Table 1Metabolic-

Juvenile osteoporosisInflammatory-

Ankylosing SpondylitisSero-negative Arthritis

NeoplasmOsteoid osteoma

CongenitalL5-S1 facet Hypoplasia

DevelopmentalLumbar Scheurmann’s

TraumaPars interarticularis

Spondylolysis & SpondylolisthesisAdolescent back pain has been reportedto affect more than 50% of school agepatients. Parents are often confounded bythe severity of the complaints and yettheir teenager continues in sports or otherextracurricular activities. After months ofcomplaints and minimal relief ofsymptoms with anti-inflammatory drugs,the family will seek an evaluation.

The adolescent with lumbar back painmay have multiple reasons other thanoveruse or “growing pains” for thediscomfort. (Table 1)

The clinical examination providesinformation about the location of the pain,muscle spasm, lumbar spine range of

motion, hamstring muscle tightness, muscle strength in the legs, reflexes,and sensation in the legs.

X-ray studies may discount several of the potential diagnoses and directthe physician to propose the diagnosis of a pars interarticularis stress injuryor fracture.

The pars interarticularis is a portion of thelumbar spine that joins the upper andlower joints together. The pars is normalin the vast majority of children.

After approximately 8 YOA, certainpatients begin to experience abnormalgrowth and development of this particularregion in the bone. A genetic weakness tothe bone has only been established incertain ethnic groups such as AlaskanIndians. It does appear that certainathletic activities or injuries (gymnastics,heavy weight lifting) may result inproblems in susceptible individuals.

There are three stages of injury to the pars interarticularis:Stress reactionFracture (Spondylolysis)Slippage (Spondylolisthesis)

Stress reaction or injury mayoccur when the boneexperiences excessive wearand tear from activities ofdaily living, sports, or a fall.The symptoms may includelumbar pain, stiffness, andhamstring muscle tightness.X-rays will not reveal anyabnormality. A bone scan willdemonstrate the inflammationin he pars. Treatment consistsof relieving the pain andrestoring spinal flexibility.After several months, themajority of patientsresume most activities.

Parsinterarticularis

Brace for stressfracture

Stress fractureon bone scan

If the pars “cracks” or fractures, the conditionis called Spondylolysis. The x-ray confirmsthe bony abnormality. Treatment iscustomized based on the severity ofsymptoms. Anti-inflammatory drugs, physicaltherapy, brace wear, and activitymodifications will be considered. Prior to arelease to activities after the pain resolves, acourse of truncal core muscle strengthening(pilates or yoga) may be prescribed tocondition the muscles and minimize reinjury.

If the fracture gap at the pars widens, then thecondition is called Spondylolisthesis. Wideningof the gap leads to the fifth lumbar vertebrashifting forward on the part of the pelvic bonecalled the sacrum. Standing lateral spine x-rays are measured to determine the amount offorward slippage.

Treatment is prescribed to decrease any acutespasm and restore spinal flexibility. One of the

mainstays of physical therapy treatment is to perform truncal corestrengthening exercises. The therapist will caution the patient on avoidinghyperextension maneuvers and excessive abdominal “crunches”.

Prognosis is affected by the amount of slippage. In general, most patientswith less than 50% slippage fend to fare well through adolescence. Withslippage of 50% or greater, the potential for additional slippage with growthand aging is greater. The small numbers of patients who do not respond toconservative medical management are evaluated for a spinal fusion.

Spondylolysis

Spondylolisthesis

Spondylolisthesis

Screw fixation ofthe vertebrae

If the pain, spasm, or slippageincreases, then the surgeon willdiscuss several potential surgicaloptions. For a majority ofchildren, fusing the 5th lumbarvertebra to the sacrum is the firstchoice. The fusion involvesremoving the loose bonyfragments and placing bone graftin such a manner that will lead tothe successful “gluing together”of the two vertebrae. The patient

is restricted postoperatively with a castor brace until healing is complete. Inolder patients the alignment of the twovertebrae may benefit from theaddition of bone screws during thehealing process.

Bone graft is still added to promote afusion that may take up to three to sixmonths to heal completely. After asuccessful fusion most athleticactivities can be enjoyed once again

Sacrum

5th LumbarVertebra

Bone graft is added topromote a spinal fusion

Sacrum

5th LumbarVertebra