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Juvenile degenerative disc disease: a report of 76 cases identified by magnetic resonance imaging
The Spine Journal 7 (2007) 332–337
Juvenile degenerative disc disease: a report of 76 cases identified by magnetic resonance imaging John R. Dimar II, MDa,b,*, Steven D. Glassman, MDa,b, Leah Y. Carreon, MD, MSca a Kenton D. Leatherman Spine Center and the bDepartment of Orthopaedic Surgery, 210 East Gray Street, Suite 900, University of Louisville School of Medicine, Louisville, KY 40202, USA
Received 4 October 2005; accepted 29 March 2006
Abstract
BACKGROUND: Persistent low back pain in the young remains a significant diagnostic and treatment challenge for clinicians. Traditionally, chronic low back pain in this population has been attributed to either serious undetected pathology or psychosocial etiologies. This assumption may be incorrect because patients in this population may have underlying juvenile degenerative disc disease (JDDD), an important pathological diagnosis in the adult population. PURPOSE: The purpose of this study is to report the presentation, radiographic findings, diagnosis, and treatment modalities of juvenile patients presenting with persistent low back pain for greater then 6 months. STUDY DESIGN: This is a retrospective review of patients less than 21 years old referred to a spine specialty practice with persistent low back pain. PATIENT SAMPLE: The charts of 1,877 patients less than 21 years old referred to a spine specialty practice for the evaluation of spinal problems. OUTCOME MEASURES: Magnetic resonance images (MRI) were obtained and reviewed by a neuroradiologist and two orthopedic surgeons. METHODS: Patients younger than 21 years old with persistent low back pain for greater that 6 months were identified. Patients with scoliosis, Scheuermann’s kyphosis, spondylolisthesis, fracture, tumor, and metabolic bone disease were excluded. Standard demographic information, relevant medical history and physical examination findings were collected. Patients were evaluated with an MRI of their spines to detect any potential underlying pathology. The success of various treatment modalities used was reviewed. The findings of this study were correlated to those of the available literature following a thorough review. RESULTS: Seventy-six patients (34 males, 42 females) with degenerative disc disease were identified on MRI. The mean age was 17.1 years (range 11.5–21.0) with a mean body mass index (BMI) of 24.5 (range 17.7–35.4). Thirty-one had associated radiculopathy. There was 11 smokers, 20 involved in athletics, 17 with co-morbidities, and 9 with a BMI greater than 30. A distinct subgroup of 13 patients with multilevel concurrent spinal stenosis was documented. Four of this subgroup required surgical intervention for severe radicular or claudication symptoms. The majority of JDDD patients were successfully treated with nonoperative modalities. CONCLUSION: The findings of this study question whether lumbosacral degenerative disc disease, commonly thought to exist only in an older population, in fact begins earlier in selected patients. Our study confirms the findings of others that there is a definite population of juveniles that present with chronic low back pain who have degenerative disc disease identified on MRI. Within this population is a subgroup of patients with concurrent congenital spinal stenosis. Most patients with JDDD appear to be well managed by traditional nonoperative treatment modalities. Ó 2007 Elsevier Inc. All rights reserved.
FDA device/drug status: not applicable. Research support received from Norton Healthcare.
1529-9430/07/$ – see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.spinee.2006.03.008
* Corresponding author. Kenton D. Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202. Tel.: (502) 584-7525; fax: (502) 584-6851. E-mail address: [email protected] (J.R. Dimar).
J.R. Dimar et al. / The Spine Journal 7 (2007) 332–337 Keywords:
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Juvenile degenerative disc disease; Congenital spinal stenosis; Degenerative disc disease; Adolescent low back pain; MRI findings in spinal stenosis; Spinal claudication
Introduction The treatment of chronic low back pain in juveniles remains a significant challenge for clinicians. Traditionally, persistent low back complaints in adolescents have either been considered indicative of significant undetected pathology [1–3] or psychosocial etiologies [4,5]. The paradigm of an all or nothing diagnosis may be incorrect. Certain patients within this population may in fact have juvenile degenerative disc disease (JDDD), an important pathological diagnosis in the adult population. Although there are numerous epidemiological studies [1,5–15] identifying the prevalence of low back pain in schoolchildren and twins, little has been written characterizing treatment options and the long-term prognosis within the JDDD population. This is a retrospective study of 76 patients less than age 21 referred to our institution, complaining of a minimum of 6 months of chronic low back pain who had JDDD identified on magnetic resonance imaging (MRI). This report documents their presentation and treatment modalities. Materials and methods Records of 1,953 patients less than 21 years of age were retrospectively reviewed after referral for the evaluation of their spines from 1998 until 2004. Pathology identified within the population included scoliosis (1,439 patients), Scheurmann’s kyphosis (163 patients), spondylolisthesis (154 patients), previous fracture (91 patients), bone tumors (28 patients), metabolic bone disease (2 patients), intraspinal abnormalities, and previous surgery. Although many of these patients exhibited concurrent back pain, they were all excluded from the study because their back pain could not be attributed exclusively to JDDD. Patients without other diagnostic characteristics exhibiting low back pain with or without radiculopathy for duration of greater than 6 months were selected for evaluation. Standard demographic information was collected including age, sex, weight, co-morbidities, family history, smoking history, sports involvement, duration of low back pain, and prior treatment modalities. The presence of neurological symptoms, including radiculopathy and spinal claudication, was also recorded. These patients were evaluated with plain anteroposterior and lateral radiographs along with a MRI for potential identifiable causes of their symptoms. All of the MRI examinations were performed at the same institution and read by a single observer. The basis of diagnosing JDDD is a reduction in the signal intensity of any of the lumbar intervertebral discs on T2-weighted spin echo images. This reduction in signal intensity occurs either as a consequence of normal
aging [16] or the presence of disc degeneration [17,18]. Because all of our patients are younger than 21 years, disc degeneration is the more probable diagnosis. The successes of the various treatment modalities were reviewed. All patients were followed for a minimum of 1 year and monitoring continues prospectively. All patients and families were counseled concerning the known etiology, long-term prognosis, and available treatment options. Career opportunities were discussed with emphasis on avoiding heavy bending and lifting vocations.
Results There were 76 patients identified by MRI as having JDDD (34 males, 42 females) with a mean age of 17.1 years (range511.5–21.0) (Fig. 1). The average follow-up was 38 months (range 24 to 101 months). The MRIs demonstrated that L4–L5 and L5–S1 were the most frequently involved levels (Table 1) and that the degenerative disc pathology was generally confined to one or two levels (Table 2). Thirty-one (40.7%) had associated radiculopathy upon presentation. There were 11 smokers. Seventeen had comorbidities such as asthma (6) and mitral valve prolapse (4). There were 20 patients active in sports including gymnastics, football, soccer, golf, track and field, and skiing. The mean body mass index was 24.5 (range517.7–35.4), with nine patients having a body mass index of 30 or greater. There was a history of low back pain in a first-degree relative in 11 of the patients. Congenital spinal stenosis was documented in 13 patients, six of whom presented with radiculopathy. The diagnosis of congenital spinal stenosis was made when the midsagittal anteroposterior diameter of the canal at the center of the posterior wall of the vertebral body to the anterior margin of the junction of the lamina was less than 12 mm [19]. The average midsagittal anteroposterior diameter in the patients with congenital spinal stenosis was 5.72 mm (SD52.60, range 3.28 to 11.69). All patients were started on a treatment regimen of nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, back and abdominal strengthening exercises, bracing, weight reduction, and career counseling. Sports activities were restricted until patients improved enough to return to play or failed to improve requiring permanent restriction. Thirteen patients who had congenital spinal stenosis continued to be symptomatic and were treated with epidural steroid injections done once a week for 3 weeks. Injections were done without fluoroscopic assistance using an interlaminar approach, by three anesthesiologists from a single pain management clinic.
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J.R. Dimar et al. / The Spine Journal 7 (2007) 332–337
Fig. 1. This is a 16 year old female cheerleader with a one-year history of severe low back pain and right leg L5 radiculopathy. (A) Sagittal MRI showing two level disc degeneration at L4–L5 and L5–S1 with centrally protruding discs. (B) Coronal image through L4–L5 and (C) Coronal image through L5–S1.
Four patients continued to be symptomatic even after epidural steroid injections and required a decompression for refractory neurological symptoms. These four patients had congenital spinal stenosis (Fig. 2); two were males and two were females, none had a body mass index greater than 30, and three were smokers. On the most recent follow-up, these patients had resolution of the radiculopathy but continued to complain of mild, tolerable back pain, responsive to NSAIDs.
of which necessitate an extensive medical and radiographic evaluation [1–3]. Unfortunately, if no significant pathology is identified, these patients are frequently felt to have underlying psychosocial etiologies [4,5]. The paradigm of an all or nothing diagnosis may be incorrect because certain patients within this population may have JDDD that would be considered an important pathological condition as an adult, requiring observation and treatment. Numerous epidemiological studies have identified a significant incidence of low back pain in the juvenile population ranging from 13% to 51% [3,4,21]. Other studies
Discussion The treatment of low back pain in juveniles remains a significant challenge for clinicians. Clinical examination has been shown to produce few clinical signs that consistently single out children with low back pain or delineate its origin [20]. Therefore, persistent low back pain in this population has traditionally been considered to be a hallmark for serious undetected pathology, including spinal cord or bone tumors, discitis, disc herniation, spondylolisthesis, and infection, all
Table 1 Levels with magnetic resonance imaging changes consistent with degenerative disc disease Level involved
Number of patients
L1–L2 L2–L3 L3–L4 L4–L5 L5–L6
8 7 17 42 53
J.R. Dimar et al. / The Spine Journal 7 (2007) 332–337 Table 2 Number of levels with magnetic resonance imaging changes consistent with degenerative disc disease in each patient Number of levels
Number of patients
1 2 3 4 5
36 28 9 1 2
followed normal school age children and demonstrated a causal relationship between low back pain and premature degeneration of the lumbar discs identified on MRI [13– 15]. Once identified, the risk of recurrent low back pain and the continued likelihood of recurrent low back pain in adulthood is significant [13,22]. The cause and outcome of juvenile low back pain differ from country to country. Twin studies from Canada [9] and large schoolchildren cohort studies from Finland [13,15,22] suggest that juvenile low back pain has a specific etiology rooted in genetics and complex environmental causes. Contrary to these findings, studies from England concluded that
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low back pain in juvenile schoolchildren should be considered a normal life experience [23,24] or to arise from a psychosocial problem [5] with no identified underlying pathology. Other studies have looked at alternate etiologies including genetics [6], body habitus [7], smoking [25], occupational risks, environmental risks, trauma, and psychological factors [1,5,8–12]. The potential familial origin of degenerative spinal disease has been documented in multiple twin cohort studies, whereas the possible genetic origin has been traced to factors such as genetically determined back muscle strength or an abnormality of the gene (COL9A2) that codes for collagen IX, which is critical for normal intervertebral disc integrity [26–30]. Although certain authors have found no relationship between physical activity and low back pain in juveniles [31], numerous others have reported that trauma is an increasingly common cause of low back pain in juveniles. The popularity of childhood athletics [32,33] has resulted in a documented increase in acute and chronic sports-related injuries [34,35]. Although the cause of these sports-related injuries most often represents an acute myofascial strain,
Fig. 2. This is a 15 year old male with a one-year history of low back pain and spinal claudication. Non-operative care did not relieve the patient’s symptoms and he eventually underwent surgical decompression. (A) Sagittal MRI showing degenerative discs at L3–L4 to L5–S1. (B) Coronal MRI showing severe congenital stenosis at L4–L5.
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the repetitive nature of these sports activities may eventually lead to significant mechanical stresses. Similar stresses have been shown to cause disc degeneration in experimental studies [6,34]. Nevertheless, the incidence of low back pain in the juvenile population secondary to degenerative disc disease needs to be characterized, along with its treatment options and long-term prognosis. This is particularly critical because the continuation of these chronic complaints, as in adults, may lead to surgical treatment which has demonstrated poor long-term results and a significant reoperation rate [35,36]. This study is not an epidemiological study that evaluated a presumed normal juvenile population but one that contains subjects who had failed treatment after having been previously examined and evaluated by primary care practitioners. Therefore, instead of having to question healthy juvenile subjects concerning the prevalence of low back pain, our presenting patient population had already been screened and referred for the treatment of existing low back pain. The patients’ prior treatment included traditional modalities such as NSAIDs, physical therapy, bracing, and activity modification. They presented for surgical evaluation with low back pain, leg pain, or a combination of both back and leg pain. Although the initial indication for the MRI was to rule out any serious unrecognized pathology, our findings confirmed the findings of several of the previously cited studies that identified a relationship between the presence of childhood lumbar low back pain and concurrent degenerative disc disease [13,22]. The MRI identified a total of 76 patients that had confirmed JDDD. This study shows that the occurrence of a serious underlying pathological condition within a juvenile population, such as a spinal tumor, was far rarer than the frequent occurrence of degenerative spinal disease. Additionally, other cited risks factors such as obesity, family history of low back pain, and involvement in sports activities were frequently noted within our study group. One of the most interesting findings within this study was the high incidence of associated congenital spinal stenosis. The origin and pathogenesis of congenital spinal stenosis in juveniles is poorly understood with a majority of previous studies focusing on acquired adult spinal stenosis [37,38]. The few studies that discuss congenital spinal stenosis reported the onset of symptoms during the third and fourth decades which is significantly later than the second decade in this study [39,40]. The data in this study suggest that there exists a distinct subset that present with both persistent severe low back pain and radicular symptoms. The MRIs of these patients demonstrated advanced lumbosacral degenerative disc disease with central discal protrusions and shortening of the pedicles. The stenosis generally involved more than one level usually affecting the bottom three motion segments. All of the patients with spinal stenosis had concurrent JDDD demonstrating a coexistent relationship between
these two different pathological processes. It is important to stress that these patients exhibited centrally protruded discs and did not demonstrate acute posterolateral disc herniations. Acute herniated discs in juveniles represent a difficult diagnostic challenge because they may present with a variety of symptoms, including low back pain and numbness, but may also report no radicular leg pain while presenting with a frank motor deficit [35,36]. Because there is no differentiation within the literature between the existence of concurrent spinal stenosis and acute herniated discs in the juvenile population, it is difficult to access the actual incidence of congenital spinal stenosis. However, it would appear from our findings that the incidence of juvenile congenital spinal stenosis is not insignificant and may easily have been confused for an acute herniated disc in prior studies where MRIs were not readily available. This subset of patients fared poorly with nonoperative care, and the four patients requiring surgery within the study were in this group. After the identification of JDDD, each patient and family were counseled concerning the nature of the problem, treatment options, long-term prognosis, and suggested restrictions of career choices. The treatment regimen consisted of NSAIDs, activity modification, physical therapy with back and abdominal strengthening, bracing, weight reduction, and career counseling. Patients who were involved in athletics were restricted from their respective sports activities until they were significantly improved enough to return or failed to do so, requiring permanent restriction. The patients with congenital spinal stenosis combined with degenerative disc disease who had significant radiculopathy were treated with epidural steroid injections. All of the patients’ symptoms were successfully treated with nonoperative modalities except for four patients with congenital spinal stenosis and degenerative disc disease who required surgical decompression owing to severe and unremitting radicular symptoms. In conclusion, the findings of this study question whether lumbosacral degenerative disc disease, commonly believed to be a disease of middle age, in fact begins in adolescents in selected patients. JDDD is not an uncommon cause of low back pain in the adolescent population and is a common finding in patients referred to a spine specialty practice. In this study, JDDD was uniformly found in patients with congenital spinal stenosis, indicating a possible coexistent relationship. However, because only symptomatic patients were included in this study and had MRIs, it is entirely plausible that a large population of asymptomatic patients with congenital stenosis exists without JDDD. Finally, JDDD responds well to continued nonoperative modalities and rarely requires surgical intervention except in patients with coexistent spinal stenosis. References [1] Roger E, Letts M. Sickle cell disease of the spine in children. Can J Surg 1999;42:289–92.
J.R. Dimar et al. / The Spine Journal 7 (2007) 332–337 [2] Sponseller PD. Evaluating the child with back pain. Am Fam Physician 1996;54:1933–41. [3] Turner PG, Green JH, Galasko CS. Back pain in childhood. Spine 1989;14:812–4. [4] Szpalski M, Gunzburg R, Balague F, Nordin M, Melot C. A 2-year prospective longitudinal study on low back pain in primary school children. Eur Spine J 2002;11:459–64. Epub 2002 May 7. [5] Jones GT, Watson KD, Silman AJ, Symmons DP, Macfarlane GJ. Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatrics 2003;111(4 Pt 1): 822–8. [6] Rannou F, Corvol M, Revel M, Poiraudeau S. Disk degeneration and disk herniation: the contribution of mechanical stress. Joint Bone Spine 2001;68:543–6. [7] Leboeuf-Yde C, Kyvik KO, Bruun NH. Low back pain and lifestyle. Part II–Obesity. Information from a population-based sample of 29,424 twin subjects. Spine 1999;24:779–83. discussion 783–4. [8] Sambrook PN, MacGregor AJ, Spector TD. Genetic influences on cervical and lumbar disc degeneration: a magnetic resonance imaging study in twins. Arthritis Rheum 1999;42:366–72. [9] Battie MC, Videman T, Gibbons LE, Fisher LD, Manninen H, Gill K. 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration: a study relating lifetime exposures and magnetic resonance imaging findings in identical twins. Spine 1995;20:2601–12. [10] Videman T, Battie MC, Gibbons LE, et al. Disc degeneration and bone density in monozygotic twins discordant for insulin-dependent diabetes mellitus. J Orthop Res 2000;18:768–72. [11] Battie MC, Videman T, Parent E. Lumbar disc degeneration: epidemiology and genetic influences. Spine 2004;29:2679–90. [12] Watson KD, Papageorgiou AC, Jones GT, et al. Low back pain in schoolchildren: the role of mechanical and psychosocial factors. Arch Dis Child 2003;88:12–7. [13] Salminen JJ, Erkintalo MO, Pentti J, Oksanen A, Kormano MJ. Recurrent low back pain and early disc degeneration in the young. Spine 1999;24:1316–21. [14] Hestbaek L, Leboeuf-Yde C, Kyvik KO, et al. Comorbidity with low back pain: a cross-sectional population-based survey of 12- to 22year-olds. Spine 2004;29:1483–91. discussion 1492. [15] Taimela S, Kujala UM, Salminen JJ, Viljanen T. The prevalence of low back pain among children and adolescents: a nationwide, cohort-based questionnaire survey in Finland. Spine 1997;22:1132–6. [16] Sether LA, Yu S, Haughton VM, Fischer ME. Intervertebral disk: normal age-related changed in MR signal intensity. Radiology 1990;177:385–8. [17] Schiebler ML, Grenier N, Fallon M, Camerino V, Zlatkin M, Kressel HY. Normal and degenerated disk: in vivo and in vitro MR imaging with histopathologic correlation. Am J Roentgenol 1991;157: 93–7. [18] Tertti M, Paajanen H, Laato M, Aho H, Komu M, Kormanc M. Disc degeneration in magnetic resonance imaging: a comparative biochemical, histologic, and radiologic study in cadaver spines. Spine 1991;16:629–34. [19] Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg [Br] 1954;36:230. [20] Gunzburg R, Balague F, Nordin M, et al. Low back pain in a population of school children. Eur Spine J 1999;8:439–43.
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[21] Jones MA, Stratton G, Reilly T, Unnithan VB. A school-based survey of recurrent non-specific low-back pain prevalence and consequences in children. Health Educ Res 2004;19:284–9. [22] Salminen JJ, Erkintalo M, Laine M, Pentti J. Low back pain in the young: a prospective three-year follow-up study of subjects with and without low back pain. Spine 1995;20:2101–7. discussion 2108. [23] Burton AK, Clarke RD, McClune TD, Tillotson KM. The natural history of low back pain in adolescents. Spine 1996;21:2323–8. [24] Burton AK. Low back pain in children and adolescents: to treat or not? Bull Hosp Jt Dis 1996;55:127–9. [25] Battie MC, Videman T, Gill K, et al. 1991 Volvo Award in clinical sciences. Smoking and lumbar intervertebral disc degeneration: an MRI study of identical twins. Spine 1991;16:1015–21. [26] Ropponen A, Levalahti E, Videman T, Kaprio J, Battie MC. The role of genetics and environment in lifting force and isometric trunk extensor endurance. Phys Ther 2004;84:608–21. [27] Annunen S, Paassilta P, Lohiniva J, et al. An allele of COL9A2 associated with intervertebral disc disease. Science 1999;285(5426): 409–12. [28] Videman T, Leppavuori J, Kaprio J, et al. 1998 Volvo Award Winner in Basic Science Studies: Intragenic polymorphisms of the vitamin D receptor gene associated with intervertebral disc degeneration. Spine 1998;23:2477–85. [29] Paassilta P, Lohiniva J, Goring HH, et al. Identification of a novel common genetic risk factor for lumbar disk disease. JAMA 2001;285:1843–9. [30] Karppinen J, Paakko E, Paassilta P, et al. Radiologic phenotypes in lumbar MR imaging for a gene defect in the COL9A3 gene of type IX collagen. Radiology 2003;227:143–8. Epub 2003 Feb 19. [31] Wedderkopp N, Leboeuf-Yde C, Bo Andersen L, Froberg K, Steen Hansen H. Back pain in children: no association with objectively measured level of physical activity. Spine 2003;28:2019–24. discussion 2024. [32] Lyle MJ, Wood R. Back pain in young athletes: significant differences from adults in causes and patterns. Pediatr Adolesc Med 1995;149:15–8. [33] Waicus KM, Smith BW. Back injuries in the pediatric athlete. Curr Sports Med Rep 2002;1:52–8. [34] Rannou F, Poiraudeau S, Foltz V, Boiteux M, Corvol M, Revel M. Monolayer anulus fibrosus cell cultures in a mechanically active environment: local culture condition adaptations and cell phenotype study. J Lab Clin Med 2000;136:412–21. [35] Parisini P, Di Silvestre M, Greggi T, Miglietta A, Paderni S. Lumbar disc excision in children and adolescents. Spine 2001;26: 1997–2000. [36] Durham SR, Sun PP, Sutton LN. Surgically treated lumbar disc disease in the pediatric population: an outcome study. J Neurosurg 2000;92(1 Suppl.):1–6. [37] Naylor A. Factors in the development of the spinal stenosis syndrome. J Bone Joint Surg Br 1979;61-B:306–9. [38] Grabias S. Current concepts review. The treatment of spinal stenosis. J Bone Joint Surg Am 1980;62:308–13. [39] Bowen V, Shannon R, Kirkaldy-Willis WH. Lumbar spinal stenosis: a review article. Childs Brain 1978;4:257–77. [40] Epstein, Nancy E. Surgical management of lumbar stenosis: decompression and indications for fusion. Neurosurg Focus 1997;3. Article 1.
Juvenile degenerative disc disease: a report of 76 cases identified by magnetic resonance imaging John R. Dimar II, MDa,b,*, Steven D. Glassman, MDa,b, Leah Y. Carreon, MD, MSca a Kenton D. Leatherman Spine Center and the bDepartment of Orthopaedic Surgery, 210 East Gray Street, Suite 900, University of Louisville School of Medicine, Louisville, KY 40202, USA
Received 4 October 2005; accepted 29 March 2006
Abstract
BACKGROUND: Persistent low back pain in the young remains a significant diagnostic and treatment challenge for clinicians. Traditionally, chronic low back pain in this population has been attributed to either serious undetected pathology or psychosocial etiologies. This assumption may be incorrect because patients in this population may have underlying juvenile degenerative disc disease (JDDD), an important pathological diagnosis in the adult population. PURPOSE: The purpose of this study is to report the presentation, radiographic findings, diagnosis, and treatment modalities of juvenile patients presenting with persistent low back pain for greater then 6 months. STUDY DESIGN: This is a retrospective review of patients less than 21 years old referred to a spine specialty practice with persistent low back pain. PATIENT SAMPLE: The charts of 1,877 patients less than 21 years old referred to a spine specialty practice for the evaluation of spinal problems. OUTCOME MEASURES: Magnetic resonance images (MRI) were obtained and reviewed by a neuroradiologist and two orthopedic surgeons. METHODS: Patients younger than 21 years old with persistent low back pain for greater that 6 months were identified. Patients with scoliosis, Scheuermann’s kyphosis, spondylolisthesis, fracture, tumor, and metabolic bone disease were excluded. Standard demographic information, relevant medical history and physical examination findings were collected. Patients were evaluated with an MRI of their spines to detect any potential underlying pathology. The success of various treatment modalities used was reviewed. The findings of this study were correlated to those of the available literature following a thorough review. RESULTS: Seventy-six patients (34 males, 42 females) with degenerative disc disease were identified on MRI. The mean age was 17.1 years (range 11.5–21.0) with a mean body mass index (BMI) of 24.5 (range 17.7–35.4). Thirty-one had associated radiculopathy. There was 11 smokers, 20 involved in athletics, 17 with co-morbidities, and 9 with a BMI greater than 30. A distinct subgroup of 13 patients with multilevel concurrent spinal stenosis was documented. Four of this subgroup required surgical intervention for severe radicular or claudication symptoms. The majority of JDDD patients were successfully treated with nonoperative modalities. CONCLUSION: The findings of this study question whether lumbosacral degenerative disc disease, commonly thought to exist only in an older population, in fact begins earlier in selected patients. Our study confirms the findings of others that there is a definite population of juveniles that present with chronic low back pain who have degenerative disc disease identified on MRI. Within this population is a subgroup of patients with concurrent congenital spinal stenosis. Most patients with JDDD appear to be well managed by traditional nonoperative treatment modalities. Ó 2007 Elsevier Inc. All rights reserved.
FDA device/drug status: not applicable. Research support received from Norton Healthcare.
1529-9430/07/$ – see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.spinee.2006.03.008
* Corresponding author. Kenton D. Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202. Tel.: (502) 584-7525; fax: (502) 584-6851. E-mail address: [email protected] (J.R. Dimar).
J.R. Dimar et al. / The Spine Journal 7 (2007) 332–337 Keywords:
333
Juvenile degenerative disc disease; Congenital spinal stenosis; Degenerative disc disease; Adolescent low back pain; MRI findings in spinal stenosis; Spinal claudication
Introduction The treatment of chronic low back pain in juveniles remains a significant challenge for clinicians. Traditionally, persistent low back complaints in adolescents have either been considered indicative of significant undetected pathology [1–3] or psychosocial etiologies [4,5]. The paradigm of an all or nothing diagnosis may be incorrect. Certain patients within this population may in fact have juvenile degenerative disc disease (JDDD), an important pathological diagnosis in the adult population. Although there are numerous epidemiological studies [1,5–15] identifying the prevalence of low back pain in schoolchildren and twins, little has been written characterizing treatment options and the long-term prognosis within the JDDD population. This is a retrospective study of 76 patients less than age 21 referred to our institution, complaining of a minimum of 6 months of chronic low back pain who had JDDD identified on magnetic resonance imaging (MRI). This report documents their presentation and treatment modalities. Materials and methods Records of 1,953 patients less than 21 years of age were retrospectively reviewed after referral for the evaluation of their spines from 1998 until 2004. Pathology identified within the population included scoliosis (1,439 patients), Scheurmann’s kyphosis (163 patients), spondylolisthesis (154 patients), previous fracture (91 patients), bone tumors (28 patients), metabolic bone disease (2 patients), intraspinal abnormalities, and previous surgery. Although many of these patients exhibited concurrent back pain, they were all excluded from the study because their back pain could not be attributed exclusively to JDDD. Patients without other diagnostic characteristics exhibiting low back pain with or without radiculopathy for duration of greater than 6 months were selected for evaluation. Standard demographic information was collected including age, sex, weight, co-morbidities, family history, smoking history, sports involvement, duration of low back pain, and prior treatment modalities. The presence of neurological symptoms, including radiculopathy and spinal claudication, was also recorded. These patients were evaluated with plain anteroposterior and lateral radiographs along with a MRI for potential identifiable causes of their symptoms. All of the MRI examinations were performed at the same institution and read by a single observer. The basis of diagnosing JDDD is a reduction in the signal intensity of any of the lumbar intervertebral discs on T2-weighted spin echo images. This reduction in signal intensity occurs either as a consequence of normal
aging [16] or the presence of disc degeneration [17,18]. Because all of our patients are younger than 21 years, disc degeneration is the more probable diagnosis. The successes of the various treatment modalities were reviewed. All patients were followed for a minimum of 1 year and monitoring continues prospectively. All patients and families were counseled concerning the known etiology, long-term prognosis, and available treatment options. Career opportunities were discussed with emphasis on avoiding heavy bending and lifting vocations.
Results There were 76 patients identified by MRI as having JDDD (34 males, 42 females) with a mean age of 17.1 years (range511.5–21.0) (Fig. 1). The average follow-up was 38 months (range 24 to 101 months). The MRIs demonstrated that L4–L5 and L5–S1 were the most frequently involved levels (Table 1) and that the degenerative disc pathology was generally confined to one or two levels (Table 2). Thirty-one (40.7%) had associated radiculopathy upon presentation. There were 11 smokers. Seventeen had comorbidities such as asthma (6) and mitral valve prolapse (4). There were 20 patients active in sports including gymnastics, football, soccer, golf, track and field, and skiing. The mean body mass index was 24.5 (range517.7–35.4), with nine patients having a body mass index of 30 or greater. There was a history of low back pain in a first-degree relative in 11 of the patients. Congenital spinal stenosis was documented in 13 patients, six of whom presented with radiculopathy. The diagnosis of congenital spinal stenosis was made when the midsagittal anteroposterior diameter of the canal at the center of the posterior wall of the vertebral body to the anterior margin of the junction of the lamina was less than 12 mm [19]. The average midsagittal anteroposterior diameter in the patients with congenital spinal stenosis was 5.72 mm (SD52.60, range 3.28 to 11.69). All patients were started on a treatment regimen of nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, back and abdominal strengthening exercises, bracing, weight reduction, and career counseling. Sports activities were restricted until patients improved enough to return to play or failed to improve requiring permanent restriction. Thirteen patients who had congenital spinal stenosis continued to be symptomatic and were treated with epidural steroid injections done once a week for 3 weeks. Injections were done without fluoroscopic assistance using an interlaminar approach, by three anesthesiologists from a single pain management clinic.
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Fig. 1. This is a 16 year old female cheerleader with a one-year history of severe low back pain and right leg L5 radiculopathy. (A) Sagittal MRI showing two level disc degeneration at L4–L5 and L5–S1 with centrally protruding discs. (B) Coronal image through L4–L5 and (C) Coronal image through L5–S1.
Four patients continued to be symptomatic even after epidural steroid injections and required a decompression for refractory neurological symptoms. These four patients had congenital spinal stenosis (Fig. 2); two were males and two were females, none had a body mass index greater than 30, and three were smokers. On the most recent follow-up, these patients had resolution of the radiculopathy but continued to complain of mild, tolerable back pain, responsive to NSAIDs.
of which necessitate an extensive medical and radiographic evaluation [1–3]. Unfortunately, if no significant pathology is identified, these patients are frequently felt to have underlying psychosocial etiologies [4,5]. The paradigm of an all or nothing diagnosis may be incorrect because certain patients within this population may have JDDD that would be considered an important pathological condition as an adult, requiring observation and treatment. Numerous epidemiological studies have identified a significant incidence of low back pain in the juvenile population ranging from 13% to 51% [3,4,21]. Other studies
Discussion The treatment of low back pain in juveniles remains a significant challenge for clinicians. Clinical examination has been shown to produce few clinical signs that consistently single out children with low back pain or delineate its origin [20]. Therefore, persistent low back pain in this population has traditionally been considered to be a hallmark for serious undetected pathology, including spinal cord or bone tumors, discitis, disc herniation, spondylolisthesis, and infection, all
Table 1 Levels with magnetic resonance imaging changes consistent with degenerative disc disease Level involved
Number of patients
L1–L2 L2–L3 L3–L4 L4–L5 L5–L6
8 7 17 42 53
J.R. Dimar et al. / The Spine Journal 7 (2007) 332–337 Table 2 Number of levels with magnetic resonance imaging changes consistent with degenerative disc disease in each patient Number of levels
Number of patients
1 2 3 4 5
36 28 9 1 2
followed normal school age children and demonstrated a causal relationship between low back pain and premature degeneration of the lumbar discs identified on MRI [13– 15]. Once identified, the risk of recurrent low back pain and the continued likelihood of recurrent low back pain in adulthood is significant [13,22]. The cause and outcome of juvenile low back pain differ from country to country. Twin studies from Canada [9] and large schoolchildren cohort studies from Finland [13,15,22] suggest that juvenile low back pain has a specific etiology rooted in genetics and complex environmental causes. Contrary to these findings, studies from England concluded that
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low back pain in juvenile schoolchildren should be considered a normal life experience [23,24] or to arise from a psychosocial problem [5] with no identified underlying pathology. Other studies have looked at alternate etiologies including genetics [6], body habitus [7], smoking [25], occupational risks, environmental risks, trauma, and psychological factors [1,5,8–12]. The potential familial origin of degenerative spinal disease has been documented in multiple twin cohort studies, whereas the possible genetic origin has been traced to factors such as genetically determined back muscle strength or an abnormality of the gene (COL9A2) that codes for collagen IX, which is critical for normal intervertebral disc integrity [26–30]. Although certain authors have found no relationship between physical activity and low back pain in juveniles [31], numerous others have reported that trauma is an increasingly common cause of low back pain in juveniles. The popularity of childhood athletics [32,33] has resulted in a documented increase in acute and chronic sports-related injuries [34,35]. Although the cause of these sports-related injuries most often represents an acute myofascial strain,
Fig. 2. This is a 15 year old male with a one-year history of low back pain and spinal claudication. Non-operative care did not relieve the patient’s symptoms and he eventually underwent surgical decompression. (A) Sagittal MRI showing degenerative discs at L3–L4 to L5–S1. (B) Coronal MRI showing severe congenital stenosis at L4–L5.
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the repetitive nature of these sports activities may eventually lead to significant mechanical stresses. Similar stresses have been shown to cause disc degeneration in experimental studies [6,34]. Nevertheless, the incidence of low back pain in the juvenile population secondary to degenerative disc disease needs to be characterized, along with its treatment options and long-term prognosis. This is particularly critical because the continuation of these chronic complaints, as in adults, may lead to surgical treatment which has demonstrated poor long-term results and a significant reoperation rate [35,36]. This study is not an epidemiological study that evaluated a presumed normal juvenile population but one that contains subjects who had failed treatment after having been previously examined and evaluated by primary care practitioners. Therefore, instead of having to question healthy juvenile subjects concerning the prevalence of low back pain, our presenting patient population had already been screened and referred for the treatment of existing low back pain. The patients’ prior treatment included traditional modalities such as NSAIDs, physical therapy, bracing, and activity modification. They presented for surgical evaluation with low back pain, leg pain, or a combination of both back and leg pain. Although the initial indication for the MRI was to rule out any serious unrecognized pathology, our findings confirmed the findings of several of the previously cited studies that identified a relationship between the presence of childhood lumbar low back pain and concurrent degenerative disc disease [13,22]. The MRI identified a total of 76 patients that had confirmed JDDD. This study shows that the occurrence of a serious underlying pathological condition within a juvenile population, such as a spinal tumor, was far rarer than the frequent occurrence of degenerative spinal disease. Additionally, other cited risks factors such as obesity, family history of low back pain, and involvement in sports activities were frequently noted within our study group. One of the most interesting findings within this study was the high incidence of associated congenital spinal stenosis. The origin and pathogenesis of congenital spinal stenosis in juveniles is poorly understood with a majority of previous studies focusing on acquired adult spinal stenosis [37,38]. The few studies that discuss congenital spinal stenosis reported the onset of symptoms during the third and fourth decades which is significantly later than the second decade in this study [39,40]. The data in this study suggest that there exists a distinct subset that present with both persistent severe low back pain and radicular symptoms. The MRIs of these patients demonstrated advanced lumbosacral degenerative disc disease with central discal protrusions and shortening of the pedicles. The stenosis generally involved more than one level usually affecting the bottom three motion segments. All of the patients with spinal stenosis had concurrent JDDD demonstrating a coexistent relationship between
these two different pathological processes. It is important to stress that these patients exhibited centrally protruded discs and did not demonstrate acute posterolateral disc herniations. Acute herniated discs in juveniles represent a difficult diagnostic challenge because they may present with a variety of symptoms, including low back pain and numbness, but may also report no radicular leg pain while presenting with a frank motor deficit [35,36]. Because there is no differentiation within the literature between the existence of concurrent spinal stenosis and acute herniated discs in the juvenile population, it is difficult to access the actual incidence of congenital spinal stenosis. However, it would appear from our findings that the incidence of juvenile congenital spinal stenosis is not insignificant and may easily have been confused for an acute herniated disc in prior studies where MRIs were not readily available. This subset of patients fared poorly with nonoperative care, and the four patients requiring surgery within the study were in this group. After the identification of JDDD, each patient and family were counseled concerning the nature of the problem, treatment options, long-term prognosis, and suggested restrictions of career choices. The treatment regimen consisted of NSAIDs, activity modification, physical therapy with back and abdominal strengthening, bracing, weight reduction, and career counseling. Patients who were involved in athletics were restricted from their respective sports activities until they were significantly improved enough to return or failed to do so, requiring permanent restriction. The patients with congenital spinal stenosis combined with degenerative disc disease who had significant radiculopathy were treated with epidural steroid injections. All of the patients’ symptoms were successfully treated with nonoperative modalities except for four patients with congenital spinal stenosis and degenerative disc disease who required surgical decompression owing to severe and unremitting radicular symptoms. In conclusion, the findings of this study question whether lumbosacral degenerative disc disease, commonly believed to be a disease of middle age, in fact begins in adolescents in selected patients. JDDD is not an uncommon cause of low back pain in the adolescent population and is a common finding in patients referred to a spine specialty practice. In this study, JDDD was uniformly found in patients with congenital spinal stenosis, indicating a possible coexistent relationship. However, because only symptomatic patients were included in this study and had MRIs, it is entirely plausible that a large population of asymptomatic patients with congenital stenosis exists without JDDD. Finally, JDDD responds well to continued nonoperative modalities and rarely requires surgical intervention except in patients with coexistent spinal stenosis. References [1] Roger E, Letts M. Sickle cell disease of the spine in children. Can J Surg 1999;42:289–92.
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