The Pediatric Spine

• Normal Spine Development• Thoracic Kyphosis =

– 20-45 deg• Lumbar lordosis =

– 20-55 deg– By age 4-5 usually 10-20

• Cervical

• Mild truncal asymmetries common – 10% of population– School screen controversial– Threshold of 7 deg.

scoliometer suggested

Spinal Flexion and Extension

• Cerebral Palsy– Tightness:

• Cervical and capital flexion

• Thoracic extension

• Lateral flexion

• Lumbar flexion»

Kyphosis

• Postural• Congenital

– Failure of formation and/or segmentation– Apex of curve between T10 and L1 most

common– Failure of formation lead to paraplegia– Progressive under 55-60 deg. – post. Fusion– More than 60 deg – ant. and post.

Scheurermann Disease

• Familial disorder of thoracic spine

• Hx of heavy physical loading from work or athletics

• Vertebral wedging and kyphosis >45 deg– <60 – encourage activity– >60 - brace

• Mild scoliosis• Tx: NSAIDs, rest, stress

reduction, TSLO for pain

Lordosis

• Variations common in typical prepubescent child

• Functional– Compensation for fixed

deformity above or below LS level

• Structural hyper/hypo– Arrest growth of post

lumbar vert with shunting or rhizotomy

– Muscular dsytrophy = hypo– Fractures = hypo or hyper

Cervical Problems

• Basilar impression– Congenital or acquired– Cervical spine extends into the formamen

magnum– May be due to osteopenia:

• rickets

• osteogenesis imperfecta

• Occipital-atlantal instability– Rare but sometimes in Down Syndrome

• Atlantoaxial instability– Due to abnormalities of odontoid or to

ligamentous laxity– Down Syndrome, Rheummatoid

arthritis, • Sx: gait disturbance, ex. Intolerance,

neck pain–Mild weakness and hyperreflexia

– Avoid cervical spine stress

Can have instability until the epiphysis closes

X-rays recommended at age 2 y.r. in the case of Down Syndrome

Case example:

7 year old high functioning child with Down Syndrome, in a regular classroom who can ride a tricycle independently. He/she falls off and becomes a paraplegic due to an unstable AA joint

Neurological Abnormalities

• Progression of scoliosis• Chiari malformation

• Tethered cord

• Tumors– Unresolved torticollis– Clumsiness– UE weakness

• Abnormal skin lesions in midline

– Dimples

– Hemangiomas

– Hair patches

– Cavus feet

– Leg atrophy

– Café au lait spots

• Referral important if– Onset before age 4 years

– Symptoms persist longer than 4 weeks or increases

– Pain interferes with function

– Recent onset of scoliosis

• Evaluate for:– Mobility and symmetry

– Tenderness

– Neurological signs – especially asymmetry

Back Pain

• Spondylolysis and Spondylolisthesis– (B) or unilat defects of pars interarticularis =

Sphondylolysis• 4% of 4 yo, 6% by maturity

– If this displaces = spondylolisthesis

– Most common form of back pain in children and adults and in children with abnormal bone or connective tissue

– Usually due to stress fracture

– Tenderness over L5-S1

– Limited SLR and forward bending

– Pain aggravated by activity, especially competitive sports

– Usually pain decreases as child becomes an adult due to decreased activity

• Benign Back Pain in Children and Adolescents– over ½ in this category

– Limit back pack weight (< 20% of body wt• Not EBP

– Encourage healthy lifestyle, activity, weight reduction

• Disc Herniation– Rare unless family hx, recent trauma, facet asymmetry, spinal

stenosis, transitional vertebrae and spondylolisthesis

– Usually L4-5 or L5-S1 with radicular pain and secondary spinal deformity

– Tx: NSAID, rest, limited activity, TLSO

– MR and disc excision if persists

Idiopathic Scoliosis

• Unknown origin

• Most common

• Infantile: birth to 3 yrs

• Juvenile: 3-10 yrs

• Adolescent: >10 yrs

• Prevalence:– 2-3% for curves <10 deg

– .2 to .3% for curves >20 deg

Nonstructural and Structural

• Correct on lateral trunk bending

• Causes:– Pelvic Obliquity

– LLD

– Tumor

– Muscle spasm

• Fixed and do not correct

• Rotary component present and visible with forward bending

• Primary and compensatory curves

Neurofibromatosis

• Mutation of neurofibromatosis (Type 1) or schwannomin (Type 2) gene– Type 2 has fewer peripheral but more intracranilal

lesions

• Scoliosis is idiopathic or dystropic• Dystropic involves short and sharp angulation and

spinal instability• Fusion is indicated because of risk of boney

dysplasia

School Screenings

• Examine posture anteriorly and posteriorly

• Forward bend test – MD and RN do this and often miss some cases

• Assess for asymmetries:– Shoulders, nipple, scapula, pelvic heights– Asymmetrical folds of trunk– Curvature of spine

Treatment for Scoliosis

• Young adolescents prepuberty will most likely progress– Curves <25 deg: observe

– Curves 25-40 deg: non-surgical methods• Goal is to maintain with exercise and brace

– TLSO 18-23 hours per day until skeletal maturity

• PT: donning orthosis, schedule, skin care, exercise for ROM (hip flexors) and strength (abdom, gluts, paraspinals)

– Curves >40 deg: surgical intervention

Surgery for Scoliosis

• Indications:– Curve >40 deg– Curve is progressing– Decompensation of spine or thoracic cavity

• Instrumentation:– Distract and compress the curve– Correct or minimize the rotory component– Stabilize and maintain– Harrington rods

• PT:– Preop and postop for ROM, trunk strengthening, deep breathing

and coughing– Early transfers and gait