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Spondylolysis and Spondylolisthesis

The four major categories that we see are spondylolysis and spondylolisthesis and that is just a slipping of one portion of the spine on another portion of the spine. Usually itís L5 on S1. Scheuermannís kyphosis is a hunchback type of deformity that we see in otherwise healthy adolescent children. Generally in very rigorous laborers, weight lifters and farm boys, we see this Scheuermannís kyphosis which is a common cause of back pain. An infection, diskitis or vertebral osteomyelitis that we see can cause back pain. Thereís a whole list of secondary things like tumors and leukemias and things like that and some metabolic things but spondylolysis/spondylolisthesis, Scheuermannís kyphosis and infection are about spondylolysis, spondylolisthesis, spondilolisis, spondilolisthesis 

Spondylolisthesis. This is L5 and this is S1 and you can see here that the posterior margin of the vertebral column up to this point is pretty smooth in the three vertebral bodies you can see and then there is a step off. This is the front of the body and this is the back and you can see that the L5 has slipped forward on S1. We call that a spondylolisthesis or a slipping of the

Scheuermannís kyphosis. It is a sharp, angular forward bend of the spine. This is in the sagittal plane. This plane is youíre looking from the side and there has got to be at least three vertebral bodies that are angulated more than 5ļ. You see these little things here in

Examine the child. Take all the childís clothes off down to their underwear. Even with babies and young children I will take their underwear completely off. There is not much surface area so there is no reason to miss something because you didnít disrobe the child. Look for cachexia, pallor. If they just donít look right to you, then they are probably not right. If they have any gait abnormalities. Do they have ataxia? Do they have a lurch? Do they have what seems to be one leg longer than the other? Anything can be diagnostic of some sort of an intraspinal lesion. Do they have any abnormal skin lesions and midline defects or hair patches which would make you think that there is some sort of myelodysplastic process going on like spina bifida. Look at their spine. See if they have any scoliosis. Have them do a forward bend and we will go into that in a few minutes. Look at their kyphosis. Do they have an unusually hunched posture which can be postural round back, which is normal, or it can be Scheuermannís kyphosis? Do they have local tenderness when you palpate over their spine? It is important because that is very unusual in children. If they have local tenderness, then you have to think about a local process that is acting right there like a tumor. Or if it is low in the spine, possibly a spondylolisthesis. Do a complete

Here is a difference in looking at the kid. You can tell this kid has a little bit of a round back deformity. He has got postural round back and his mom keeps telling him to straighten up and put his shoulders back and if he does that it will go away. This kid, this is not a postural round back. This is a sharp angular curve that you see in Scheuermannís kyphosis and you canít mistake that for that. They are two different entities. He cannot straighten it out if he stands up straight. In fact, he canít even lay on his back because it hurts him to lay on the prominence of that. That probably will require surgical treatment because this is pretty far along but I thought it was a good picture for a demonstration of Scheuermannís kyphosis.

So what diagnostic studies should you get? This is a hair patch, in case you hadnít guessed, and underneath there there is spina bifida. There is a midline defect. You wonít see ones as pronounced as that. That is sort of one so you wonít forget what it looks like. But that

If the history is unclear, in other words they donít have a history of trauma, they wake up with it or they develop it over a couple of days, if there are minor physical examination findings, maybe some tight hamstrings, maybe you see a little bit of a curve, then I would suggest getting an AP and lateral of the spine standing. If you think that there is a little bit of tightness in the hamstrings, there may be a spondylolisthesis or a spondylolysis, you might need obliques of the lumbosacral spine to bring out that area of the spine which is

If you are looking for a spondylolysis or a spondylolisthesis and you are not going to treat it, donít get the x-rays. If they have an unclear history or minor physical examination findings, send them to an orthpod because that is when I would start to worry that this kid has got something bad going on. More times than not the x-rays that I get from a primary care physicianís office I canít use. I have to send them to x-ray. The parents get upset because it is a second radiation and they say, "Arenít these good enough?" And I have to say, "No. They arenít good enough. If Iím going to treat your back pain, I need x-rays I can read." "Then why did we get these?" "I donít know." I donít have a good answer. So, if you see a

Here is a more subtle hair tuft. That is kind of one of the ones you will see. But along with that, you canít just limit your examination there. He has an asymmetry in his scapula here too and that is abnormal as well. We donít do this anymore, and this is not my patient. This is a myelogram and you can see the dye column injected into his dura, and there is this. There is no dye there which means that there is something there displacing the dye and that is a spike of bone right in the middle of the cord that is splitting the cord in two. That is called a diastematomyelia. Basically it is a Latin word meaning "splitting of the cord" and this patient has a spike of bone here that is splitting the cord in two and that patient will have neurologic symptoms. Maybe they are not major but you need to know that

This is a great physical test for abnormalities in the thoracic spine and that is how you pick this up. It is an abdominal reflex. You take a sharp instrument like the back end of a hammer, you take it from the four quadrants around the umbilicus, you draw the hammer to the