Four Year History Of Recalcitrant Back Pain In A Teenager

Abstract

HISTORY: A 15-year-old volleyball and soccer player has had back pain since 2004 with recent recurrence. She first came to see us in July, 2007. At that time she had right lower back pain and buttock pain since November, 2005. In August, 2007 she was diagnosed with bilateral L5 spondylolysis and treated with a Boston Overlap brace, activity modification, and physical therapy. Over the course of the next 7 months, the patient improved to the point where she was pain-free, and she resumed playing soccer in March, 2008. In August, 2008, the patient developed a recurrence of right sided back pain and buttock pain with playing volleyball. Additionally, she developed subjective right leg weakness and numbness and tingling radiating down the leg. PHYSICAL EXAMINIATION: Examination in clinic revealed tenderness over the right L4-L5 paraspinal region and the superior portion of the right SI joint. Patient had antalgic gait. Patient was capable of heel and toe walking. Patient had pain on the right lumbar region with facet loading maneuvers. Sensory exam revealed diminished sensation to light touch on right lateral and medial thigh, right lateral and medial lower leg, and right lateral and medial foot. Strength was 5/5 in the distribution of L3-S1. DTR's were +1 at patella and achilles bilaterally. Figure 4 stretch caused pain in right buttock. Slumped straight leg raise on right caused right buttock pain. DIFFERENTIAL DIAGNOSIS: 1. Recurrence or incomplete healing of bilateral spondylolysis 2. Disk bulge or neural foramina narrowing 3. Piriformis inflammation with sciatic nerve entrapment TEST AND RESULTS: MRI lumbar spine 8/08 possible left-sided spondylolysis with suggested cortical thickening of right pedicle disc height and neural formanina L1-S1 normal Bone scan 10/08 ongoing changes consistent with healing in the left pars of L4 and bilateral pars of L5 CT scan lumbar spine normal pars without evidence of fracture finding suggestive of disc bulge at L2-L3 and L3-L4 WORKING DIAGNOSIS: Bilateral pars fractures with resolution and then disc herniation. TREATMENT AND OUTCOMES 1. Medrol dose pack 2. Repeat MRI 3. With-holding from volleyball at this time