2001 OITE Question 263

Question

A 13 year-old girl with scoliosis has mild intermittent back pain. A bone scan, CT scan, and an MRI scan would most likely reveal which of the following conditions?

1- Spondylolysis

2- Spondylolisthesis

3- Scheuermann’s disorder

4- Slipped vertebral apophysis

5- No other condition

Figures

Answer (click for answer)

Preferred response: 5

Back pain in children is considered rare and is sometimes thought to be a red flag for serious underlying problems or conditions. It can be caused by spondylolysis or spondylolisthesis, trauma, infection, neoplasm, conversion disorder, etc. Scoliosis has in the past been discounted as a cause of back pain. This has led to many aggressive work-ups for patients with scoliosis who present with pain in search of an identifiable cause. The study cited looked at 560 patients with a diagnosis of idiopathic scoliosis who presented with the complaint of back pain. Of these patients, only 48 (9%) were found to have an underlying pathologic condition besides the scoliosis. These included 29 with spondylolysis/spondylolithesis, 9 with Scheuermann’s kyphosis, 5 with a syrinx, two with a disc herniation, one tumor, one tethered cord, and one hydromyelia. Furthermore, identification of these pathologic conditions was made from plain radiographs in 31 of the 48 cases. Thus, the authors concluded that a thorough H & P and plain radiographs are often all the work-up that is needed in cases of painful childhood scoliosis and conservative back pain treatment (meds, exercises) along with appropriate scoliosis management (observation, bracing, surgery) is often adequate. The two factors found to be most predictive of an underlying pathologic condition were a painful left thoracic curve or an abnormal neurologic finding on exam, but these numbers were still quite small and inconclusive.

Reference: Ramirez N, Johnston CE, Brown RH: The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am 1997;79:364-368.