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

4/4/2014 Roger Saldana, MD Pediatric Orthopedic Surgeon Baptist Health Medical Group � Approach to child with spinal/back complaints � Back pain � Scoliosis � Spondylolysis � Spondylolisthesis 1

4/4/2014 � 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 2

4/4/2014 � 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 3

4/4/2014 � 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 4

4/4/2014 � School/community based � Adams forward bend test � Scoliometer 5

4/4/2014 � 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 6

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4/4/2014 � Age � During growth spurts � Double curves � Thoracic curves � More severe curves � Menarche � Voice change in boys � Risser sign � Bone age 8

4/4/2014 � Pain � Neurofibromatosis � Neurologic abnormalities � Connective tissue disorders � Left curves � Foot deformity � 10-25 degrees � 25-40 � >40 9

4/4/2014 � Defect in the pars interarticularis � Common cause of back pain � L5 most common location 10

4/4/2014 � Anterior slippage of vertebral body � L5 on S1 most common 11

4/4/2014 � Trauma 50% � Genetic predisposition � Repetitive hyperextension � Gait � Palpation � Step off � ROM � Popliteal angles � Hyperextension � Neurologic � L5 12

4/4/2014 � 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 13

4/4/2014 � Failed conservative treatment � Neurologic symptoms � Grade 3-4 slips Thank you 14

4/4/2014 � 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 at age of onset. J Bone Joint Surg Br 36:36-49, 1954 � Dickson RA: Conservative treatment for idiopathic scoliosis. J Bone Joint Surg Br 67:176-181, 1985 � Izatt MT 1 , 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 15