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Virtual Pediatric Hospital: Back Pain in Children: Case Examples of Back Pain in Children: Case 3 Back Pain in Children: Case Examples of Back Pain in Children

Case 3

Michael P. D'Alessandro, M.D.
Peer Review Status: Internally Peer Reviewed


Sixteen year old tennis player with long standing low back pain. On physical exam he had a positive hyperextension test. His laboratory values were unremarkable. The clinical picture was unclear.

Plain films of the lumbar spine were unremarkable (Not provided).

case 3: image 1 iconImage

A diagnosis of spondylolysis at L5-S1 was made.

Spondylolysis is due to stress fractures of the posterior vertebral elements at the pars interarticularis  from repetitive microtrauma. The pars interarticularis is the weakest part of the vertebra. Spondylolysis is associated with hyperextension sports such as gymnastics, diving, weight lifting, football, soccer and hockey. It is bilateral in up to 75% of cases, and is most common at L5-S1. It is present in 5% of the population, but is usually asymptomatic. Plain films early on can show sclerosis of the pars interarticularis, and later on can show the fracture lucency in the pars interarticularis known as the "Scotty dog" deformity. This is best seen on the oblique plain film. The contralateral pedicle is often sclerotic due to stress from increased load bearing. A bone scan, which is done with tomographic imaging to increase sensitivity, shows increased uptake at the fracture. CT, which is rarely necessary, shows an incomplete ring sign. If spondylolysis is bilateral, the patient can go on to develop vertebral subluxation at that level, resulting in spondylolisthesis. Spondylolisthesis is graded by the Meyerding Classification, where Grade I is 0-25% slippage, Grade II is 25-50% slippage, Grade III is 50-75% slippage, and Grade IV is 75-100% slippage.

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