My achin’ back! Spondylolysis/spondylolisthesis

Case presentation

A 15-year-female presents with low back pain for 2 months. She had no trauma preceding the pain but is very active and plays soccer. The pain increases with activity. She has tried ibuprofen multiple times, with some relief. Her mother took her to her primary care provider last week where a urine test was performed, which was unremarkable. She has not had fever, vomiting, abdominal pain, vaginal bleeding, vaginal discharge, numbness, or weakness.

Her physical examination reveals a well-appearing child who is afebrile. Her heart rate is 65 beats per minute, respiratory rate is 20 breaths per minute, blood pressure is 125/75 mm Hg, and pulse oximetry is 100% on room air. Her weight is 44 kg. She has an unremarkable examination except for mild midspinal lumbar tenderness without crepitus, warmth, or deformity to palpation. She ambulates with a steady gait. Her neurologic examination is benign, with equal tone and strength throughout.

Imaging considerations

Not every pediatric patient with nontraumatic back pain requires imaging. Imaging should be considered in patients with localized pain, neurologic deficits, worsening pain, or persistent pain. Feldman et al. devised an algorithm for the evaluation of nontraumatic pediatric back pain utilizing history, physical examination, complete blood count (recommended in children under 10 years of age in this study due to the association of back pain and leukemia in younger patients), and imaging (plain radiography and magnetic resonance imaging [MRI]). In this group of close to 100 patients, if radiographs were positive and correlated with historical and physical examination findings, then the patient was treated accordingly; if the radiographs were negative and concerning pain was reported (such as constant pain or night pain) or there was an abnormal neurological examination, an MRI study was obtained and positive findings on MRI were treated accordingly. Patients who had negative radiographs and intermittent pain were treated for presumed overuse syndromes or sprains with rest, physical therapy, and nonsteroidal antiinflammatory medications. Using this algorithm, 36% of the patients in the study group were diagnosed with a specific condition, 68% of these patients had a positive finding on initial radiographs, and the remaining patients in this group who had negative initial radiographs had positive findings on MRI.

A study by Ramirez et al. had similar results when examining the utility of MRI in patients after employing the Feldman et al. algorithm of history, physical examination, and plain radiography. These investigators found that 34% of patients in their study had an identifiable cause of back pain, with diagnostic yield increasing from 8.8% (based on history, physical examination, and plain radiographs) to 36% with the use of MRI. Of the 89 patients who had confirmed pathology, 26% were discovered with plain radiographs and 74% with MRI.

Bhatia et al. also employed an algorithm similar to Feldman et al. utilizing history, physical examination, laboratory investigation, and plain radiography in 73 patients; 57 (78%) of the patients in this study had no identifiable cause of back pain and none of these had abnormal radiologic or laboratory findings. Of the remaining 16 patients, 9 were diagnosed with spondylolysis (with or without spondylolisthesis), with the remaining patients having another diagnosis (osteoid osteoma and disk herniation). Thirteen patients (nearly 18%) in this study had a definitive diagnosis, and of those patients, 10 had abnormal plain radiography, 8 of whom were diagnosed with spondylolysis with or without spondylolisthesis (scoliosis was not considered an etiology of back pain).