SPONDYLOLYSIS AND SPINAL STRESS SYNDROME

By: Dr. Keith P. Mankin 

Introduction:

     The spinal column is made up of a number of bones called vertebrae.  The bones are held together by joints and discs which allow motion and shock absorbance.  There are four parts of the spine; the cervical spine, or neck, the thoracic spine where the spine attaches to the rib cage, the lumbar or lower spine, and the sacrum where the back connects with the pelvis and hips.  Most low back pain involves the area where the lumbar spine joins with the sacrum, often called the L-S spine.

 

Low Back Pain:

     Although low back pain is common in adults, it occurs less frequently in kids under 18 years.  This is probably due to the fact that the discs in kids are springier and give more support.  However in today’s society, where the book bags are heavier, sports are faster and more strenuous and there is arguably more stress on teenagers, orthopaedists are seeing more children with back issues.  Many of these cases are simply muscular strain, but other children may be more severe problems with the development, the stability or the alignment of the lower back.  In general, all back pain that lasts more than a few days should be evaluated by a specialist.

            Although there may be rare occurrences of infection or tumors causing back pain in kids, most cases of severe pain are caused by three processes:

• Disc disease leading to pressure on the lower part of the spinal cord

• Stress fracture, or spondylolysis

•  Spinal stress syndrome

     Disc bulging is surprisingly common in kids, but is seldom severe enough to need surgery.  In fact many disc bulges seen on MRI may be incidental findings without any symptoms.

     Spondylolysis may be caused by repetitive stress or by an acute injury to the lower back.  A portion of the frame of the vertebra cracks, leading to pain.  In some cases if the crack area stretches out, the upper vertebra may slip forward, leading to a condition called spondylolisthesis.

     Spinal stress syndrome arises from postural stress at the L-S spine and may be related to too much motion in the lower spine.

     Most back pain cases are dues to spondylolysis or spinal stress syndrome.

 

Treatment Options:

     Since much of back pain is mechanical in nature, treatment is most often directed at improving the mechanical function of the lower spine.

     I will often use a flexible brace to give relative support and immobilization for the lower back.  This improves any inflammation in the spine and is generally worn for approximately one month.  In some cases, a more rigid brace may be used to provide more overall support.

     After bracing, if the back pain is improved, the patient will start a course of physical treatment, usually under the guidance of a physical therapist.  Physical Therapy sessions may continue for one to two months, but it is most important that the child continues to do exercises for her back after stopping the formal therapy.  Chiropractic treatment may complement the therapy, but aggressive manipulative therapy of the back should be avoided in the healing stage.

     Although steroid injections are frequently used in adults with mechanical low back pain, their role in children remains very controversial.  Children as a rule tolerate the injections poorly.  Furthermore, because the pain is often due to instability, the effectiveness of the injection may be less than in patients with joint arthritis or nerve irritation.  Finally, the effect of steroids on the growing child has not been fully studied. 

     If bracing and therapy does not improve the pain, in some cases surgical treatment may be helpful.  The surgical treatment provides decompression of the tight spinal canal and also stabilization of the hypermobility of the lower spine.

     Children’s bones heal more solidly and quickly than adults, so in most cases the surgery can be performed using only bone graft without the need for rods, screws or other instrumentation.  We call this in situ fusion of the lumbosacral spine.  Although the child will need to be in a brace for approximately two months to allow the bone to heal solidly, in the long run, the absence of hardware will probably allow the spine to be more mobile and will allow easier x-ray interpretation of the healing process.  Also, if the patient does require further surgery later on in life, it will be easier to perform if there is no metal in place beforehand.

 

Lumbar Fusion Surgery – The Surgery and Hospital Stay:

     In situ fusion is performed with the child completely asleep and rolled on her stomach onto a spine frame.  The skin incision is relatively small, usually measuring only 2 – 3 inches in the middle of the lower back.  The muscles are retracted off the back of the vertebrae and the joints connecting the bones together are cut out.  If there is a tight spinal canal, the middle bony structures are removed to essentially deroof the canal.  Bone graft, usually made of synthetic material, is placed into the area of the joints and along the side of the bones to heal as a bridge.  The skin is then closed watertight with buried stitches and a sterile dressing is placed over the incision.  The procedure usually takes between 1 ½ and 2 hours to perform.

     After the child is asleep, a Foley catheter may be placed into to the bladder to collect urine.  This will make post-operative care easier since the child will not have to worry about rushing to the bathroom.  The catheter is generally removed by the first or second day after surgery.

     Since surgery of this type may be quite painful, the patient will have a pump to infuse pain medicine on demand.  The pump, called Patient Controlled Analgesia (or PCA), is usually used for the first day and the child is then switched to pain pills or liquid.

      Activity is very important to the healing process.  Physical therapy is begun on the first post-operative day, and continues to advance until the patient can walk comfortably with or without an assistive device such as a walker, transfer in and out of bed and climb up and down stairs safely.

     In order to hold the spine still until fully healed, a brace is used post-operatively.  The brace is usually fitted before the surgery and placed on the first or second day after surgery.  The initial brace is a rigid shell spanning from the upper part of the child’s hips to the lower part of the rib cage.  A thigh attachment holds one of the patient’s legs outward so the spine cannot twist.

     When the patient can move about, eat well, go to the bathroom and wear the brace comfortably, she is discharged home, usually on the second or third day after surgery.

 

Post-Operative Home Course:

     The brace with the leg attachment is worn continuously, except while in bed, for approximately one month.  At that point, the surgeon will check an x-ray of the spine to see if the healing process is going well.  If so, the leg portion will be removed and the patient will wear just the body shell, usually for another month.

     Outpatient Physical Therapy is started two weeks after surgery.  The first portion involves movement and flexibility exercises in a therapeutic (95 degree) swimming pool.  The second program starts at one month and will consist of strengthening of the muscles and increasing the child’s stamina.  Physical Therapy usually continues for about 4 – 6 weeks until the child can come out of the rigid brace and start a home exercise program.  Some activities, such as swimming or light running may be resumed during the Physical Therapy program, but usually it is 3 – 4 months before the patient can return to full activities.

     In the long term, the patient will need to continue to do back exercises to maintain the posture and alignment of the spine.

 

Surgical Outcomes:

     Unfortunately, no surgery can be performed with a guarantee of perfect results, and lower back surgery in general may only improve pain in up to 75% of patients.  In children, the rates of improvement are much higher, especially when the patient carefully follows the post-operative course as prescribed by her surgeon.  In my practice, all patients have fully healed the bone, while approximately 95% have had pain relief and were able to return to full activities, include dance and gymnastics!  

     Complications are rare, but can occur from any surgery.  Infection have been reported in up to 1% of patients, although is usually superficial and requires only antibiotic medication.  A small number of patients may have trouble urinating and may need the catheter in place longer than the typical 2 – 3 days.  Nerve injuries have been reported in the literature.  To date, no patient in my series has required transfusion of blood.

 

Summary:

     Back pain in older children and adolescents is becoming a more significant problem.  Most cases respond well to exercise and stretching programs.  Occasionally, a soft or rigid brace may be used to decrease inflammation before starting mechanical treatment.

     In rare cases, the pain may persist or worsen despite conservative treatment.  In these cases, in situ fusion of the lower spine may improve pain and function without limiting lifelong activity.

     In all patients with back pain, it is critical for the child to continue to exercise, maintain proper weight and healthy lifestyle and look out for the back to prevent the pain from returning.  

 

L-S Spine x-ray with a Spondylolysis

 

L-S Spine after Fusion

 

Post Operative Spinal Brace