Facet joint innervation is from posterior primary rami, each of which supplies the corresponding joint at its level, one higher and one lower. Basic principles of assessment \200 Low back pain can arise from damage or in \202 ammat ion of the thoracic or lumbar spines or from the posterior pelvis. Pathology in retroperitoneal abdomi nal and pelvic viscera can result in referred pain to the low back. A simple way of categorizing back pain is to consider its cause to be mechanical, in \202 ammatory, neurologic, or referred, or due to bone pathology (see Table 2.10). Over 90% of episodes of low back pain in adults are mechanical, self- limiting, and do not require investigation. Indicators for further investigation include age > 55 years, stiffness, focal pain, pain that disturbs sleep, nerve root symptoms, and chronic persistent (> 6 week s) pain. LOW BACK PAIN AND DISORDERS IN ADULTS 71 Table 2.10 Common and/or serious causes of low back pain in adults Hypermobility (see Chapter 16) Mechanical/ degenerative (very common) Facet joint arthritis Disc disease (annular tear, internal disruption, prolapse) Scoliosis/kyphosis Spinal stenosis Sacroiliitis In \202 ammatory (uncommon) AS (Chapter 8) Sacroiliitis (e.g., AS, brucellosis) Infection (rare) Osteomyelitis (e.g., Staphylococcus aureus, TB, brucellosis) (see Chapter 17) Bone disease (common) Osteoporotic fracture (see Chapter 16) Paget \200\231s disease Osteomalacia Neoplasia (rare) Secondary metastases Multiple myeloma Other Sickle cell crisis Renal disease (e.g., tumors, infection) Gynecologic disease Fibromyalgia (see Chapter 18) The low back is often a focus for those who may use pain (consciously or unconsciously) as a protective device in the face of domestic, emotional, or occupationa l stress. These stresses commonly in \202 uence the description and impact of pain but rar ely act alone in causing pain \200\224there is usually some underlying organic pathology. Taking a history Differentiate whether the pain is likely to be primarily mechanical or in \202 ammatory, due to bone pathology or referred \200 The site and extent of the pain do es not easily discriminate the cause. All disorders may be associated with mechanical defor mity and/or muscle spasm that may cause pain in a more diffuse distribution. \200 General ly, pain due to mechanical lesions is acute in onset, while patients with pain from in \202 ammatory lesions present after symptoms have been present for some time. In \202 ammatory pain is often associated with morning stiffness that can last for several hours and is eased by movement. Mechanical lesions tend to worsen with use. Many mechanica l or degenerative lesions may have an in \202 ammatory component, e.g., internal disc disr uption causing discogenic pain. CHAPTER 2 Regional musculoskeletal conditions 72 Intrinsic bone pathology often causes severe, unremitting, focal pain. Sleep is disturbed. Pain does not ease substantially with movement. About 3% of patients presenting with back pain have nonmusculoskeletal causes. A signi \201 cant proportion of women have pelvic conditions su ch as ovarian cysts or endometriosis. Pain may be cyclical. For those aged over 55 with no previous similar episodes of pain, a search for an underlying neoplastic lesion is required. Associated systemic symptoms are common in osteomyelitis and may be present if a malignancy has disseminated. Ask about pain radiation and symptoms in the legs \200 Progressive neurologic leg symptom s suggest a worsening/expanding lesion such as a tumor, infection/vertebral collapse, Paget \200\231s disease, or lumbosacral spinal stenosis. Pressure on nerves below the spinal cord (i.e., the cauda equina) suf \201 cient to cause a disturbance in perineal sensation and/or bowel/ bladder paralysi s is a neurosurgical emergency (i.e., cauda equina syndrome). Leg pain caused by nerve root irritation/compression is often clearly de \201 ned and shar p, often accompanied by numbness or paresthesias. The most commonly involved nerve roots ar e L4, L5, or S1. Pain generally radiates to below the knee and often, but not always, to th e heel and big toe. Sciatic nerve entrapment at the level of the piriformis muscle can produce identical radicular symptoms to L5 or S1 nerve root entrapment. Neurologic symptoms in the distribution of the femoral nerve (primarily anterior thigh musculature) might suggest a high lumbar nerve root lesion (L1 \200\223L3 for example). Disc prolapse is the most common cause of nerve root pain, but bony encroachment at the ner ve root exit foramen by vertebral end plate or facet joint osteophytes and/or soft tissue t hickening or \201 brosis can also lead to foraminal stenosis, which can also cause nerve root pain. Disks do not need to prolapse to cause pain. Annular tears and internal disruption (i.e., microfractures in vertebral end plates) can cause a pattern of p ain, termed discogenic pain, characterized by low back and referred buttock/posterior thigh pain aggravated by movement. Generally, all mechanical lesions of the lumbar spine can result in referred pain around th e pelvis and anterior thighs. However, pain from lumbar facet joints and probably other seg mental structures can be referred to the lower leg. Aching in the back and posterior thighs after standing is typical of, but not speci \201 c for, spondylolisthesis. There are often added spasms of acute pain, especially if there is segmental instability. The symptoms of spinal stenosis are often relieved by sitting bent slightly forward, since the spinal canal dimensions increase in this position. LOW BACK PAIN AND DISORDERS IN ADULTS 73 Sacroiliitis often causes referred pain to the buttocks and back of thighs. It occurs commonly in spondyloarthropathy (see Chapter 8). \200 Sacroiliac pain c an occur in multiparous women \200\224the condition may be associated with hypermobility. Note the description of the pain \200 Pain may be severe, whatever the cause; however, no te whether the patient \200\231s descriptors of it suggest nonorganic in \202 uences. Sharp, lancinating leg pains suggest nerve root irritation/compression (radicular pain) whereas leg pain referred from other structures within a lumbar segment is generally deep and aching. The distribution may be similar. More persistent, rather than e pisodic, radicular pain may denote stenosis of the nerve root exit foramen. A description of bilateral buttock/leg pain that worsens on walking is consistent with spin al stenosis, especially in those with normal peripheral pulses and no bruits. A change in the description of pain in someone who has an established diagnosis may be important, e.g., subacute, severe, unremitting localized pain in a patient with AS who normally has mild in \202 ammatory pain might re \202 ect a superimposed dis citis; or, acute severe unremitting sleep-disturbing pain in an elderly woman with known ch ronic mechanical pain associated with OA might suggest osteoporotic fracture. Florid descriptions of the pain and its severity are associated with psychological modulators of pain. Previous back pain and trauma, occupation, and family history \200 Scheuermann \200\231s disease (which is associated with irregular vertebral endplates) causes spinal pain in adol escence. It is a risk for spinal degeneration and kyphosis in adults. Previous trauma may have caused pars interarticularis fractures (an antecedent of spondylol isthesis), vertebral fracture (risk of further mechanical damage), or ligament rupture (sub sequent segmental instability). It is generally accepted that the high prevalence of disc disease among manual workers at a relatively young age provides some evidence for a causal relationship. It is often the case that patients with chronic pain following (sometimes trivial) trauma may be dissatis \201 ed with the quality of care received at th e time of the injury. Be aware that many believe that the way in which spinal pain is handl ed at its onset signi \201 cantly in \202 uences its subsequent course. Sacroiliitis is an early part of brucellar arthritis (20 \200\22351% of patients). Poor ani mal- or carcass-handling hygiene or ingestion of infected foodstuffs or milk can lead to in fection. Spondylitis is a late feature and is characterized by erosions, disc infection, an d abscesses. A positive family history of low back pain might, in context, suggest SpA (sacroiliitis), h ypermobility (see Chapter 16), or generalized osteoarthritis (see Chapter 6). CHAPTER 2 Regional musculoskeletal conditions 74 Examination Inspect the undressed patient from the side and behind \200 Note the \202 u idity of movement when the patient is undressing. \200 Check the skin for redness, local swelling, and skin markings. Redness and swelling occasionally accompany osteomyelitis. Lipoma, hairy patches, caf -au-lait patches, or skin tags often re \202 ect underlying structural nerve or bone abnormality, e.g., spina bi \201 da, diastematomyelia, or neuro \201 bromatosis. Skin folds often suggest an underlying signi \201 cant structural change such as osteoporotic fracture or spondylolisthesis. Note any deformity: hyperlordosis (associated with L5/S1 damage and weak abdominal musculat ure), prominent thoracolumbar kyphosis (multiple disc degeneration or vertebral fractures), scoliosis (degenerative, compensatory muscle spasm for unilateral pain). \200 Look from the side. A gentle lordotic curve is normal. Flattening suggests muscle spasm or fusion in SpA. With major spondylolisthesis, a step between spinou s processes can sometimes be seen. Observe active movements while the patient is standing Lumbar forward \202 exion ( \200 \234 \200 with your legs straight, slowly reach down to try and touch your ankles \200 \200\235), lateral \202 exion ( \200\234 \200 with your legs and back straight, tip sidew ays and run your hand down your leg toward your knee \200 \200\235) and extension ( \200 \234 \200 with your legs straight, slowly bend back- wards \200 \200\235). Note: \202 ex ion can be mediated by the hip joints; extension can be affected by slight pelvic tilt and body sway. Ask what can be achieved normally and what is painful. \200 Abnormal movements are not speci \201 c for any condition, although they may help to localize a problem. Pain in extension is characteristic of retrospondylolisthesis, facet joint arthritis, or impinging spinous processes. All may be relieved by \202 exion. Failure of the spinous processes to separate in a patient who manages good forward \202 e xion would be consistent with permanent spinal stiffness, e.g., AS, with \202 exion media ted by the hip joints. Forward \202 exion can be measured using the modi \201 ed Sch ber \200\231s test. When erect, mark the skin at the point midway between the posterior superior iliac spines ( Venus \200\231 dimples) and again 10 cm above and 5 cm below. Measure the increase in dista nce between the outer marks at full forward \202 exion \200\224in a young adult this is n ormally more than 6 cm. Ask the patient to stand on one foot then lift onto their toes a few times. Weakness might imply an L5 nerve root entrapment (gastrocnemius/soleus). Observe the gait pattern An abnormality of gait may re \202 ect any spinal or lower limb p roblem: \200 An antalgic gait. \200 A wide-based gait suggests unsteadiness (due to diz ziness, muscular weakness, proprioceptive, or cerebellar de \201 cit etc.). Leaning forward/stiff legged \200\224although not speci \201 c, in older people this may denote spinal stenosis. LOW BACK PAIN AND DISORDERS IN ADULTS 75 Examiner straightens leg to elicit nerve root pain down leg. Look for difference between R and L leg response Fig. 2.11 The slump test identi \201 es pain from lumbar disc and nerve root irritation or compression (see text). Shuf \202 ing, which could suggest Parkinsonism (back pain/stiffness is a recognized early sign). Foot drop, which could suggest L5 or S1 nerve root compression. \200 Flat feet, hind feet valgus, and genu recurvatum on stance phase, might suggest general hypermobility \200\224associated with various low back lesions. Check extension and lumbar rotation (patient seated) With the patient seated on the couch, check lumbar extension and rota- tion (the pelvis is now \201 xed). \200 Typically, com bined rotation and extension can elicit pain from arthritic facet joints. It is a sensitive though not speci \201 c test. \200 Slumping forward (see Figure 2.11) stretches the dur a. Increased lumbar pain may be elicited in cases of disc prolapse but, more importantly, l eg pain can be elicited in cases of nerve root entrapment. A more provocative test can be d one by gently extending each knee in turn in the slump position. Look for asymmetry. Examine the sacroiliac joints and hips (patient supine) With the patient supine, examinatio n of the sacroiliac joints and an exam- ination of the hips should be done to exclude pain arising from these structures. \200 Test \202 exion and the rotational range of each hi p by lifting the leg, \202 exed at the knee, so that the upper leg is vertical. Passive movement should normall y be pain free. No SI joint stress test is speci \201 c. Tests are designed to reproduce pain in cases of SI joint dysfunction or sacroiliitis. Here are two: \200 Press down and out \201 rmly over both anterior superior iliac spines at the same time. CHAPTER 2 Regional musculoskeletal conditions 76 Lift one leg, \202 ex, and abduct the hip slightly. Exert an axial force into the acetabu lum at two or three different angles. This test is considered by many to be more useful, an d probably stresses both the joint and many of the sacral ligaments, but is less speci \201 c if the hip joint is abnormal. Straight leg raise (Lasegue \200\231s test) The normal variation in straight leg raise rang es from 60 to more than 90 in adults. Compare sides. \200 Discomfort from normal tigh tening of the posterior thigh or calf muscles must be discriminated from a positive test. A positive test (leg raising restricted to 40 or less by radicular pain) is most speci \201 c in patients aged <30 years and fo r L5 or S1 nerve root lesions. A crossed straight leg raise (pain elicited by raising the unaffected leg) is even more speci \201 c for nerve root entrapment. To identify more subtle cases of nerve root entrapment, apply additional foot dorsi \202 exion at the maximum possible angle of (pain- free) leg raise. Lasegue \200\231s test does not always reproduce pain in every patient who has sciatica. It is also often negative in older patients with the condition when it is chi e \202 y due to foraminal stenosis and when central posterior disc prolapse occurs (giving bilateral sciatica but no root compression). Neurologic examination \200 Neurologic examination of the legs is essential in suspected cases of nerve root entrapment, cord compression, spinal stenosis, and cauda equina syndrom e. Examination of the prone patient Ask the patient to turn to lie prone. Palpate low back and over sacrum. \200 Diffuse tenderness may be due to muscle spasm. \200 Super \201 cial tenderness over the spinous processes or interspinous interval might suggest interspinous ligament disruption or impinging processes. Paravertebral bony tenderness may suggest facet joint arthritis. \200 Costovertebral angl e (CVA) tenderness could indicate renal pathology. \200 Tenderness over the SI joints is not speci \201 c for sacroiliitis. \200 A positive femoral stretch test reproduces L1 \200\223L4 (especially L3) radicular pain in the anterior or medial part of the thigh. Flex the patient \200\231s knee to 90 and passively extend the hip. Other examination \200 In suspected cases of spinal stenosis or cauda equina syndrome, it is essential to check for sensory loss in the sacral nerve dermatomes. It is also important to check anal sphincter tone by rectal examination (S5). \200 In suspected cases of spinal stenosis, the patient can be asked to walk until limited by pain, then re-examined. If ther e is any ischemia of the cauda equina or of a nerve root (from foraminal stenosis), nerve r oot signs may become more obvious. LOW BACK PAIN AND DISORDERS IN ADULTS 77 Table 2.11 Testing muscle strength in the lower limbs (patient supine unless otherwise stat ed). Weakness may denote nerve root entrapment Muscle or muscle group Nerve roots Test* Hamstrings (knee \202 exion) L5, S1, S2 Ask patient to \202 ex the knee to 45 , hold patient \200\231s ankle and ask them to ben d the knee further against your hold Iliopsoas (hip \202 exion/ internal rotation) L1, L2, L3 Ask patient to lift the leg with a bent knee, hold up the upper leg and resist your push. T ry to push the leg down and slightly outwards Quadriceps femoris (hip \202 exion, knee extension) L2, L3, L4 1. Hold the patient \200\231s relaxed upper leg above the couch (grasped underneath above t he knee). The lower leg should drop loosely. Ask them to straighten the lower leg against y our resistance 2. From patient standing test repetitive squatting for more subtle weakness Tibialis anterior (ankle dorsi \202 exion).Tibialis posterior (ankle inversion and dorsi \202 exion) L4, L5 1. With the knee straight ask the patient to pull back their foot (show them \201 rst) ag ainst your pull. Resist dorsi \202 exion 2. Standing or walking on heels tests for more subtle weakness. Note: if the hind foot rest s in valgus or the patient signi \201 cantly everts the foot during dorsi \202 exion, the test may also recruit peroneal muscles (L5, S1) Extensor hallucis longus L5, S1 Ask the patient to pull their big toe back against your \201 nger (at the base) Gastrocnemius and soleus(ankle plantar \202 exion) S1, S2 1. Ask the patient to point their toes. Resist the movement by pressing against the ball of the foot 2. Standing or walking on the toes tests for more subtle weakness Compare sides. Score according to scale, for example: 0 = no muscle contraction; 1 = contra ction visible; 2 = active movement, gravity eliminated; 3 = active movement against gravity ; 4 \200\223/4/4+ = active movement against slight/moderate/strong resistance; 5 = normal p ower. CHAPTER 2 Regional musculoskeletal conditions 78 Table 2.12 A mnemonic : principal combinations of signs used for identifying lumbar nerve r oot lesions Nerve root Paresthesias and sensory change Muscle weakness Tendon re \202 ex changes L2 Upper thigh: anterior, medial + lateral surfaces Hip \202 exion and adduction None L3 Anterior surface of lower thigh Hip adduction + knee extension Knee jerk possibly reduced L4 Anteromedial surface of lower leg Knee extension, foot dorsi \202 exion +inversion Knee jerk decreased L5 Anterolateral surface of lower leg + dorsum/medial side of foot/toe 1 Hip extension and abduction. Knee \202 exion. Foot/toe 1 dorsi \202 exion None S1 Lateral border + sole of foot. Back of heel + calf Knee \202 exion. Plantar \202 exion andeversion of foot Ankle jerk decreased Diagnostic procedures \200 There are two important initial steps in investigating low bac k pain. First deciding whether radiographs will help. Second, although relatively rare in p ractice, the possibility of infection, malignancy, and cauda equina compression always need s to be considered. Simple radiographic views are insensitive indicators of these condition s and, in most cases, are not speci \201 c although most radiologists would agree they are desirable in addition to CT or MR. Laboratory tests are mandatory in all suspected cases o f in \202 ammation, infection, and malignancy. Radiographs \200\224decision-making in requesting them (see Table 2.13) \200 Lumbar spine radiographs are not always helpful. Remember that nine out of ten cases of back pain in th e primary care setting are mechanical and self-limiting. Features on a plain radiograph of the lumbar spine correlate poorly with the presence or pattern of pain. Spondylosis is common, age related, and often not symptomatic. \200 Children, athletes, a nd young adults with back pain need prompt radiographic investigation. Failure to detect an d treat a pars interarticularis fracture may lead on to a spondylolysis. Abnormalities are more readily appreciated in these age groups as the frequency of age-related degenerative c hanges in the spine is low. Obtaining radiographs to help in the management of patients is a different issue than obtai ning them to aid diagnosis and one that requires careful thought, e.g., is the patient like ly to perceive that they have received suboptimal care if a radiograph is not requested? LOW BACK PAIN AND DISORDERS IN ADULTS 79 Spondylolysis may be seen on a lateral view but is more easily seen on oblique views. Obliq ue views will also show pedicle stress fractures in athletes. Spondylolisthesis may be identi \201 ed and graded by a lateral \201 lm. Flexion and ext ension views may be helpful in delineating subtle cases and instability (spondylolytic). General osteopenia is a risk factor for low bone mass; however, it is not a sensitive indicator of low bone mass. Look for vertebral squaring (in AS), non-marginal syndesmophytes (in other SpA, such as pso riatic), or \202 owing syndesmophytes (in DISH). \200 Consider obtaining an AP view of the pelvis. Established (but not early) sacroiliitis can be ruled-out. A further \200\234c oned \200\235 view is often helpful. Sacroiliitis (periarticular osteoporosis, erosion, sclerosis of bone, widening joint space) occurs in all types of SpA. It can be unilateral. \200 Sclerosis of the SI joint on the lower iliac side alone suggests osteitis condensans ilii, which may be associated with back pain in multiparous women. Joint space i s normal and joint margin well de \201 ned. Patterns of metabolic bone disease, Paget \200\231s disease and hip pathology are usually readily identi \201 able on a pelvic \201 lm. Bone scan \200 A bone scan is an extremely sensitive test for infection or malignancy. It is a useful investigation in patients with previously diagnosed malignancy who present w ith back pain, especially in those who have had no previous skeletal metastases. A lack of additional lesions strongly suggests against a single spinal abnormality being malignancy r elated. It is not speci \201 c for the various degenerative lesions but can help localize the site of a lesion. Bone scan SI joint appearances in sacroiliitis can be unreliable. CT or MR? The choice of i maging depends largely on likely clinical and radiographic differential diagnosis: \200 F or spondylolytic spondylolisthesis, CT shows the exact site of pars \200\231 defects. The usual appearance is of sclerotic irregular edges. Nerve impingement can be shown by CT or MR. \200 Intervertebral disc prolapse, both poste rior and posterolateral, can be shown by either technique. Prolapse material is of similar CT density and MR signal to the disc and well de \201 ned against epidural fat. \200 Cha nges in the normal disc signal pattern are associated with age- related disc degeneration. Discogenic pain has been associated with MRI abnormalities class i \201 ed according to Modic. On T 2-weighted MR, disc material is usually of higher signal than \200\234scar \200\235 ( e.g., \201 brosis from a previous lesion), in which signal decreases with aging. Recent s carring enhances immediately but old scarring does so only slowly. This discrimination requ ires gadolinium-enhanced MR. CT or MR shows early sacroiliitis in AS when X-rays are normal. \200 The shape and outlin e of the spinal canal are ideally shown on CT but are also seen with MR. It is dif \201 cu lt to distinguish \201 brous structures CHAPTER 2 Regional musculoskeletal conditions 80 Table 2.13 Commonly reported patterns of radiographic abnormality in adults, the interpreta tion, and suggested reaction Radiographic abnormalities Lesion suggested Sensible further action Lumbosacral anomalies Risk for future back pain May not be clinically signi \201 cant. Risk for low back pain (esp. if hypermobile) Generalized osteopenia Osteoporosis Measurement of bone density. Rule out secondary causes, e.g., myeloma Narrowed disc space, marginal vertebral end-plate osteophytes or both Intervertebral disc disruption MR if persistent symptoms or signs of same level nerve root entrapment, spinal or nerve roo t exit foramen stenosis Localized lucent or sclerotic lesion, loss of cortex Tumor, infection, or fracture Discuss case with radiologist. MR or CT may be advised. A bone scan may be helpful. Initiat e appropriate laboratory tests immediately Facet joint OA Facet joint syndrome Consider whether there is associated spinal/nerve root exit foramen stenosis (?radicular sy mptoms) or symptoms suggestive of spondylolisthesis. CT or MR is then likely to be appropri ate Pars interarticularis defect Spondylolysis/ ?spondylolytic Probable prior fracture. Further oblique \201 lm centered on suspected level or CT should con \201 rm. Association with symptoms or signs of disc disease or spondylolisthesis sugg ests an unstable segment. Flexion and extension lateral view radiographs may show instabili ty. MR helpful for imaging soft-tissues including nerves Short lumbar pedicles Spinal stenosis Consider MR if symptoms suggest spinal stenosis Mixed patchy sclerosis and lucency in entire (enlarged) vertebra(e) Paget \200\231s disease Neurologic leg symptoms suggest spinal/exit foramen stenosis or vascular \200\230 \200\234 steal \200\231 \200\235 LOW BACK PAIN AND DISORDERS IN ADULTS 81 from sclerotic or cortical bone on MR, but it discerns intrathecal contents more readily, w hich is an advantage in identifying intradural tumors. Spondylodiscitis (part of SpA), if chronic, may be dif \201 cult to discriminate from degenerative disc/vertebral end-plate disease. Fat- suppressed or gadolin ium-enhanced sequences may show high signal at the anterior disc vertebral end-plate juncti ons. Screening for infection, malignancy, or metabolic bone disease \200 In cases where the hi story and examination suggest a mechanical condition, but where the clinician wishes to be more con \201 dent of excluding an in \202 ammatory condition, an ESR and CRP are suggest ed. An elevated ESR/CRP might indicate a need for further laboratory investigation. An infection screen should include a CBC (with differential), ESR, CRP, and blood and urine cultures. If spinal tuberculosis (Pott \200\231s disease) is suspected, imaging studies an d appropriate microbiological testing should be performed, although radiographic changes oc cur late in the course of disease. Traditionally, three, early morning urine samples are se nt for culture, but the diagnostic yield is quite low. Serum and urine protein electrophoresis (with immuno \201 xation) are essential tests in t he work-up for myeloma. CMP is also important since hypercalcemia and acute renal impairmen t have prognostic signi \201 cance in this condition. Routine blood tests may point to an underlying metabolic bone disorder such as Paget \200 \231s disease or osteomalacia. These tests are normal in postmenopausal osteoporosis. If osteoporosis is diagnosed (see Chapter 16) a screen for secondary causes should include ESR (and if raised, serum and urine protein electrophoresis), calcium, phosphate, and sex h ormones, and also serum 25-hydroxyvitamin D, iPTH, TFTs, LFTs, and Cr. Treatment (also see Chapter 20 for greater detail) \200 An important therapeutic interven tion in the case of acute pain is to take the patient seriously, take a positive view, and in the absence of bad prognostic signs (e.g., nerve root pain), urge early mobility. Analgesics and muscle relaxants can be used in the short term, initially regularly, then as required. Physical therapy with graded-activity programs may be of value, certainly early in disc disease or spondylosis. Cord compression due to bone collapse from a tumor is an acute emergency and should be discussed immediately with an oncologist or radiation oncologist, a nd a spine-orthopedic or neurosurgeon. Cases with disc prolapse failing to respond to conservative therapy, or cases where there i s ongoing or rapidly progressive neurologic de \201 cit, should be referred for surgery. Available surgical techniques for acute or persistent disc disease include decompression procedures (e.g., nerve root decompression and partial facetectomy), prosthetic intervertebral disc replacement, intradiscal thermocoagulation, and intradiscal steroid injections, CHAPTER 2 Regional musculoskeletal conditions 82 although evidence for long-term ef \201 cacy is lacking for all these procedures. Surgery for spinal stenosis is useful for relieving leg neurogenic features but not indicat ed if there is no signi \201 cant neurologic compromise. Surgery is not usually done if th e only effect of spinal stenosis is back pain. In chronic back pain, aerobic exercises combined with behavioral methods may be more effect ive than exercise alone and can help motivate the patient. Methods may also incorporate psy chological and social assessment and management. The common treatments available for chronic back pain include: analgesics and muscle relaxants \200 antiepileptics/antidepressants for neuropathic pain \200 local anesthetic/steroid injections \200 acupuncture \200 transcutaneous electri cal nerve stimulation (TENS) \200 physical therapy \200 ergonomic advice \200 multidi sciplinary programs: counseling \200 cognitive therapy \200 education \200 relaxation \200 corsets and b elts. Timely surgery for structural scoliosis (more common in JIA than the general population) can lessen spinal curvature. This page intentionally left blank CHAPTER 2 Regional musculoskeletal conditions 84 Spinal disorders in children and adolescents (See also Chapter 20.) Background \200 Common conditions in adults such as degenerative back pain and interverte bral disc disease are rare in childhood or adolescence. \200 In hospital series, up to 85 % of referred children have identi \201 able causes (see Table 2.14) although spinal hypermobility in the context of generalized hypermo bility and \201 bromyalgia has not been adequately addressed. Not all presentations are with pain. Some children present with either deformity or neurologic symptoms. A diagnosis must be \201 rmly established (or at least rigorously sought) because serious disease can present with few symptoms. Taking a history Keep an open mind about whether a history from the child, parents, or prim ary caregiver provides the most useful information. There are merits in consulting all of t hem, although this process may be time-consuming. Table 2.14 Cause of childhood back pain. Experience of an orthopedic clinic (a review of 23 3 referrals) Cause of back pain Frequency (%) Nonspeci \201 c (i.e., no cause found) 32 Scoliosis 21 Spondylolysis/Spondylolisthesis (nontrauma) 11 Scheuermann \200\231s disease 7 Infection 6 Tumors, e.g., osteoid osteoma 4 Psychogenic 4 Disc prolapse 3 In \202 ammatory, e.g., spondyloarthropathy 3 Trauma (excluding strains) 2 Limb length inequality/biomechanical 2 Renal pain <1 Rickets <1 Congenital anomalies <1 SPINAL DISORDERS IN CHILDREN AND ADOLESCENTS 85 Severity, distribution, and quality of pain \200 Pain may be mild even in the presence of a serious underlying disorder. If the pain occurs (or initially occurred) during sports, consider pars interarticularis fr actures, spondylolytic spondylolisthesis or Scheuermann \200\231s disease (vertebral epiphy seal osteochondritis). \200 Persistent pain, unrelieved by rest and disturbing sleep, req uires consideration of a bone, bone and/or disc infection, or osteoporotic fracture (steroid-rela ted or juvenile idiopathic osteoporosis (JIO)). \200 JIO is rare, occurs between 6 and 13 years of age and is more common in boys. The main differential diagnosis is osteogenesis i mperfecta (see Chapter 16). Although uncommon, neurologic symptoms such as burning pain, paresthesias, and weakness in the legs suggests nerve root irritation. Spinal stiffness in a child (typically between 2 and 6 years of age) associated with irritability and a diffusely tender back may be due to infectious discitis (though organisms are only found in 50%). In an older child or adolescent (typically 10 \200\22315 years of age) and with a less striking history, immobility-related stiffness cou ld represent juvenile enthesitis related arthritis (ERA). If pain is absent \200 Spinal conditions are not always associated with pain. Occasionall y a child may present with back deformity or neurologic symptoms in the legs alone. \200 The history may be nonspeci \201 c and, for example in a very young child, nothing more than a refusal to walk. Scheuermann \200\231s disease commonly presents in teenagers with a painless thoracic kypho sis. Pain is more likely to be present if the chondritis is thoracolumbar rather than thora cic. The condition is often asymptomatic. Spinal dysraphism (bony abnormality \200\224usually spina bi \201 da, associated with neur al anomaly \200\224invariably cord tethering) and spinal cord tumors can often present with neurologic leg symptoms/signs alone without back pain. Symptoms may be mild initially. Scoliosis is usually pain free. Pain with scoliosis usually indicates signi \201 cant underlying pathology. The differential is wide (see Table 2.15). \200 Th e most frequent single cause of a scoliosis in schoolchildren (40%), found from radiographi c screening, is pelvic tilt due to leg length inequality. Past developmental, medical, family, and social history \200 Ask about milestones in musc uloskeletal development. Abnormality or delay might suggest spinal dysraphism or neuromuscu lar conditions. \200 Osteoporosis may be evident from previous fragility fracture \200 \224 axial or appendicular \200\224or may be intimated from risk factors, e.g., steroid use . \200 Previous low back trauma may have been pars interarticularis fractures preceding (the current) vertebral slip or disc prolapse. \200 Irradiation (e.g., of previ ous Wilms \200\231) is a cause of scoliosis. CHAPTER 2 Regional musculoskeletal conditions 86 Table 2.15 Causes of scoliosis in children and adolescents Idiopathic: infantile (0 \200\2233 years); juvenile (3 \200\22310 years); adolescent (> 10 years) Structural scolioses (vertebral rotation, vertebral structural change, and loss of normal s pinal \202 exibility) Neuromuscular Congenital: failure of vertebral formation, segmentation, or both Neuro \201 bromatosis Heritable disorders of connective tissue, e.g., osteogenesis imperfecta Trauma: fracture; surgical (e.g., post- laminectomy); irradiation Spondyloepiphyseal dysplasia Metabolic bone disease Lumbosacral anomalies (e.g., spondylolytic spondylolisthesis) Cervicothoracic anomalies (e.g., cervical fusion (Klippel \200\223Feil)) Rheumatoid arthritis Extraspinal contractures (e.g., postempyema, postburns) Nonstructural scolioses (lateral spinal curvature but no vertebral rotation)* Postural Nerve root irritation associated Abdominal pain associated (e.g., appendicitis, renal pain) Associated with local in \202 ammation Spinal infection Spinal tumors Secondary to leg length discrepancy Related to soft-tissue contractures around the hip Psychogenic It is characteristic of nonstructural scolioses that if the underlying cause is successfull y dealed with, the scoliosis resolves. Ask about previous TB or risk factors for TB in patients you think are at risk of TB osteomyelitis. Torticollis may be associated with chronic squint, previous trauma (which may be associated with a psychogenic component), and neuroleptic drugs. It can be a sign of an underlying ne urologic or in \202 ammatory lesion or occurs because of an underlying structural anomaly. SPINAL DISORDERS IN CHILDREN AND ADOLESCENTS 87 A history of a heritable disease of connective tissue can often be elicited from the family of a child with structural scoliosis. A history of back pain is sometimes elicited from families of children with nonspeci \201 c back pain. Joint dislocation and multiple soft-tissue musculoskeletal injury (especially overuse) in family members raises the possibility of general hypermobility \200\224either j oint hypermobility syndrome or a heritable connective tissue disease, e.g., Marfan syndrome (see Chapter 16). The existence, or child \200\231s perception, of social disharmony at home or school is lik ely to be more important in in \202 uencing the impact of back pain rather than a cause of it. Nevertheless, in children with nonspeci \201 c spinal pain or \201 bromyalgia, soci al con \202 ict resulting in stress and anxiety may be very important in generating sympto ms. Examination It is best, and certainly ultimately more informative, to undertake the examina tion only when the child is comfortable with the situation, with their modesty and dignity preserved, and with consent to go ahead after a reassurance that the examination will be st opped if it is painful. With younger children there may be \200\234an examinable moment \200\235, usually after the child has gained con \201 dence in the surroundings and with t he situation. Observing a young child while playing is a considerate way of starting the ex amination. Age-related variations in biomechanical development and gait patterns \200 Walking while holding a hand or furniture develops by 12 months and normally independent walking by 18 months. Until 3 years the stance is broad-based in relation to pelvic width, the knee may not fully extend, and the ankle may be plantar \202 exed at foot- strike. Climbing stairs is usually done using alternate feet by age of 3 years. \200 Tiptoe walki ng is not abnormal at \201 rst but should disappear by 2 years. If this pattern remains, consider spasticity, tethered cord, or muscle weakness. Flat feet up to age 5 are normal (a consequence of the distribution of fat and paucity of muscle development). Only investigate if symptomatic. Leg alignment often concerns parents. Up until 2 years of age it is normal to have genu varum. From 2 to 5 years, mild genu valgum may occur. Angles of >10 o r asymmetry may be associated with underlying disease. Regression of motor development is a clue to the presence of disease. Observation Observe c hildren unclothed to underwear if possible. Look for weakness, scoliosis, kyphosis, and swe llings. \200 The main cause of spinal asymmetry will be scoliosis (see Table 2.15). \200 Localized soft tissue swelling may denote soft tissue extension of a spinal though an apparent kyphosis associated with scoliosis is usually a result of spinal rotation. CHAPTER 2 Regional musculoskeletal conditions 88 In children with neck pain, look for a short neck (rule out Klippel-Feil) or asymmetric sca pulae (Sprengel \200\231s deformity: a congential abnormality associated with a higher, hyp oplastic scapula). Adolescent kyphosis may be due to Scheuermann \200\231s disease or fractures. Unless there has been steroid use, the former is more likely. \200 Note any sk in markings such as caf -au-lait spots, skin indents (lumbar area) and lumbosacral hair. They may be markers of bony abnormality.