Adolescent Spine Research Articles

Long-term Outcome After Posterolateral, Anterior, and Circumferential Fusion for High-Grade Isthmic Spondylolisthesis in Children and Adolescents

A cross-sectional study to evaluate the long-term result of posterolateral (PLF), anterior (AF), and circumferential fusion (CF) for isthmic spondylolisthesis. To assess the long-term effects of PLF, AF, or CF for high-grade isthmic spondylolisthesis on lumbar spine in children and adolescents by using MRI. Short- and mid-term clinical and plain radiographic results of isthmic spondylolisthesis and of PLF, AF, and CF in severe slip are well documented. The long-term effect of the fusion on soft tissues, on the intervertebral discs inside and above fusion in particular, is, however, unclear. Between 1977 and 1991, PLF (n = 21), AF (n = 22), or CF (n = 24) was performed on 67 patients (42 females, 25 males) with high-grade (slip > or =50%) isthmic spondylolisthesis. The average age of patients at the time of operation was 14.4 (range, 8.9-19.6) years. Clinical, spinal mobility and trunk strength in addition to MRI and plain radiograph examinations were performed on these patients after an average follow-up time of 17.3 years (range, 10.7-26.0 years). Three (14%) patients in the PLF and AF groups, but none in the CF group, reported back pain often or very often at rest. The mean Oswestry Disability Index (ODI) was 9.7 (range, 0-62) in the PLF, 8.1 (0-32) in the AF, and 2.3 (0-14) in the CF group (P < 0.05). The mean slip before surgery was 66% (range, 50%-100%) and at the last follow-up visit 66% (range, 26%-106%). Disc degeneration was most common in the PLF group (P = 0.0014) and inside the fusion and in the lowest moving intervertebral disc spaces in all subgroups. Only 1 patient had an asymptomatic prolapse. In MR images, none of the patients had lumbar central canal stenosis inside or above the fusion. In contrast, the spinal canal was wide at the spondylolysis and spondylolisthesis level in 23 (34%) patients. Of the patients, 19 (28%) patients (32 neural foramens) had severe narrowing of the neural foramen with impingement of the nerve root. No patients had clinically confirmed L5 nerve root symptoms. Muscle degeneration was found in 29 (43%) of patients. Longer fusion and muscle degeneration, but not disc degeneration, were associated with lower performance in spinal mobility and trunk-strength measurement tests. The clinical outcome was best in the CF group as measured by ODI. Degenerative changes were most commonly found at the level of the slip and above the fusion level. The prevalence of disc prolapses was low. Spinal fusion for isthmic spondylolysis is not associated with central canal stenosis above the fusion. Radiologic nerve root stenosis was common but asymptomatic. Mild muscle atrophy was common.

Treatment of Severe Spondylolisthesis in Adolescence With Reduction or Fusion In Situ: Long-term Clinical, Radiologic, and Functional Outcome

Retrospective follow-up study with two cohorts: one treated with reduction and the other with fusion in situ. To assess the long-term effects of reduction versus fusion in situ on lumbar spine in children and adolescents with severe L5 isthmic spondylolisthesis. Severe isthmic spondylolisthesis is commonly treated with fusion in situ, but modern surgical techniques and instrumentation permit the reduction of a severely slipped fifth lumbar vertebra. Advocates of one or another of these procedures present different claims to defend their choice. However, to our knowledge, no long-term results of the reduction maneuver exist. Between 1983 and 1991, 22 adolescents with severe (more than 60%) slip were treated surgically. In 11 of them, reduction was performed with a Magerl/Dick transpedicular device, followed by fusion posteriorly from L4 or L5 to S1 and anteriorly from L5 to S1. In the others, fusion was performed in situ posteriorly from L4 (n = 7) or L5 (n = 4) to S1 and anteriorly from L5 to S1. The average age of patients at surgery was 14.7 years (range 10.7-18.5). Radiographs obtained before surgery, after surgery, and at the final follow-up evaluation were assessed for quality of fusion. In addition, magnetic resonance imaging was obtained at the last follow-up visit. Average follow-up time was 14.8 years (range 11.6-18.7). Physical examination, spinal mobility, and nondynamometric trunk strength measurements were used to assess, and Oswestry Disability Index and Scoliosis Research Society scores were used to calculate outcome at the last follow-up visit. In the reduction group, mean Oswestry Disability Index was 7.2 (range 0-20) and in the fusion in situ group, was 1.6 (range 0-4) (P = 0.0096). The Scoliosis Research Society total score averaged 90.0 (range 39-107) in the reduction group and 103.9 (range 93-120) in the fusion in situ group (P = 0.046). At the last follow-up evaluation, mean vertebral slip had decreased from the preoperative value of 90% to 57% in the reduction group but remained the same (80% vs. 78%) in the fusion in situ group (P = 0.04 and 0.013, respectively, for preoperative and postoperative comparison). On magnetic resonance imaging, disc degeneration above the fusion was more common in the reduction group (P = 0.004). None of the patients had spinal stenosis above the fusion. Nerve root canal impingement at the L5-S1 level was more common in the fusion in situ group (P = 0.03), but all patients were free of L5 nerve root symptoms. There was no difference in spinal mobility or trunk strength measurements between the groups. The fusion in situ group seems to perform better in almost all clinical parameters measured. These findings suggest that fusion in situ should be considered as a method of choice in severe L5 isthmic spondylolisthesis.

Nonspondylolytic Etiologies of Lumbar Pain in the Young Athlete

Approximately 50% of adolescent athletes with persistent lumbar pain can be diagnosed with spondylolysis or spondylolisthesis. The remaining 50% will have suffered injury of the vertebral body, intervertebral disc, ring apophysis, pelvis, articular processes, spinous processes, interspinous ligament, or other soft tissues of the lumbar spine. The adolescent spine is prone to these injuries as a consequence of the growth spurt and skeletal immaturity. Accurate diagnosis is mandatory in order to achieve successful treatment. History, physical examination, imaging modalities, and precision spinal injections can be employed to accurately diagnose the source of the symptoms. Appropriate treatment measures can then be prescribed to optimally treat the adolescent spine injury.

Gunshot Wounds to the Spine in Adolescents

ABSTRACTOBJECTIVE:The incidence of spinal instability after penetrating gunshot wounds to the spine in adolescents is unknown. We describe our experience over a 15-year period.METHODS:Hospital records were reviewed retrospectively. After injury and emergency care, patients were transferred to a rehabilitation facility. Examinations were completed using the American Spinal Injury Association and Frankel scales on admission, discharge, and 6 and 12 months after injury. Severity of injury was described by: 1) degree of neurological damage, 2) degree of preserved neurological function, and 3) presence of instability.RESULTS:Sixty patients were identified with a mean age 15.6 years (± 2.7 yr). Twelve patients had cervical, 31 thoracic, and 17 lumbosacral injuries. No operative treatments were used in their care. Thirty-four patients had complete neurological deficits. Mean acute hospitalization was 21.1 days (± 22.8 d), and mean rehabilitation stay was 86.3 days (± 48.9 d), for a total hospitalization of 107.4 days (± 65.9 d). At 1 year, 19 patients were ambulatory and 53 were autonomous. Despite the presence of bony involvement in all, no evidence of spinal instability was noted on follow-up dynamic imaging. Even in two patients with apparent two-column disruption, no instability was noted. At 1-year follow-up, significant (nonfunctional) improvement was noted in the neurological examination (P &amp;lt; 0.0001). Improvements were most notable in those patients with cervical injuries, followed by thoracic and lumbar injuries.CONCLUSION:After penetrating gunshot wounds to the spine, patients at 1-year follow-up examinations have evidence of significant, but nonfunctional, improvement. No evidence of spinal instability was noted in this study, and no surgical intervention was required.

Gunshot Wounds to the Spine in Adolescents

The incidence of spinal instability after penetrating gunshot wounds to the spine in adolescents is unknown. We describe our experience over a 15-year period. Hospital records were reviewed retrospectively. After injury and emergency care, patients were transferred to a rehabilitation facility. Examinations were completed using the American Spinal Injury Association and Frankel scales on admission, discharge, and 6 and 12 months after injury. Severity of injury was described by: 1) degree of neurological damage, 2) degree of preserved neurological function, and 3) presence of instability. Sixty patients were identified with a mean age 15.6 years (+/- 2.7 yr). Twelve patients had cervical, 31 thoracic, and 17 lumbosacral injuries. No operative treatments were used in their care. Thirty-four patients had complete neurological deficits. Mean acute hospitalization was 21.1 days (+/- 22.8 d), and mean rehabilitation stay was 86.3 days (+/- 48.9 d), for a total hospitalization of 107.4 days (+/- 65.9 d). At 1 year, 19 patients were ambulatory and 53 were autonomous. Despite the presence of bony involvement in all, no evidence of spinal instability was noted on follow-up dynamic imaging. Even in two patients with apparent two-column disruption, no instability was noted. At 1-year follow-up, significant (nonfunctional) improvement was noted in the neurological examination (P < 0.0001). Improvements were most notable in those patients with cervical injuries, followed by thoracic and lumbar injuries. After penetrating gunshot wounds to the spine, patients at 1-year follow-up examinations have evidence of significant, but nonfunctional, improvement. No evidence of spinal instability was noted in this study, and no surgical intervention was required.

Vertebral fractures and separations of endplates after traumatic loading of adolescent porcine spines with experimentally-induced disc degeneration

Abnormalities of the intervertebral discs have been found in a high frequency among young elite athletes. Several studies have also reported that the adolescent spine, especially the vertebral growth zones, is vulnerable to trauma. However, there is incomplete knowledge regarding the injury mechanism of the growing spine. In this study, the injury patterns of the adolescent porcine spine with disc degeneration were examined. Twenty-four male pigs were used. A degenerative disc was created by drilling a hole through the cranial endplate of a lumbar vertebra into the disc. Two months later the animals were sacrificed and the degenerative functional spinal units (segments) were harvested. The segments were divided into three groups and exposed to axial compression, flexion compression or extension compression to failure. The load and angle at failure were measured for each group. The segments were examined with magnetic resonance imaging and plain radiography before and after the loading and finally examined macroscopically and histologically. The degenerated segments required considerably more compressive load to failure than non-degenerated segments. Creating a flexion injury required significantly more load than an extension injury. Fractures and/or separations of the endplates from the vertebral bodies were seen at the margins of the endplates and in the growth zone. Only severe separations and fractures could be seen on plain radiography and magnetic resonance imaging. The weakest part of the adolescent porcine lumbar spine with experimentally-induced degeneration, when loaded in axial compression, flexion compression or extension compression, was the growth zone, and, to a lesser extent, the endplate. Degenerated discs seem to withstand higher mechanical loads than non-degenerated discs, probably due to altered stress distribution.

Modern Surgical Treatment of Primary Aneurysmal Bone Cyst of the Spine in Children and Adolescents

Aneurysmal bone cyst (ABC) is a benign but locally aggressive tumor-like condition. Treating children with spinal involvement poses special hazards due to the proximity of the lesion to the spinal cord and the need to preserve spinal stability and balance after surgery. Twelve children with ABC treated between 1990 and 2002 at a tertiary pediatric musculoskeletal tumor center using modern surgical techniques and technology were retrospectively reviewed. A surgical technique using a four-step approach of intralesional curettage, high-speed bur, electrocautery, and bone grafting was found to have a significantly reduced rate of recurrence (0/8 cases) compared with traditional intralesional curettage and bone grafting (4/4 cases) (P < 0.002). Short-segment spinal fusion with instrumentation was also done in five cases immediately after excision of the ABC under the same anesthesia and was a nonsignificant marker for reduced rate of recurrence (P < 0.08), likely secondary to wide exposure. Overall, at last follow-up, all 12 patients were alive and well with no evidence of disease and no significant spinal deformity. The four-step approach to treatment of ABC of the spine with appropriate spinal instrumentation and fusion is recommended for successful treatment of this aggressive lesion.

Fracture Patterns of the Adolescent Porcine Spine: An Experimental Loading Study in Bending-Compression

To expose functional spinal units from adolescent porcine to mechanical flexion-compression and extension-compression to failure. The biomechanical, radiologic, magnetic resonance imaging, and histologic characteristics are described. The aim of the present study was to investigate the fracture pattern of functional spinal units from adolescent porcine lumbar spines in in vitro compression loading and bending. In several studies, it has been shown that the adolescent spine, especially the vertebral growth zones, is vulnerable to trauma. A high frequency of abnormalities affecting the spine has been found among athletes participating in sports with high demands on the back. The etiology of these abnormalities is still a controversial issue. Sixteen functional spinal units obtained from eight adolescent male pigs were used. Eight functional spinal units were exposed to flexion-compression and eight functional spinal units to extension-compression loading to failure. They were examined with plain radiography and magnetic resonance imaging before and after the loading. The functional spinal units were finally examined macroscopically and histologically. Fractures/separations were seen in the growth zone anteriorly and more frequently, posteriorly in functional spinal units exposed to flexion-compression. In the extension-compression group, such injuries occurred only anteriorly. Only large fractures could be seen on plain radiographs and on magnetic resonance imaging. Macroscopically, a fracture/separation could be seen in 15 cases and histologically in all 16 cases. The median angle at failure for the flexion group was 17 degrees (range, 12-19) and for the extension group 17 degrees (range, 13-19 degrees). The median ultimate compression load in the flexion-compression group was 1894 N (range, 1607-3138 N) and in the extension-compression group 1801 N (range, 1158-2368 N). The weakest part of the growing porcine lumbar spine, when compressed into flexion- or extension-compression, was the growth zone. The injury was more extensive in extension loading than during flexion loading. Growth zone injuries of the adolescent spine may go undetected on plain radiographs and magnetic resonance imaging.

Resting energy expenditure and respiratory quotient in adolescents following spinal fusion surgery.

Prospective, 2-factor design. The first factor was the group with 2 levels, spine surgery and control. The second factor was timing with 3 levels, baseline, 1-week follow-up, and 6-week follow-up. The purpose of this study was to assess changes in caloric requirements and the body's nutritional substrate utilization following spinal surgery in adolescents. In an effort to optimize recovery from and assure best possible outcomes after spinal surgery in adolescents, the nutritional requirements of spine surgery patients were evaluated. Indirect calorimetry was used to measure resting energy expenditure, a measure of caloric requirements, and respiratory quotient, an indication of percentages of fat, protein, and carbohydrate utilization. Twenty-three patients undergoing spinal fusion surgery were evaluated immediately before surgery, at an average of 4.8 days after surgery, and at an average 53 days follow-up. A control group of 15 patients completed the same series of 3 tests: baseline, 1-week later, and 6-weeks later. Resting energy expenditure increased significantly by 150 kcal/day (2.7 kcal/kg/day) following spinal fusion surgery in adolescents. By 6 weeks postoperation, patient's caloric requirements returned to baseline level. No changes in resting energy expenditure occurred in the control group between the 3 test periods. Anterior/posterior surgeries and single surgeries had similar kcal/kg/day requirements after surgery. Respiratory quotient decreased significantly following surgery (0.79 to 0.70), indicating a shift to fat oxidation after surgery. At 6 weeks postoperation, the respiratory quotient returned to baseline level. The control group demonstrated no change in the respiratory quotient during the 3 testing periods. Substrate utilization shifts to fat oxidation in adolescents following spinal surgery, indicating lipids would be the alimentation of choice immediately after surgery. Caloric requirements increase 9% above the baseline measurements. Anterior/posterior surgeries and single surgeries (anterior or posterior alone) have the same increase in kcal/kg/day. Because of the substrate utilization change by the body after surgery, a preponderance of these calories should initially be given as lipids. After approximately 6 weeks, both resting energy expenditure and respiratory quotient returned to preoperative levels following spinal surgery in adolescents, indicating special nutrition is not required beyond 6 weeks.

Union of defects in the pars interarticularis of the lumbar spine in children and adolescents. The radiological outcome after conservative treatment.

Lumbar spondylolysis can heal with conservative treatment, but few attempts have been made to identify factors which may affect union of the defects in the pars. We have evaluated, retrospectively, the effects of prognostic variables on bony union of pars defects in 134 young patients less than 18 years of age with 239 defects of the pars who had been treated conservatively. All patients were evaluated by CT scans when first seen and more than six months later at follow-up. The results showed that the spinal level and the stage of the defects were the predominant factors. The site of the defects in the pars, the presence or development of spondylolisthesis, the condition of the contralateral pars, the degree of lumbar lordosis and the degree of lumbar inclination all significantly affected union.

Bone mineral density of the lumbar spine in children and adolescents with celiac disease on a gluten-free diet in São Paulo, Brazil.

To compare bone mineral density (BMD) in children and adolescents with celiac disease (CD) and control subjects and to evaluate diet adequacy and calcium metabolism in patients with CD. Thirty patients with asymptomatic CD (17 children, 13 adolescents), on a gluten-free diet, and 23 healthy subjects were studied. BMD of the lumbar spine (dual energy x-ray absorptiometry) was performed on all patients and control subjects. In patients, food diaries for nine nonconsecutive days were obtained and analyzed. In patients, laboratory tests pertaining to calcium balance were obtained. The mean weight and height of the adolescents with CD were lower than those of control subjects (weight: 45.8 +/- 10.5 kg v 55.3 +/- 10.5 kg, P = 0.037; height: 153.0 +/- 11.0 cm v 167 +/- 12.0 cm, P = 0.007). The mean BMD in adolescents with CD was significantly lower than that of the control subjects (0.917 +/- 0.116 g/cm2 v 1.060 +/- 0.158 g/cm2, P = 0.015), whereas no significant difference was found between children with CD and control subjects (P = 0.595). A multiple-regression model shows that increases in BMD relative to height were lower in adolescents with CD than in control subjects. The proportion of adolescents who had started a gluten-free diet after 2 years of age was higher than that of children with CD (P < 0.001). High percentages of magnesium, calcium, and phosphorous deficiencies were present in CD patients' diets. The serum levels of ionized and total calcium and parathormone were normal. The BMD of adolescents with CD was lower than that of the control subjects, whereas no difference was found between the BMD of children with CD and that of control subjects.

Bone Mineral Density of the Lumbar Spine in Children and Adolescents With Celiac Disease on a Gluten‐Free Diet in São Paulo, Brazil

ABSTRACTBackgroundTo compare bone mineral density (BMD) in children and adolescents with celiac disease (CD) and control subjects and to evaluate diet adequacy and calcium metabolism in patients with CD.MethodsThirty patients with asymptomatic CD (17 children, 13 adolescents), on a gluten‐free diet, and 23 healthy subjects were studied. BMD of the lumbar spine (dual energy x‐ray absorptiometry) was performed on all patients and control subjects. In patients, food diaries for nine nonconsecutive days were obtained and analyzed. In patients, laboratory tests pertaining to calcium balance were obtained.ResultsThe mean weight and height of the adolescents with CD were lower than those of control subjects (weight: 45.8 ± 10.5 kg v 55.3 ± 10.5 kg, P = 0.037; height: 153.0 ± 11.0 cm v 167 ± 12.0 cm, P = 0.007). The mean BMD in adolescents with CD was significantly lower than that of the control subjects (0.917 ± 0.116 g/cm2v 1.060 ± 0.158 g/cm2, P = 0.015), whereas no significant difference was found between children with CD and control subjects (P = 0.595). A multiple‐regression model shows that increases in BMD relative to height were lower in adolescents with CD than in control subjects. The proportion of adolescents who had started a gluten‐free diet after 2 years of age was higher than that of children with CD (P &lt; 0.001). High percentages of magnesium, calcium, and phosphorous deficiencies were present in CD patients' diets. The serum levels of ionized and total calcium and parathormone were normal.ConclusionsThe BMD of adolescents with CD was lower than that of the control subjects, whereas no difference was found between the BMD of children with CD and that of control subjects.

Definition of two types of anterior superior iliac spine avulsion fractures.

Fractures of the anterior superior iliac spine (ASIS) in adolescents are usually due to avulsion of the sartorius origin from the ASIS; however, the authors here report a second type due to avulsion of the tensor fascia lata origin. Eight patients were identified with ASIS avulsion fractures. Type II sartorius avulsion fracture was due to sprinting in various sports (n = 6). The fragment was smaller and displaced anteriorly. Type II tensor fascia lata avulsion fractures were due to swinging a baseball bat. The two muscular males were both injured during the initial phase of batting. The bony fragment was much larger and displaced laterally as confirmed by three-dimensional computed tomography scans.

Profiles of the cervical, thoracic, and lumbosacral spine in children and adolescents with lumbosacral spondylolisthesis.

The sagittal and frontal profiles of the entire spine are poorly studied in lumbosacral spondylolisthesis. It was the purpose of this study to further investigate these profiles. Standing posterior-anterior and lateral radiographs in 24 children with lumbosacral spondylolisthesis were reviewed (18 isthmic, 6 congenital). Cervical lordosis, lumbar lordosis, thoracic kyphosis, sagittal vertebral axis, sacral inclination, slip magnitude, slip angle, and sagittal rotation were measured. Cobb magnitude, Risser sign, curve location, and direction were noted for those with scoliosis. Relationships between sagittal variables were explored (Pearson correlation). The average age of patients was 14.7 +/- 2.5 years, slip magnitude was 38 +/- 38%, slip angle was 5 +/- 31 degrees, sagittal rotation was -6 +/- 31 degrees, thoracic kyphosis was 29 +/- 16 degrees, cervical lordosis was -1 +/- 12 degrees, and lumbar lordosis was 62 +/- 22 degrees. Correlations were noted between thoracic kyphosis and sacral inclination, percent slip, slip angle, and sagittal rotation. Sacral inclination decreased as the slip increased. Scoliosis was present in 10 children, with an average curve of 19 +/- 6 degrees. Thoracic kyphosis was less in those with scoliosis (21 +/- 25 degrees versus 33 +/- 25 degrees, p = 0.033). In children with lumbosacral spondylolisthesis, the sacrum becomes more vertical as the slip worsens. As the sacrum becomes more vertical, the thoracic spine becomes more lordotic, which is likely an adaptive mechanism used by the body to maintain forward visual gaze.

Idiopathic scoliosis in three dimensions: a succession of two-dimensional deformities?

A geometric analysis of computerized three-dimensional (3-D) reconstructions of the spine of adolescents with idiopathic scoliosis. To analyze and describe the 3-D location of scoliotic curves with respect to the global frontal, sagittal, and transverse planes of each subject. Clinical two-dimensional (2-D) measurements cannot fully describe the 3-D deformity of a scoliotic spine because they are done in the 2-D frontal or sagittal plane projection of a subject and do not correspond to the actual deformity. The spinal deformity from T1 to L5 of 50 adolescents with thoracic idiopathic scoliosis was reconstructed in 3-D using a multiplanar digital radiographic technique allowing the visualization of the vertebral line of the spine in any projection using auto CAD software. The curvature was segmented in three distinct curves for each subject: a high thoracic, a thoracic, and a lumbar. A regional plane passing through the two end-vertebrae and the apical vertebra was defined, and a series of geometric manipulations were performed to realign each regional plane with the global axis system of each subject. A total of 91% of the 147 curves studied were found to be entirely contained within its 2-D regional plane, and all scoliotic curves were found to be oriented in a 3-D location different from the classic frontal, sagittal, and transverse orthogonal planes of each subject. In thoracic idiopathic scoliosis the deformity of the spine is 3-D, but the regional deformity of each high thoracic, thoracic, or lumbar curve is almost always 2-D. The orientation in space of each 2-D plane is such that it cannot be seen in its true frontal or sagittal projection using standard frontal or sagittal radiologic views of the subject.

Intervertebral disc modeling using a MRI method: Migration of the nucleus zone within scoliotic intervertebral discs

MRI is increasingly being used for etiologic examination of scoliosis and for intervertebral disc disorder analysis, but until now has not been applied to geometric modeling. The aim of this study was to develop a new geometric model of intervertebral discs using MRI and to quantify the migration of the nucleus zone within scoliotic intervertebral discs. Fourteen lumbar scoliotic children (Cobb angles 22 ± 7°) were examined using MRI. The protocol consisted of sagittal and coronal plane acquisitions of the entire spine. An image processing software allowed the outline detection of the nucleus zone (intervertebral high intensity portion). The vertebral bodies were also reconstructed. Using a pre-post processor, the nucleus zone migration and a wedging angle were quantified. Statistical tests showed the repeatability of the method ( p > 0.4). Nucleus zone migration was correlated to the wedging angle ( r 2 = 0.488, p < 0.0001) in the coronal plane. Our results were in agreement with the literature: when two vertebrae move deforming the disc, the nucleus moves into the convexity of the curvature. But should we talk about the nucleus? Despite image processing software allowing the highlighting of image features (automatic color lookup tables applied to grayscale images using pixel intensity measurements), it is impossible to differentiate the nucleus from the annulus on T2 weighting images of adolescent spine. This new geometric model of the intervertebral disc, used for the quantification of the nucleus zone migration, should be of interest for further investigation of stiffness parameters of spine.

Bone mineral density of the lumbar spine of Brazilian children and adolescents aged 6 to 14 years.

The authors performed a study of bone mass in eutrophic Brazilian children and adolescents using dual-energy X-ray absorptiometry (DXA) in order to obtain curves for bone mineral content (BMC) and bone mineral density (BMD) by chronological age and correlate these values with weight and height. Healthy Caucasian children and adolescents, 120 boys and 135 girls, 6 to 14 years of age, residents of São Paulo, Brazil, were selected from the Pediatric Department outpatient clinic of Hospital São Paulo (Universidade Federal de São Paulo). BMC, BMD and the area of the vertebral body of the L2-L4 segment were obtained by DXA. BMC and BMD for the lumbar spine (L2-L4) presented a progressive increase between 6 and 14 years of age in both sexes, with a distribution that fitted an exponential curve. We identified an increase of mineral content in female patients older than 11 years which was maintained until 13 years of age, when a new decrease in the velocity of bone mineralization occurred. Male patients presented a period of accelerated bone mass gain after 11 years of age that was maintained until 14 years of age. At 14 years of age the mean BMD values for boys and girls were 0.984 and 1.017 g/cm2, respectively. A stepwise multiple regression analysis of paired variables showed that the "vertebral area-age" pair was the most significant in the determination of BMD values and the introduction of a third variable (weight or height) did not significantly increase the correlation coefficient.

Prevalence of pain related to schoolbag carriage in adolescents

Study design: A descriptive qualitative and quantitative cross sectional study design was chosen.Objective: To investigate the prevalence of lower back, neck, and shoulder pain in 13 to 15 year old scholars in Pretoria, South Africa, and how it related to methods of school bag carriage and perceived weight of school bags.Summary of background data: Unilateral loading has been linked to scoliotic type curves in the adolescent spine. More recent studies have also found that the weight of school bags may be related to the experience of pain, but very little research has been done on the prevalence of this pain.Methods and materials: A stratified random sample of nine schools was drawn from a total of 98 schools in the Pretoria District of the Gauteng Department of Education. The sample of 250 Grade 8 and 9 scholars was randomly selected. A questionnaire of open and closed ended questions was administered with five main sections, namely: demographics, method of carrying school bag, perceived school bag weight, areas of experienced pain, and awareness of adverse postural effects of carrying a school bag.Results: Thirty two percent of the sample reported pain either in the lower back, neck and/or shoulders. Principle Component Analysis and Chi-square tests showed no relationship between how the school bag was carried (over one/two shoulders; in one hand; swopping sides) and scholars’ reports of pain. A high level of significance (0.001 &lt;p&lt;0.042) was found when perceived bag weight was compared to the scholars’ reports of pain.Conclusion: Scholars in the Pretoria area present with a 32% prevalence of pain in the lower back, neck and/or shoulders. This is strongly correlated with the perceived weight of their school bags, regardless of how the school bag is carried.

Open reduction and internal fixation in flexion-distraction injuries to the lower spine in children and adolescents involved in traffic accidents as car occupants. A report and literature review.

Flexion-distraction injuries of the spine are reported after traffic accidents in individuals wearing only lap seatbelts. We examine here this type of injury in one child and two adolescents who all were seated in the rear seat of cars involved in traffic accidents. All of the children were wearing regular three-point safety belts not adjusted to children. They were all treated surgically. Two of the patients had no neurological impairment, while one patient suffered persistent complete paraplegia. In two patients intra-abdominal lesions required surgery. Flexion-distraction injuries in individuals with an immature skeleton, wearing standard three-point safety belts, have not been reported in the literature. The pathomechanism of the lesion in the lower spine may well involve damage to the intestines, particularly at the junction between the mobile intra-abdominal and the fixed retroperitoneal part of the gut. Reduction and stable fixation preserve the anatomy of the lower spine, while unstable fixation methods do not secure reduction sufficiently to allow early mobilisation.

Pediatric spine and spinal cord trauma

The purpose of this work was to analyze the literature published in English and to review the experience of the Barrow Neurological Institute (BNI) with spine and spinal cord injury (SCI) in children. Standard computerized data bases were queried for information regarding SCI, spinal injury, spinal instability, and spinal cord regeneration to produce a review of the epidemiology, diagnosis, treatment, outcome and directions for future research. We also reviewed our experiences in the management of infants and children with spine injuries and SCIs and with spinal instability from all causes. A total of 132 articles were identified and obtained from the Medical Library at St. Joseph's Hospital and Medical Center in Phoenix, Ariz. and through interlibrary loan. All these articles were read, although not all were used in the final review. A review of all children with SCIs revealed that fractures treated over the past 20 years at the BNI were very rare in preadolescent children, who suffered mostly from ligamentous injury or SCI without radiographic abnormality. A total of 68 children aged 16 years or younger who had been treated over the past 15 years and who had undergone spinal fusions for trauma, congenital anomalies, or tumor resection were identified. Occipitocervical fusion is well tolerated in children as young as 11 months when internal stabilization with a threaded titanium rod is used. Posterior instrumentation, including pedicle screw fixation, is feasible in children as young as 4 years. Fusion techniques derived from the adult spinal instrumentation experience were found appropriate except for the youngest patients. Fusion in the newborn period was futile in our experience. The adolescent spine does not differ from the adult spine in terms of sensitivity or response to fixation. Children past the neonatal period can be successfully instrumented for spinal stability without apparent long-term sequelae. Related advances are needed in the area of prevention. Long-term advances in spinal cord regeneration can be expected from ongoing basic science investigations.