Early Adolescent Lumbar Intervertebral Disc Injury: A Case Study
SOURCE: Chiropractic & Manual Therapies 2013 (Apr 26); 21: 13
Chris T Carter, Lyndon G Amorin-Woods and Arockia Doss
School of Health Professions,
Murdoch University,
Murdoch, Western Australia, Australia
This article describes and discusses the case of an adolescent male with lumbar intervertebral disc injury characterized by chronic low back pain (LBP) and antalgia. A 13-year-old boy presented for care with a complaint of chronic LBP and subsequent loss of quality of life. The patient was examined and diagnosed by means of history, clinical testing and use of imaging. He had showed failure in natural history and conservative management relief in both symptomatic and functional improvement, due to injury to the intervertebral joints of his lower lumbar spine. Discogenic LBP in the young adolescent population must be considered, particularly in cases involving even trivial minor trauma, and in those in which LBP becomes chronic. More research is needed regarding long-term implications of such disc injuries in young people, and how to best conservatively manage these patients. A discussion of discogenic LBP pertaining to adolescent disc injury is included.
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Background
LBP in children and adolescence is an important and increasing problem, and prevalence increases with age [1]. Systematic review and meta-analysis studies of LBP in adolescence found mean LBP point prevalence and one-year prevalence for adolescents to be around 12%, and 33% respectively [2,3]. Watson et al. [4] reported a one month period prevalence of 24% in schoolchildren aged 11–14 years in northwest England. Historically considered as trivial and non-limiting, LBP in this age-group may have both immediate and long-term consequences for an important proportion of those affected [4]. Risk factors have been debated, although ergonomics of school furniture, school bag weight and mechanics, trauma, history of scoliosis, and involvement of strenuous physical activity may be associative or causative factors in young persons with LBP [5]. There is also increasing evidence that psychological and psychosocial factors may play a significant influence in the aetiology of LBP in this age group [6, 7].
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Most cases of LBP in the younger population are considered ‘mechanical’ and ‘uncomplicated’, with pathological causes such as neoplasm and infection being very rare [6]. Conservative management and natural history are quite favourable, with the percentage of cases that persist with discomfort longer than one week being less than 15% [5, 6]. Therefore, should a young person diagnosed with uncomplicated LBP not respond as quickly as expected to conservative management, pathological causes should again be considered and further clinical examination undertaken. Additionally, less common, non-pathological causes of low back pain such as ‘active’ spondylolysis must be re-introduced into the differential diagnosis [8].
An important and probably underappreciated source of LBP in children and young adolescent persons is the intervertebral disc (IVD) joint. Lumbar disc herniation (LDH), encompassing the categories of protrusion, extrusion, and sequestration is well known to cause LBP [9-11]. Involved in the herniation process are annular tears and other intervertebral joint sources of LBP such as end plate subchondral oedema [9]. For the paediatric patient lumbar disc herniation is less common compared to adults, affecting no more than 5% of the population, and paediatric patients have been shown to constitute only 0.5–6.8% of all patients hospitalized for LDH [12]. Multiple factors have been identified as potential causes, with 30–60% of cases of children and adolescents with symptomatic LDH having had a history of trauma before the onset of their LBP [12].
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