Paediatrics: Spinal disorders

Spinal disorders

General management

History

Pain, onset of deformity, loss of weight, night sweats, family history, disa-bility, other disorders.

Examination

•   Inspection: asymmetry, scapular prominence, skin lesions (especially midline pits and haemangiomas), café au lait spots (associated with neurofibromatosis), foot deformity, leg atrophy.

•   Feel: spinal tenderness.

•   Move: forward flexion, hamstring tightness.

•   General: neurological examination.

•   Investigations: radiographs, CT, MRI, bone scan.

General spinal disorders

Back pain

Take it seriously! More likely to be caused by significant pathology than in adult (e.g. osteoid osteoma, eosinophilic granuloma). Beware of the following, especially in young children—several weeks of symptoms; night pain; increasing symptoms; abnormal neurology; recent onset of scoliosis; night sweats. Pain may be referred from intra-abdominal or intrathoracic process. Investigate thoroughly, but remember 50% of children experience back pain by 15yrs of age.

Discitis

Inflammation (probably infection) of the disc space:

•   Age group: any age (infants and children rather than adolescents).

•   Symptoms: fever; irritability; unwilling to walk; back pain, abdominal pain. Symptoms may be vague.

•   Investigations: bloods (i CRP and ESR); MRI; bone scan.

•   Treatment: antibiotics (according to local policy), at least until inflammatory markers return to normal.

•   Outcome: usually do well.

Congenital anomalies

Diastematomyelia: spinal cord is split by a central cartilaginous/bony prom-inence.

•   Signs: other abnormalities are common (e.g. scoliosis, clubfoot, cavus foot); cutaneous lesions seen in most children; positive neurology seen in 50%.

•   Management: consider resection of spur if neurology appears/is progressive.

•   Spina bifida.

Regional spinal disorders

Cervical spine: torticollis

Thoracic spine 

See Scheuermann’s disease

Lumbar spine: spondylolysis and spondylolisthesis

• Definition: defect of pars interarticularis (spondylolysis). If bilateral and at the same level may result in anterior displacement of one vertebra upon another (spondylolisthesis). Usually due to a stress fracture through a congenitally dysplastic pars.

• Incidence: uncommon, associated with spina bifida, metabolic (e.g. osteopetrosis), connective tissue (e.g. Marfan’s), hyperextension sports (e.g. gymnastics).

• Symptoms/signs: sudden/insidious onset of pain exacerbated by activity. Decreased forward flexion and straight leg raise.

• Investigations: X-rays—lateral and oblique spinal views. Look for ‘Scotty dog’s collar’. Bone scan/SPECT for occult fractures and evidence of healing.

• Management: non-operative usually. Rest and change of activities; consider short-term bracing, analgesia, hamstring stretches, and core strengthening. Operative intervention seldom required for stabilization.

Sacral spine: sacral agenesis

• Definition: hypoplastic/absent sacrum; most common in infants of diabetic mothers.

·Signs: abnormal pelvic ring affecting lower limbs with associated neurology.

·Management: tailor towards severity of agenesis and neurology.