– lumbar lordosis begins around age 3 (some say it begins when you walk)
– spondylolysis probably first develops in children at the age of 5-6 years
– progression of spondylolisthesis is highest in the 10-15 year area (adolescent growth spurt)
– spondylolysis may have a number of causes – repetitive trauma is well supported; the upright posture and lumbar lordosis contributes to this. Increased lumbar lordosis in young children during early phase of gait may place increased stress on the pars – leading to pars fracture.
– in Scheurman’s, 50% incidence of spondylolysis, perhaps secondary to the compensatory lumbar lordosis
– spondylolisthesis is found in 4-5% of population but has not been shown to have a significant association with low back pain. It is a common source of back pain in kids, but is rarely symptomatic as an isolated, first time entity in adults over 40.
– psueudosubluxation in the child is related to ligamentous laxity, the more horizontal (not sagittal) alignment of the facets, and is seen most commonly at C2-3 (but also at C3-4). At the age of 8, the child’s spine should be more like an adults and pseudosubluxation is NOT seen.
– there are three types of scoliotic curves associated with spondylolisthesis: olisthetic, sciatic, and idiopathic. The olisthetic and sciatic are related to the spondylolisthesis. The olisthetic curves is a torsional lumbar curve that begins at the spondylolytic area. The sciatic curve is a nonstructural lumbar curve caused by muscle spasm. By fixing the spondylolisthesis, these two curves tend to go away. The idiopathic curves are like the normal idiopathic curves – they usually persist after you do the spondylolisthesis stabilization.
– the asymptomatic Grade I slip in a gymnast – probably just watch. If she becomes symptomatic – restrict activity. If that doesn’t help – then TLSO.
– beware the low grade slip in the young, female, high slip angle, dysplastic slip, with flex/ext. instability. These have a high chance of progressing
Scheuermann’s disease: 5 degrees of wedging in at least 3 adjacent vertebrae; look for irregular vertebral end plates, Schmorl’s nodes, and reduction in the disk space height. An associated nonprogressive scoliosis of 10-20 is common.
– pain is common with Scheuerman’s
– indications for bracing in Scheuermann’s include:
– initial curve less than 70
– Risser 3 or less (has at least 1 year of growth remaining)
– thoracic curves are best with lower (T9 or below) apex
– minimal vertebral wedging
– factors that suggest that the brace will work include moderate deformity ( 65 kyphosis – between 65 and 75 – do posterior fusion
– over 75 – probably need anterior release too (of if the
curve is very stiff)
– in congenital kyphosis: a failure of segmentation does not lead to paraplegia very often – it is much different than the failure of formation. Most kids with congenital kyphosis do not need anterior fusion with their posterior fusion because their growth plates are abnormal to begin with, so crankshaft is less of a problem.
– for odontoid fractures in 7 year olds: they may occur from minimal trauma; before the age of 8 their neurocentral synchondrosis has not closed, so these fractures are really physeal injuries; like the adults, these are displaced anteriorly.
– unlike adults, pediatric odontoid fractures heal well with halo.
– the majority of the length of the dens comes from the PROXIMAL physis, not at the base. The proximal physis is called the chondrum terminale. Failure of growth of this region may