Children

F. Balagué

J. Dudler

Most review articles claim that the majority of spondylolysis and olisthesis cases in children are asymptomatic (1,2). However, a fundamentally contrary view is defended by Österman et al., who argue that “spondylolisthesis is the most important cause of back pain in children and adolescents…” (3). Such controversy is not without any impact on our clinical practice. If indeed children are asymptomatic, we have to rely on large prospective general population cohort studies for information on the disease. The implication is also that diagnosis will heavily rely on sophisticated radiological studies applied to a large, more and less selected population. On the opposite side, if the majority of patients seek medical attention, we should focus on the appropriateness of the history and clinical examination and their respective sensitivity and specificity for the populations at hand. A rather unique radiographic study including 500 unselected first-graders and their families demonstrated that the incidence of spondylolysis increased with age (4). In the several subjects where a pars interarticularis defect developed while under observation, it seems that none complained of discomfort or pain. Similarly, progression of olisthesis was found to be quite unusual, particularly after adolescence, and never symptomatic in this population from age 6 to age 25. This study supports the notion that both pathologies are frequently asymptomatic, at least at the young age when they initially appear (4). However, spondylolysis in children is considered to have a genetic predisposition, while lesions occurring in adolescents, particularly athletes, are considered to be stress fractures due to excessive load of the spine without predisposition (5). Such differences may also have an impact on clinical presentation and explain the opposite claims previously mentioned. Therefore, children and adolescents will be addressed separately in this chapter. Finally, when approaching this literature, the reader has to keep in mind a few limitations. Obviously, scarce information from the physical examination of asymptomatic subjects is scarce. Therefore, we rely mainly on published series of cases, which do not necessarily reflect the signs and symptoms of common subjects but the ones that required medical attention. Also in children, medical attention is sought by parents and not directly by the subjects themselves and probably reflects both the subjects’ symptoms and the parents’ perception of severity.

SYMPTOMS

Children

In his reviews, Hensinger stated that symptoms have reported to be “relatively uncommon in children” and also that “a significant number of children do not have pain and only seek medical evaluation because of postural deformity or abnormality of gait” (6,7). Perhaps such abnormalities are biased through signs- and symptoms-induced parental
anxiety. A recent paper focused specifically on children diagnosed before the age of 5 (8). The authors identified eight cases (4.2%) diagnosed responding to this criterion among a group of 188 spondylolisthesis patients, all younger than 20 years old. At diagnosis, these patients were aged from 9 months to 5 years (average 3.5 years), and in two cases the etiology was traumatic or secondary to the treatment of an intradural tumor. These authors highlight the fact that postural deformities, abnormal gait secondary to hamstring tightness, and skin anomalies, rather than back pain, were the main reasons for seeking medical attention (8). Again, this is a good example of our tendency to apply adult definitions to assess children and low back pain. Children are in a general learning process, including expression of pain in an adequate and acceptable fashion, both socially and culturally (9). In younger children, reported symptoms are more a reflection of parents’ beliefs and anxiety than complaints from the child himself or herself, but we should be careful not to deny analgesic treatment if it seems necessary.

Adolescents

On the contrary to children, spondylolysis appears to be symptomatic in adolescents. Around 90% of teenagers with moderate spondylolisthesis reported low back pain in a retrospective study of 149 patients (10). In cases of advanced spondylolisthesis, 11 treated conservatively and 27 surgically, symptoms also began between the ages of 10 and 15 years in 4 patients treated conservatively and 14 patients treated surgically (11), underlining the fact that symptoms are more common in adolescents and perhaps etiology differs with children. It is difficult to know the actual prevalence of pain among subjects with spondylolysis in the general population. However, figures from a cohort of more than 900 football players described by Iwamoto et al. demonstrated that roughly 80% of the subjects with spondylolysis reported low back pain as compared with one third of those without any radiological abnormalities (12). In a similar study carried out among 3,152 top notch Spanish athletes, Soler and Calderón reported that 46% of the subjects with spondylolysis and 23.5% of those without such a lesion reported low back pain at any time (13). The common presentation is an insidious onset lumbar pain, rather than lumbosacral or thoracolumbar. Initially, pain may be reported after strenuous physical activities and rest usually relieves the symptoms. With progression of symptoms, even daily living activities may become painful. Extension or rotation may increase symptoms, however the correlation between exacerbating factors and painful spondylolysis “has not been well assessed in the literature” (14). Radiations to the buttocks or the posterior aspect of the thigh may occur alone or in conjunction with low back pain. In Seitsalo’s series with conservatively and surgically treated teenagers, radiating pain alone was reported by 8% and 43% of patients, respectively, and both low back and radiating pain by 8% and 40% (10). Finally, true radicular symptoms and bowel or bladder dysfunction are very rare (2,5,6), but cauda equina syndrome has been described to occur in cases of Grade 4 spondylolisthesis or spondyloptosis (2).

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