Spine Service

The most common condition seen in the Spine Clinic is scoliosis (a lateral/ sideways curvature of the spine). The management of scoliosis is individualised for each child depending on his/her age, amount of curvature, and amount of time remaining for skeletal growth. Children with a spinal disorder are often followed by the Spine Clinic for many years until they stop growing. Scoliosis will require frequent examinations by your child's physician to monitor the curve as your child grows and develops.

The onset of scoliosis is gradual and usually painless, and a significant curvature can develop without the parent or child noticing. Early detection is important to prevent the curve from progressing. Many spine curves do not progress significantly enough to warrant surgical treatment.  Only an orthopaedic surgeon with specialised training in spinal disorders has the experience and knowledge to make that determination.

Scoliosis cannot be cured by exercise, physiotherapy, osteopathy or chiropractics. If left untreated, scoliosis can cause problems with pain, mobility, and in very large curves, even heart and lung function. Be sure to have your child checked by your doctor if you have a family history of scoliosis.

There are many classifications of scoliosis. The most commonly seen curvatures of the spine treated in the Starship Children’s Hospital Scoliosis Clinic are:

1. Idiopathic scoliosis
2. Neuromuscular scoliosis
3. Congenital scoliosis

For more information you may find www.srs.org and www.iscoliosis.com useful sites to visit.

The term neuromuscular scoliosis is used to describe curvature of the spine in children with any disorder of the neurological system. Common categories include cerebral palsy, spina bifida, muscular dystrophies, spinal muscular atrophy, spinal cord injuries, arthrogryposis and so forth. The muscles of a child with a neuromuscular disorder are often weaker and therefore are not able to provide adequate support to the spine during the growing years. As the muscles and ligaments progressively weaken, they can no longer effectively support the spine so it begins to curve. These curves tend to be progressive, with the rate of progression becoming worse during rapid growth. For children confined to a wheel chair, progressive curves may affect the child's ability to be seated comfortably, thereby affecting their quality of life and function. Changes in posture place weight on structures unsuited to the stress, and full expansion of the chest cavity becomes difficult. This may impair breathing already made difficult by weakened respiratory muscles.

What is the treatment for neuromuscular scoliosis?

Children with a neuromuscular scoliosis have a curve that is more likely to increase in severity and therefore is more likely to require treatment. Spinal surgery is often necessary at a younger age due to faster progression of the scoliosis. Non-surgical treatments such as seating modification and bracing are not usually effective because they do not usually control curve progression. Braces are generally not well tolerated by children with a neuromuscular condition because they often restrict breathing and can cause pressure area problems.

(1)  Observation

A curve of less than 20 degrees is considered mild. This means that nothing needs to be done at this stage. Regular clinical examinations and X-rays will be required to assess changes in the curve measurement. These check-ups are continued until your child is skeletally mature.

(2)  Surgery

If the curve in your child’s spine continues to increase in severity (above 45 degrees), your doctor may recommend surgery. This is called a spinal fusion. A spinal fusion involves metal implants and bone graft. Spinal implants consist of a variety of metal rods, hooks, wires and screws, which are used to hold the correction of the spine whilst the bone fusion heals. The implants used depend on a number of factors including age of child, type and location of curve.

The aim of surgery is to:

1. Correct or lessen the curvature and to stabilise the affected area of the spine
2. Optimise  / preserve lung function
3. Decrease back pain and postural fatigue
4. Improve sitting posture in a chair
5. Prevent pressure areas that occur as a result of being tilted to one side in a chair.

Facts about neuromuscular scoliosis

• The younger the child at the time of diagnosis, the greater the risk of progression.
• These curves tend to be progressive, with the rate of progression becoming worse during rapid growth.
• In neuromuscular spinal deformities, progression occurs much more frequently than in idiopathic scoliosis.
• Progression often continues into adulthood.
• In general, the greater the neuromuscular involvement, the greater the likelihood and severity of scoliosis.
• Braces are poorly tolerated because they further restrict the thoracic (chest) muscles.

Congenital scoliosis is defined as a lateral curvature of the spine that is the result of malformations of one or more vertebra. In the involved area of the spine there is absent or abnormal growth potential due to an area of missing bone (formation defect) or missing growth plates (segmentation defect). This disrupts the normal alignment of the spine, producing different types of deformities. The term congenital means that the condition occurs during the very early stages of pregnancy. There are many causes of congenital abnormalities. Some can be explained and others have no known causes. The process of development of a baby from a fertilised egg involves millions of complicated steps, any of which can go wrong. We do know that there was nothing that you could have done, or did not do, during pregnancy to cause or prevent this condition. The developmental defect occurred during the 4th-6th weeks of development in utero (after conception). The baby is less than an inch long during this phase of development.

One person in every 10,000 is affected and approximately 75% increase in severity and require treatment. It occurs about 60% of the time in girls, 40% in boys. Children with a congenital scoliosis are more likely to have other problems as well. The spinal column develops in utero at the same time as several other major organ systems.

Some of the problems that may be present are as follows:

Kidney or urinary tract abnormalities
Abnormalities of spinal cord development
Congenital heart defects
Talipes - club feet
Sprengel’s shoulder - shoulder deformity
Absent or fused ribs

If your doctor is concerned he may organise tests to exclude these conditions.

What is the treatment for congenital scoliosis?

Congenital scoliosis usually has serious consequences in spinal growth during childhood. The severity of the congenital deformity depends on the type of anomaly, the site at which it occurred, and how much growth the child has left.

Goals of treatment:

1. To allow the child to reach the end of growth with a reasonably straight, balanced spine.
2. To allow the spine to grow as much as possible.
3. For younger children, allowing for the chest cavity to grow and develop and allowing the lungs to increase in size.

(1)  Observation

Observation is appropriate for small curves and balanced patterns of malformations. Some patterns of congenital scoliosis are minor enough that no treatment is needed and the long-term prognosis is good.

(2)  Surgery

Surgery is often the treatment of choice because 75% of curves are progressive. Surgery is used to attempt to maintain spinal balance while preserving as much trunk height as possible during growth.

Kyphosis is the term used to describe the forward curvature of the thoracic spine. Everyone has this normal rounding of the upper back. The acceptable range of thoracic kyphosis is from 20 - 45 degrees. A curvature of the thoracic spine that is greater than 45 - 50 degrees is considered excessive.

There are many different causes for kyphosis of the spine, but in children there are three specific types:

1.  Postural kyphosis

Excessive kyphosis may simply be postural and can often be corrected with exercises and proper posture. Postural kyphosis is due to stretching of the ligaments, with the vertebrae themselves being normally formed. This type of kyphosis is mobile (voluntarily corrected). Most postural kyphosis straightens by itself as your child matures.

2.  Scheuermann's kyphosis

A small percentage of children/adolescents with kyphosis have a more rigid deformity than the postural type. This is called Scheuermann’s Kyphosis. This type of kyphosis is the most common cause of structural kyphosis of the thoracic and thoracolumbar spine. Several of the vertebrae develop into a wedge shape. Their shape is narrower in the front (anterior) of the spine. This narrowing causes the spine to curve abnormally as your child grows. This type of kyphosis is fixed and cannot be corrected voluntarily.
Scheuermann’s Kyphosis usually develops during the early teens (12-15 years). During this period of rapid growth, a growth disturbance of the thoracic vertebrae occurs. Its cause is unknown but there is often a strong hereditary tendency. The incidence of Scheuermann’s Kyphosis is 0.4% - 0.8% and is twice as common in females. A minor scoliosis is also present in 25% of children but usually does not require treatment. Biomechanical factors play a large role in the progression of Scheuermann’s Kyphosis. As the kyphosis (hunching) increases, cartilage growing in front of the spine is placed under increasing pressure, causing the growth of the cartilage to slow. This slowed growth in front of the spine coupled with faster growth in the back of the spine (the posterior elements) worsens the kyphosis.

3.  Congenital kyphosis

Congenital Kyphosis is the name given to defects of vertebrae of the spine that are present at birth. The most common birth defect is called hemivertebra, which means half of one side of a vertebra forms while the other side doesn’t (failure of formation). The vertebra appears wedge shaped. Another defect is called a unilateral bar (failure of segmentation). Several vertebra are “stuck” or fused together on the anterior (front) portion of the vertebrae. As the spine matures, only the posterior portion (back) of the spine is able to grow. This results in an increasing curvature of the spine. There is no known cause for these defects. Congenital kyphosis may be quite significant and evolves rapidly during the first years of life. Children with a congenital kyphosis are more likely to have other problems as well. Kidney or urinary tract abnormalities, abnormalities of spinal cord development, and congenital heart defects are some of the problems that may be present. If your doctor is concerned he may organise tests to exclude these conditions.

What is the treatment for kyphosis?

Braces are rarely used. They are poorly tolerated by children as they are uncomfortable and restrict activity.

1.  Postural kyphosis

Exercises may be prescribed to strengthen the muscles that straighten the upper back and to prevent excessive lumbar lordosis. Exercises that relax and lengthen the “tight” thigh (hamstring) muscles may also be beneficial. A physiotherapist will teach an exercise regimen to your child and sets up a home program. The physiotherapist should periodically see your child, to ensure that the exercises continue to be done properly.

2.  Scheuermann's kyphosis

Goals of treatment

1. Correct or lessen the curvature and to stabilise the affected area of the spine
2. Improve the cosmetic appearance
3. Decrease discomfort or postural fatigue

(1)  Observation

Often, no treatment is necessary. For curves less than 60 degrees, regular assessment and x-rays will be required until your child finishes growing (skeletal maturity). Progression of the curve depends upon the amount of skeletal growth, or how skeletally mature, your child is. Curve progression slows down or stops after your child reaches puberty.

(2)  Surgery

If the curve in your child’s spine continues to increase in severity and persistent back pain is unresponsive to non operative treatment, your doctor may recommend surgery. This is called a spinal fusion. A spinal fusion involves instrumentation and bone graft. The term “instrumentation” refers to a variety of metal rods, hooks, wires and screws, which are used to hold the correction of the spine whilst the bone fusion heals.

3.  Congenital kyphosis

Goals of treatment

1. To allow the child to reach the end of growth with a reasonably straight, balanced spine.
2. To allow the spine to grow as much as possible.
3. For younger children, allowing for the chest cavity to grow and develop and allowing the lungs to increase in size.
4. Prevent compression of the spinal cord which can lead to nerve damage or even paralysis.

In very mild forms treatment may be delayed, however most cases require prompt and thorough evaluation as well as early surgical treatment. With congenital kyphosis, surgery is usually performed while the child is still growing because there is a significant chance of compression on the spinal cord if the curve continues to increase.

Spondylolisthesis is the term used to describe when one vertebra slips forward on the one below it. Spondylolisthesis usually occurs towards the base of your spine in the lumbar area. The commonly involved vertebral segment is L5, slipping forward on the first sacral segment (S1). Spondylolisthesis is caused by a defect in a part of the bone called the pars interarticularis. The pars interarticularis is part of the ring of bone at the back of the spine. This ring of bone protects the spinal cord and the nerves which run off it.

When a spondylolisthesis occurs it may cause compression on the spinal nerves which run in the area of the defect. This compression may cause leg pain, tingling and numbness in the legs, or even leg weakness. Severe cases may even cause changes in bladder function. Approximately 5-6% of males and 2-3% of females have a spondylolisthesis. It becomes apparent more often in people who are involved with very physical activities such as weightlifting, gymnastics, or football. Males are more likely than females to develop symptoms from the disorder, primarily due to their engaging in more physical activities. Spondylolisthesis is categorised from Grade 1 to 5, with 5 being the greatest slip.

Types of Spondylolisthesis

Dysplastic (Developmental) Spondylolisthesis

Developmental spondylolisthesis is caused by an anomaly (dysplasia) of the bones of the spine. A child is born with an abnormality of the posterior bones of the spine. Because of the abnormal orientation of the bones, the normal ability of the spine to resist slippage is lost and the vertebral body of L5 slips forward on S1. Usually occurs most commonly in girls, with some familial predisposition, and can be associated with other congenital dysplasia e.g. spina bifida occulta.

Isthmic Spondylolisthesis

Isthmic spondylolisthesis is the most common type seen in children and young adults. Isthmic spondylolisthesis is caused by a defect in a part of the bone called the pars interarticularis. The pars interarticularic is part of the ring of bone at the back of the spine. This ring of bone protects the spinal cord and the nerves which run off it. It occurs when the pars interarticularis which connect the facet joints in the posterior spine are fractured causing a forward slip of the vertebra. The pars serves as a check-rein for movement of the vertebra and when fractured, the vertebra are able to move past each other producing symptoms ranging from mild low back ache to severe neurological deficits (due to compression on spinal nerves).

What is the treatment for Spondylolisthesis?

(1)  Observation

Observation is adequate for the child who has a minimal spondylolisthesis and no symptoms. Regular outpatient clinic appointments with x-rays will enable your doctor to monitor your child’s condition. Symptoms often abate once precipitating activities cease. Treatment may involve restriction of activities causing stress to the lumbar spine (e.g. heavy lifting, gymnastics, and football), physiotherapy, anti-inflammatory and pain reducing medications. Children, or their parents, must discuss their daily activities and hobbies with their orthopaedic surgeon to see if they are all right to continue.

Have your child reassessed immediately by your doctor if he/she develops:

• Changes in bladder control
• Experiences weakness, numbness of the legs or has trouble walking
• Develops pain that radiates down one or both legs.

(2)  Surgery

If your child has neurologic involvement and pain that can not be relieved by conservative measures, your orthopaedic surgeon may recommend surgery. Surgical treatment is designed to stop either the progression of the slip or the abnormal motion which creates pain.

Facts about Spondylolisthesis

• Spondylolisthesis is a Greek term for "slipped vertebral body".
• Spondylolisthesis usually occurs towards the base of your spine in the lumbar area.
• Approximately 5-6% of males and 2-3% of females have a spondylolisthesis.
• In many people, spondylolysis and spondylolisthesis are present, but without any obvious symptoms.
• Isthmic spondylolisthesis is the most common cause of back pain in adolescents; however, most adolescents with spondylolisthesis do not actually experience any symptoms or pain.
  

Back pain in children is abnormal and should be investigated thoroughly. There are a large variety of causes for back pain, ranging from benign musculoskeletal pain to more sinister causes such as spinal cord tumours. Luckily, the vast majority of back pain in children is post-traumatic in nature, and is due to musculoskeletal strain. This type of pain is usually self-limiting, and can be treated with conservative measures such as oral analgesia and rest. Back pain that is not self-limiting, and persists beyond two to three weeks should be investigated.

Seek medical attention as soon as possible if your child has back pain accompanied by:

• Fever or weight loss
• Weakness, numbness, trouble walking or pain that radiates down one or both legs
• Bowel or bladder dysfunction
• Pain that interferes with sleep
• Squats down with a straight spine to reach a toy on the floor, rather than bend over.

Diagnosing the Cause of Back Pain

X-rays

The doctor may take several x-ray pictures of the spine and pelvis from various angles.

Bone Scan

Useful for diagnosing subtle bone fractures that may not show up on a routine x-ray. Bone scans are also useful for detecting infection or tumours.

CT Scan

Computerised Tomography uses a combination of x-rays and computer technology to produce more detailed images of bones and internal organs. It creates cross-sectional images (like slices) of the inside of the body.

MRI Scan

A Magnetic Resonance Imaging Scan uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. It is used to evaluate the spinal cord and spinal nerves which cannot be seen on an ordinary x-ray.

Lab Tests

Laboratory tests may include checking white and red blood cells (complete blood-cell count) and looking for system-wide inflammation (measuring erythrocyte sedimentation rate).

Classification of back pain:

1.  Mechanical problems

• Overuse injury
• Direct traumatic injury
• Ruptured disc

Muscle strain in the middle or lower back gets better on its own with rest. Many teenagers may have "mechanical low back pain".  This is often related to tight hamstrings and weak abdominal muscles. These individuals seem to do well with a physical therapy program stressing hamstring stretching and abdominal strengthening.

2.  Developmental abnormalities

• Spondylolysis / spondylolisthesis
• Congenital scoliosis or kyphosis
• Scheuermann's kyphosis - kyphosis is a common cause of middle (thoracic) back pain in adolescents. Vertebrae become wedged, causing a rounded or hunched back. The curve may ache, and pain may get worse with activity.

3.  Inflammatory and infectious diseases

• Diskitis
• Vertebral osteomyelitis
• Juvenile rheumatoid arthritis
• Epidural abscess

4.  Neoplastic disorders/tumours

• On rare occasion, tumours can be responsible for back pain. Tumours of the surrounding soft tissue of the spine, tumours of the bone, or tumours within and around the spinal cord. Pain may be constant and progressive, is unrelated to activity and/or happens at night.

Treatment

• Treatment options for back pain in children vary and depend on the cause of the back pain.
• Overuse injury or mild spondylolisthesis - most often, this back pain will improve by itself, or with rest, analgesics (such as ibuprofen) and sometimes, physical therapy.
• Surgical intervention may be required for more advanced problems.
• Antibiotics will be required for back pain caused by infections.

Facts about back pain in children

• Unlike the adult population in whom back pain may be the most common pain report, children rarely complain of back pain.
• In the adolescent age group, back pain may be related to similar causes as in adults including acute musculoskeletal strain or overuse injury.
• Back pain due to a traumatic event or overuse injury typically is improved with rest and simple analgesics in two to three days.
• There is a gradual increase of reports of back pain as children age.
• Back pain is exceedingly uncommon in the pre-teenage years. If a young child has back pain, he or she should be evaluated by a qualified health care professional.
• Back pain in children accompanied with a fever, changes in bowel or bladder dysfunction, or changes in strength or sensation of arms / legs requires urgent evaluation.

About 1 in 200 babies have torticollis, a shortening of a muscle in the neck causing their head to tilt to one side. The muscle affected is called the sterno-cleido-mastoid muscle (SCM), and it goes from the sternum (breast bone) to the skull just behind the ear. 'Torticollis' means twisted neck, and 'congenital' means that it is present at birth. Torticollis can be due to congenital defects, trauma, inflammation, tumours, and neurological or other factors.

Congenital Torticollis

Usually torticollis is picked up several weeks after birth when it is noticed that the baby's head is usually turned to one side, and it is difficult to turn his head to the other side. The baby's head is usually tilted so that he will look up as well as to the side. This tilt is due to the shortened muscle on the opposite side of the neck. The muscle feels tight, and there can be a small swelling in the middle of the muscle. Most commonly the muscle on one side of the neck is shorter than the one on the other side because the baby's head was held in a twisted position in the womb before birth. For some babies, there may have been an injury to the muscle during birth. As the injury heals, scar tissue develops which makes the muscle tighter. A baby can develop muscle shortening if the head is turned to the same side most of the time, eg. for sleeping. This is not a congenital torticollis, but treatment is the same. Rarely torticollis can also be caused by congenital abnormalities of the cervical spine, so sometimes x-rays or a CT scan are required. About 20% of babies with congenital torticollis also have abnormal development of the hip (developmental dysplasia of the hip) or feet which are twisted (talipes). Congenital muscular torticollis is usually painless.

What is the treatment for congenital torticollis?

Congenital muscular torticollis usually improves with range of motion and stretching exercises and massage, but it can lead to positional plagiocephaly (flattened skull) and facial asymmetry if your child's head lies in the same position all of the time. If it isn't quickly improving, then your child may need to be evaluated by a physical therapist. The muscle is passively (and gently) stretched by turning the baby's head so that the chin is moved towards the affected side. 'Passive' means that the stretching is done by a parent or someone else, not the baby. A physiotherapist or your doctor will be able to show you how to do this. The baby can also be encouraged to stretch her muscle (active stretching) by putting things that she will be interested in looking at on her unaffected side. Usually there will be improvement within 2 to 3 months and the baby will be able to move her neck fully in less than 12 months. In cases that aren't improving by 12-18 months, a surgical release/lengthening of the sternocleidomastoid muscle may be required.

Acute Torticollis

Torticollis can also come on suddenly in children and adults due to spasm in the SCM muscle. Usually this is due to a small injury caused by sudden movement, or sometimes by an infection in the neck or damage to the bones. Any neck pain that comes on suddenly needs to be checked by a doctor.

The Starship Hospital Spine Service also treats children with fractures of the bones in the spine or injuries to the spinal cord.  Usually, children are admitted acutely through the Emergency Department or are transferred from another hospital.  Children with ongoing disability will require extensive rehabilitation.  The Spine Service work closely with the Rehabilitation Service based at Wilson Centre For Children to achieve this.  Older adolescents may be managed by the Auckland Spine Unit.

Treatment

Treatment varies depending on where in the spine the injury occurred as well as severity of the injury.  Some injuries will require surgery with metal rods and screws to stabilise the spine while others may only require a brace.  The aim of all treatments is to prevent movement of the bones in the spine while they heal and to protect the spine cord from damage.