enrolled for 2 years. The analyses included of a cross-tabulations and nonparametric chi-square to compare the prevalence according to geographic region, disc severity, and conscription year.

RESULTS

The prevalence of HIVD among 19-year-old male was 0.47%. Seoul had the highest prevalence of HIVD (total HIVD was 0.60%, and severe HIVD was 0.44%). The prevalence of HIVD was lower in Jeollabuk- do and Jeollanam-do (total HIVD was 0.25-0.27%, and severe HIVD was 0.16-0.17%). Annual prevalence of HIVD was slightly decreased in 2009, but geographic distribution annually was not different.

CONCLUSION

In Korean 19-year-old male, the national prevalence of adolescent HIVD was 0.60%, but different geographic distribution was observed. It is quite possible that secondary contributing factor(s) interfere with the different geographic prevalence of HIVD.

Prevalence of Lumbar Disc Herniation in Adolescent Males in Seoul, Korea: Prevalence of Adolescent LDH in Seoul, Korea

OBJECTIVE

The authors surveyed the prevalence and the clinical character of lumbar disc herniation (LDH) in Korean male adolescents, and the usefulness of current conscription criteria.

METHODS

The data of 39,673 nineteen-year-old males that underwent a conscription examination at the Seoul Regional Korean Military Manpower Administration (MMA) from October 2010 to May 2011 were investigated. For those diagnosed as having lumbar disc herniation, prevalences, subject characteristics, herniation severities, levels of herniation, and modified Korean Oswestry low back pain disability scores by MMA physical grade were evaluated. The analysis was performed using medical certificates, medical records, medical images, and electromyographic and radiologic findings.

RESULTS

The prevalence of adolescent LDH was 0.60%(237 of the 39,673 study subjects), and the prevalence of serious adolescent LDH with thecal sac compression or significant discogenic spinal stenosis was 0.28%(110 of the 39,673 study subjects). Of the 237 adolescent LDH cases, 105 (44.3%) were of single level LDH and 132 (55.7%) were of multiple level LDH, and the L4-5 level was the most severely and frequently affected. Oswestry back pain disability scores increased with herniation severity (p<0.01), and were well correlated with MMA grade.

CONCLUSIONS

In this large cohort of 19-year-old Korean males, the prevalence of adolescent LDH was 0.60% and the prevalence of serious adolescent LDH, which requires management, was relatively high at 0.28%. MMA physical grade was confirmed to be a useful measure of the disability caused by LDH.

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.

Lumbar disc herniation in teenagers

We report 48 patients operated on for lumbar disc herniation in the second decade of life (aged 13-20 years) in our Neurosurgical Division. To analyze the clinical and diagnostic features and surgical outcome of the disease in teenagers and to point out any differences from adults, we made a detailed study of over 900 juvenile cases and compared them with 11000 adult cases reported in the literature. Low-back pain proved to be less frequent among youngsters both as a first symptom and at diagnosis, while sensorimotor deficits have the same frequency in the two age groups. Herniation occurs more often at L4-L5 and is more frequently median among teenagers. The long-term surgical results in children and adolescents are better than in adults.

Clinical significance of ring apophysis fracture in adolescent lumbar disc herniation

STUDY DESIGN

Retrospective review and post-test-only control group design.

OBJECTIVE

To study the incidence and associated factors of ring apophysis fracture in adolescent lumbar disc herniation and to evaluate the long-term morbidity of untreated apophyseal fracture.

SUMMARY OF BACKGROUND DATA

Ring apophysis fracture is a feature in adolescent disc herniation, but the incidence and prognosis are unknown. It is still controversial whether to remove the apophyseal fragment at time of discectomy.

METHODS

We studied 96 adolescents (mean age, 14.7 years) with clinical diagnosis of disc herniation proved by computerized tomography (CT). In CT scan ring, apophyseal fracture is classified by the size (large/small) and the location (central/lateral). We used modified Oswestry classification in the nonoperative patients for pain and functional evaluation. Patients with and without apophyseal fracture were compared to define the significance of the lesion.

RESULTS

Twenty-seven of the 96 CT studies (28%) demonstrated apophyseal fractures. All but 2 were at the level of the herniated disc. Large-central fragments were the most common in 16 patients (48%), large-lateral fragments in 2, small-central fragments in 6, and small-lateral fragment in 6. Rate of surgery was significantly higher in the disc herniation patients with apophyseal fractures. Sixty-four nonoperative patients were evaluated 6.6 years (range, 2.3-14.3) after the CT study and questionnaires were completed in 54 patients (84%). Patients with large apophyseal fragments had more chance of chronic back pain and limitation of daily activities than the patients with small fragments and patients without apophyseal fracture.

CONCLUSION

Apophyseal fracture is not uncommon in adolescent lumbar disc herniation. The surgical decision must depend on clinical symptoms instead of radiologic findings, but disc herniation with apophyseal fracture may exhibit more severe symptoms. Patients with large apophyseal fragments must be informed of a greater chance of chronic back pain later on. Small apophyseal fragments had no clinical significance.

Pediatric disk disease

Intervertebral disk herniation in pediatric patients is a rare but potentially disabling entity that is frequently difficult to diagnose. This article reviews the fundamentals of pediatric intervertebral disk herniation with the intention of presenting a rational and simple strategy for the evaluation and treatment of disk herniation in children, with specific emphasis on how it differs from adult disk disease in presentation, pathologic findings, and treatment options.

Adolescent lumbar disc disease: findings and outcome

BACKGROUND

Lumbar disc herniation is mainly a disease of elderly people as degenerative changes progress with age.

RESULTS AND DISCUSSION

Present retrospective analysis was performed on 742 patients of lumbar disc disease operated over 11 years. Of 742 cases aged 20 years or less, 25 has been evaluated to see the clinical features, radiological features, operative findings, and outcome of lumbar disc surgery. The incidence of lumbar disc herniation in pediatric and adolescent populations was 3.5% (aged 20 years or less). All patients presented with low back pain with or without radiculopathy (n = 25). Diagnosis was easily made on magnetic resonance imaging. Gross degenerative changes in disc and end plates were uncommon (16%) in this population. The trauma may not be a predisposing factor in most of them. In 88% (n = 22) of the cases, only 1 level was affected; the commonest was L4-5 (n = 13). Disc herniation was centrolateral in 72% (n = 18) and central in 28% (n = 7). Disc was mostly soft, hydrated, and rubbery in 92% (n = 23). Disc herniation were subligamentous in 80% (n = 20) and extruded in 4% (n = 1). Sixteen percent (n = 4) of the patients had disc bulge with intact annulus.

CONCLUSIONS

Operative intervention in the form of simple discectomy offers good result in 92% (n = 23) cases irrespective of approach and method. Longer follow-up is mandatory because the chances of recurrence or another level involvement cannot be denied.

THE HISTORY OF NEUROSURGERY AT THE HOSPITAL FOR SICK CHILDREN IN TORONTO

The tradition of selfless charity for children in Toronto was established by Elizabeth McMaster, founder of the Hospital for Sick Children, or "Sick Kids," in 1875. The tradition of fortitude and perseverance in trying to cure children who were deemed incurable by others was sealed into the history of the Hospital by early pioneering surgeons, including Drs. Clarence Starr, A.W. Farmer, and William Gallie. Dr. William Gallie recognized the importance of neurosurgery for the future of the Hospital and encouraged Dr. William Keith to acquire training in pediatric neurosurgery in Chicago and London. Dr. Keith began the practice of pediatric neurosurgery at Sick Kids in 1935 and worked in the primordial phase of the subspecialty for the next 20 years until he was joined by Dr. E. Bruce Hendrick in 1955. In time, Dr. Hendrick was joined by Drs. Harold Hoffman and Robin Humphreys who led a decidedly strong pediatric neurosurgery unit between 1975 and 1995. During this epoch, the pediatric neurosurgery service grew to become one of the busiest and most progressive units in the world. Over the years, numerous neurosurgery fellows and faculty from all over the world have trained at or have visited Sick Kids to learn how pediatric neurosurgery is practiced in Toronto. The purpose of this article is to review the history of the individuals who founded the Hospital for Sick Children and its Division of Neurosurgery.

Lumbar disc herniation in adolescence

Lumbar disc herniation very rarely occurs in adolescence. The aim of this study was to assess the radiological, clinical and surgical features and case outcomes for adolescents with lumbar disc herniation, and to compare with adult cases. The cases of 17 adolescents (7 girls and 10 boys, age range 13-17 years) who were surgically treated for lumbar disc herniation in our clinic between 1998 and 2003 were retrospectively reviewed. The mean follow-up time for these cases was 60 months. The collected histories revealed that 14 (82%) of the 17 cases involved trauma or intense sports activity. Low back pain was the most common complaint (15 cases, 88%). None of the 17 patients had major symptoms during follow-up, and most were engaged in intense sports or heavy work-related activities during this period. The main features of lumbar disc herniation in adolescents are different from those seen in adults. Careful assessment is vital to avoid misdiagnosis and prevent undesirable results from inappropriate surgery. When surgery is indicated and patients are carefully selected, the results of lumbar discectomy in adolescence can be satisfactory.

Surgically treated lumbar disc disease in the pediatric population: an outcome study

OBJECT

This outcome study was undertaken to investigate the long-term results obtained in surgically treated pediatric patients with lumbar disc disease by using standardized medical outcome scales and clinical follow-up examination.

METHODS

Twenty nine patients 17 years of age or younger underwent surgery between 1968 and 1998 for lumbar disc disease. The follow-up period ranged from 4 months to 30.5 years (mean 8.5 years). Outcome scores (health profiles) were generated using a standardized medical outcome scale, the Short Form health survey questionnaire (SF-36), and a condition-specific back pain outcome scale. Clinical follow-up data were obtained by telephone interview. The health profile of the study population closely paralleled that of the normal population and was distinctly different from the health profile of adults with low-back pain. Only physical functioning, as measured by a scale of the SF-36, was found to be impaired in a subset of the study population. The rate of reoperation was 24% over the course of the follow-up period. In contrast to similar studies in adults, there were no identifiable predictive factors for either reoperation or poor outcome.

CONCLUSIONS

Lumbar disc disease in the pediatric population does not appear to lead to chronic complaints of back pain, and it does not appear to have a negative impact on overall health. This finding suggests that pediatric lumbar disc disease may be a separate entity distinct from adult lumbar disc disease, and therefore, the same conclusions regarding long-term outcome cannot be applied to the pediatric population.

Back pain in children

Children and adolescents occasionally have back symptoms, but rarely come to a physician's office for more severe back pain. When a child or adolescent appears in the clinic with complaints of back pain, a careful detailed evaluation is appropriate. The incidence of findings in children with significant back pain is high; therefore, a detailed history, physical examination, and evaluation are needed. It is also legitimate to continue monitoring children even if no obvious cause is initially identified because often a diagnosis subsequently will be made.

Long-term outcome of lumbar discectomy in children and adolescents sixteen years of age or younger

We retrospectively reviewed the cases of seventy-two consecutive patients who had a lumbar discectomy, between 1950 and 1983, when they were sixteen years of age or younger. There were forty boys and thirty-two girls. At the time of the lumbar discectomy, twelve patients (17 per cent) also had a spinal arthrodesis. The mean duration of follow-up was 27.8 years (range, twelve to forty-five years). Twenty patients (28 per cent) had one reoperation or more, with the first reoperation performed at a mean of 9.7 years after the initial discectomy. Fourteen patients had one reoperation, four had two reoperations, one had three, and one had five. Fifty-two patients (72 per cent) did not need a reoperation. At the time of the latest follow-up, forty-eight (92 per cent) of the fifty-two patients either had no pain or had occasional pain related to strenuous activity and fifty-one (98 per cent) could participate in daily activities with no or mild limitations. Survivorship analysis showed that the overall probability that a patient would not need a reoperation was 80 per cent at ten years and 74 per cent at twenty years after the initial operation. With the numbers available for study, we could not show that age, gender, or an arthrodesis performed at the time of the initial operation were risk factors for a reoperation. We could not detect a difference, with respect to pain or the level of activity, between the patients who had had an arthrodesis at the initial operation and those who had not or between those who had a coexisting structural abnormality of the lumbar spine and those who did not.

Multilevel lumbar disc herniation in 12-year-old twins

Herniation of a lumbar disc in the pediatric age group is rare. A 12-year-old female twin developed backache and left sciatica after a mild lifting injury. Magnetic resonance imaging of the spine showed multilevel lumbar disc herniation. The patient was managed conservatively and her symptoms subsided within 6 weeks. Magnetic resonance imaging of her asymptomatic twin sister revealed a similar pattern of disc degeneration and multilevel herniation. This report emphasizes the hereditary nature of juvenile lumbar disc degeneration.

Lumbar radiculopathy associated with anterior intraspinal bony lesions

Thirty-one patients underwent posterior decompression for anterior intraspinal bony lesions which were causing symptoms. The diagnoses were a displaced apophyseal endplate, vertebral corner bulge, and an ossified posterior longitudinal ligament or disc. Symptoms were caused by associated lumbar disc herniations or by gradual impingement by the bony lesion on neural tissue. The success rate after operation was 84%. Anterior spinal canal compromise by bony lesions can be treated by decompression through a posterior approach with minimal destruction of the laminae and facets.

Primary spinal epidural extraosseous Ewing's sarcoma

The case of a 7-year-old boy with a spinal epidural extraosseous Ewing's sarcoma (EES) is presented. He is in complete remission without neurologic deficit 40 months after diagnosis. Another 15 cases were found in the literature and are discussed together with this patient. Twelve of them were male patients. The mean age of the patients was 17.5 years (range, 4 to 47). Symptoms included back pain and/or radicular pain (100%), paresis of one or both legs (83%), sensory disturbances, and bladder and bowel dysfunction. The mean diagnostic delay was 5.8 months. Each patient underwent laminectomy; complete resection of the tumor was impossible in more than 50% of the cases. Most patients received radiation therapy and/or chemotherapy. Four patients suffered from local recurrence, eight from metastases. Ten (63%) patients died, 1 to 48 months (mean, 16) after diagnosis. The differential diagnosis is discussed, including disk herniation and several benign and malignant tumors.

Posterior lumbar vertebral rim fracture and associated disc protrusion in adolescence

Two cases of posterior lumbar vertebral rim fracture and associated disc protrusion in adolescents are presented. Disc compliance and developing vertebral structure were thought to be primarily responsible for this unusual injury. Occurring primarily in adolescent males, this entity most commonly affects the L-4 vertebra. One of the cases involved disc rupture at three levels. This injury is thought to be due in part to union of the anuli by the posterior longitudinal ligament, and in part to rim fracture and limited prolapse rather than frank single-level herniation in an adolescent. A review of the embryology, literature, and theoretical mechanism for occurrence at multiple levels is included.

Results of lumbar discectomy in the pediatric patient

To determine the results of lumbar discectomy in pediatric patients, a review was conducted of the medical records of 74 consecutive patients (40 males and 34 females) younger than 17 years who underwent lumbar disc surgery between 1950 and 1983. During this period, only 3% of patients younger than 17 years who presented with the chief complaint of low-back pain eventually had lumbar disc operation. In 43 patients it was thought that an injury had precipitated the symptoms. Thirty-seven patients had a nerve deficit at the time of initial evaluation. Water-soluble contrast myelography with repeated postmyelographic computerized tomography is currently used to confirm the diagnosis. The disc operations were performed at the L4-5 level in 47% of patients, the L5-S1 level in 45%, the L3-4 and L4-5 level in 4%, and the L4-5 and L5-S1 level in 4%. Fourteen of the 74 patient underwent spinal fusion with their first operation. At 9 months postoperatively, 95% had good or excellent results. During an extended follow-up period of up to 34 years, 16 of the patients with early successful results required further back procedures. After all medical and surgical treatment in this group of patients, the results were excellent in 57%, good in 38%, and poor in only 4%.

Simultaneous occurrence of herniated disc and mesothelial cyst in a 16-year-old male

The unusual, simultaneous occurrence of both a herniated disc and an intraspinal mesothelial cyst in an adolescent is reported. The patient was a 16-year-old white male who presented with sciatic pain in his left lower extremity. Myelography revealed evidence of a left L4-5 discal herniation, and a L5-S3 midline sacral lesion that proved to be a mesothelial cyst.

Calcified lumbar disc protrusion in an adolescent

The case of an adolescent operated on for a calcified lumbar disc protrusion is reported. The literature reviewed shows the rarity of this condition. Moreover, the comparison of our case with similar ones shows that it is extremely peculiar.

Lumbar disc protrusion in children

Forty-three cases of surgically treated lumbar disc protrusion in patients 21 years or younger are analyzed. The results were generally good. Ten percent of the patients required reoperation within 3 years. No major complications were experienced. Follow-up observation ranged from 4 to 30 years. Disc protrusion should be considered in the differential diagnosis of children with back and sciatic pain, and early myelography should be carried out in the refractory case. The symptoms, signs, myelograms, and surgical findings are usually similar to those of the adult patient with a disc protrusion.

The CT appearance of avulsion of the posterior vertebral apophysis. A case report

Avulsion and posterior dislocation of the posterior dislocation of the posterior part of the vertebral apophysis is a rare condition, occurring mainly in adolescence. If the avulsed part is ossified it may be diagnosed with conventional X-rays including myelography. The present case shows that CT scan with sagittal reconstruction gives exact information of the nature of the lesion as well as its extension into the spinal canal, and that CT alone is sufficient for preoperative diagnosis.

The relationship of juvenile lumbar disc disease and Scheuermann's disease

Between 1969 and 1979 five children were found to have lumbar disc disease and were evaluated for clinically unsuspected thoracic spine abnormalities. Of these five children, two had Scheuermann's disease and one had disc space narrowing associated with Schmorl's nodes. One other had narrowed disc spaces without bony defects, and one had a normal thoracic spine. A unitary concept of childhood lumbar disc disease, Schmorl's nodes and Scheuermann's disease is suggested.