Back Pain in the Adolescent a User-Friendly Guide by Jordan D

A Clinical Guide Vol. 17, No. 2 for Pediatricians February 2005

Back Pain in the Adolescent A User-Friendly Guide by Jordan D. Metzl, MD, FAAP “Jodie,” a 15-year-old female volley- much,” she says. cal.” This type of back pain is largely ball player, comes to the offi ce complain- When they arrive in the offi ce for related to muscular weakness, infl ex- ing of steadily increasing low back pain further evaluation, Jodie and her mom ibility, cartilaginous disk abnormal- of 4 weeks’ duration. She cannot recall say that they want to fi gure out what’s ity, and arthritic degeneration of the any specifi c injury, and instead describes wrong and take care of it right away. “I lumbar spine. an aching pain in her lumbar spine love playing volleyball and I have to get Back pain is also common in ado- that has developed over the course of the back as soon as possible,” she says. lescents. Retrospective school-based season and has worsened every time she The pediatrician in this fi ctional vi- surveys of 1700 and 1400 adolescents plays. “The past month has been terribly gnette must quickly sort out the many found that 27% and 30%, respectively, painful,” she says. possible causes of Jodie’s back pain. had experienced low back pain at When asked specifi cally, Jodie The most common sources of back some time in the past.1 Another study describes a “dull ache at the bottom of pain in adolescence are bone-related, my spine,” that hurts, “especially when I muscular, and discogenic, although serve.” She denies paresthesia or radicu- other etiologies must be considered. Goals and Objectives lopathy into the feet or toes as well as This article will discuss the most After reading this issue, pediatricians pain that awakens her in the night. The common types of back pain and who care for patients with back pain pain is clearly worse after volleyball, briefl y address less typical etiologies. will be better prepared to: she says, and is worst when she serves The text will give clues for appropriate • List the types of back pain most commonly seen in adolescents the ball. “I can barely serve it hurts so evaluation, treatment, and referral of • Do a comprehensive assessment adolescents who present to the medi- • Perform an appropriate physical Jordan D. Metzl, MD, FAAP, is the cal offi ce with back pain. examination medical director of the Sports Medicine • Complete a differential diagnosis Institute for Young Athletes, Hospital for • Identify criteria for further diagnostic Special Surgery, New York City and Old HOW COMMON IS IT? evaluation Greenwich, CT. Dr. Metzl, who treats pedi- Studies suggest that between 70% • Discuss the role of imaging and other atric, adolescent, and adult athletes, is on and 80% of the general population diagnostic tools the editorial boards of Pediatrics, Pediatric will experience low back pain at some • Develop a management plan for treat- Emergency Care, and Pediatric Annals, 1 ment of the most common forms of and is the author of The Young Athlete, A point in their lives. In the majority back pain Sports Doctor’s Complete Guide for Parents of adult cases, pain is located in the • Delineate criteria for referral (Little, Brown and Company, 2002). lumbar spine and is termed “mechani-

Supported through an educational Section on Adolescent Health grant from Nestlé Nutrition Institute™ of 100 student athletes ages 12 to 18 Adams test for scoliosis, asking the be further assessed by x-ray. who presented to the sports medi- patient to extend her arms and put • Ask the patient to bend backward. cine clinic of a children’s hospital for both palms together, then slowly Pain on bending backward often evaluation of back pain attributed the bend forward from the waist. Stand suggests spondylolysis or a stress pain to spondylolysis in 47%, disk behind the patient and position your fracture. problems in 11%, lumbosacral strain fi eld of gaze at the level of the spine. • Instruct the patient to put hands on of muscle-tendon units in 6%, and Look for asymmetry of the thoracic hips and twist back to left and right, lordotic or mechanical causes in 26%.2 cage or lower back. Curvature in the looking for any pain on either side of spine suggests scoliosis, which may the spine. Pain with twisting would TAKING THE HISTORY be consistent with muscle spasm or In evaluating back pain in an ado- muscle pain. lescent, the history is a key part of the Checklist for the • Ask the patient to sit on the examin- equation. Clinical Encounter ing table with legs dangling for a Listen closely to ascertain the The following questions can help straight leg raise test. Straighten out mechanism of injury. Elicit informa- structure history-taking for back-re- one leg, then the other, and look for tion about types of movement and lated problems: any pain associated with one side or activities associated with pain. Ask 1. What was the mechanism of the other. If there is pain bending about prior injuries or periods of back injury (eg, acute traumatic injury, forward and with a leg raise on a overuse injury, specifi cs that led to pain. Inquire as to the site of pain and specifi c side, consider a disk problem injury)? whether or not it radiates. (See Check- 2. (If not injury-related): When did on that side. list for the Clinical Encounter) this pain begin? How did it begin? Do you remember what you were do- Further Examination THE PHYSICAL ing the day before the onset of pain? After the active motion tests, exam- EXAMINATION Was the onset acute or insidious? ine the patient further via palpation, Physical examination of the patient Have you had pain like this before? strength testing, and a neurosensory 3. What activity makes the pain with back pain includes observation worse (eg, pressure, movement in a examination. of gait and posture followed by active given direction, rest)? Do any sports • Palpate the spine and look for areas motion, strength, and neurosensory activities make it worse (eg, serving of tenderness along spinal processes tests. a volleyball, bending backward in (bones). To begin the physical examination dance class, twisting in basketball)? • Palpate the iliac crest, specifi cally of the spine, ask patients to let you 4. Does the pain awaken you at cartilaginous apophyses or growth watch them walk across the room. night? plates. 5. What eases the pain? Ideally, they should be in a gown that 6. Are there neurological or • L5 disk herniation would cause is open in back, dressed in shorts, with radicular symptoms? weakness of the hallucis longus mus- no top and no brassiere. Look to see 7. What is the prior history of cle. To test for that, ask the patient to whether they have a normal gait. Are injuries or problems? extend the great toe upward against they comfortable? Are they tilted to 8. Where is the pain located (lum- your resistance. one side? Next, look at the spine. Is the bar, upper/lower thoracic, midline, • Test quadriceps and hamstring paraspinal)? hip height equal on both sides? Are muscles, asking the patient to push 9. Are there any other symptoms the shoulders equal on both sides? If on the review of systems (eg, bowel the leg out as if to kick, then pull there is a fold of skin above the hips, or bladder problems, abdominal it back, both times against your does one side look more creased than pain, fever, weight loss)? resistance. the other? 10. Are there symptoms not • L4 weakness would be detected related to the back that suggest with inversion of the foot. To test for Active Motion Tests systemic infection, neoplasm, or a this, ask the patient to evert the foot collagen vascular problem (eg, fever Ask the patient to move as directed or painful joints)? against resistance. while you observe the lumbar spine. 11. Is there a family history of • Check for L4 nerve root involve- • Instruct the patient to bend all the back stiffness or spondyloarthropa- ment by assessing dorsal and plantar way forward. Pain bending forward thy? fl exion of the foot. is most often discogenic. Do the • Check refl exes in the patellar tendon,

2 the L4 nerve root. A diminished twisting or lifting. Sometimes there is tion is required. Defi nitive diagnosis is refl ex in the L4 nerve root suggests a a history of acute injury, as in the case made through a spine radiograph. possible disk herniation between the of a teen who twists during a baseball L3 and L4 vertebrae. game and develops an acute back Diagnosis and treatment of • Look for a diminished Achilles spasm with a sharp pain along the muscular back pain refl ex, which would indicate disk side of the lumbar spine in the para- In general, the physical examination herniation at the L5 level. spinous muscles. More often, however, is suffi cient for diagnosis and evalua- Findings from the physical examina- the scenario for muscular back pain is tion of muscular back pain. However, tion will direct the clinician’s next an overuse injury, as in the adolescent if there is scoliosis associated with the steps, which may include further di- who lugs a 60-pound backpack to pain, spinal radiographs are recom- agnostic tests, physical therapy, and/or school daily and then complains of an meded for measurement of the curve. referral to a specialist. Weak or di- ache in the paraspinous muscle group. While anti-infl ammatory agents minished refl exes may suggest a nerve The specifi c fi ndings on physical are sometimes helpful for temporary problem or a herniated disk. Consider examination of the adolescent with pain management, steroids and muscle referral to an orthopedic or sports muscular back pain include tenderness relaxants generally are not indicated. medicine specialist if there is pain on to palpation along the paraspinous Treatment of muscular back pain bending forward or backward, pain on muscles and the feeling of a “knot” in involves muscular stretching and the straight leg test, diminished deep the back. strengthening, which may include tendon refl exes, or apophyseal pain on Adolescents with muscular back referral to a physical therapist. The palpation. pain generally will not have pain with referral should stipulate a diagnosis of forward fl exion (bending forward) or muscular back pain and recommend MOST COMMON TYPES OF extension (bending backward). Rather, a plan for evaluation and treatment BACK PAIN muscular back pain tends to occur including ultrasound, electrical Most adolescent back pain will with spinal rotation. To best elicit this stimulation, heat, and ice. With physi- fall into 3 general categories: mus- fi nding, the examiner should have the cal therapy, muscular back pain will cular, bone-related, and discogenic. patient slowly twist from side to side usually resolve within 4 to 6 weeks. In (See Table 1) while stabilizing the hips. The slow our offi ce, we encourage patients to twist will cause the muscles to hurt remain active when being treated and Muscular back pain because they are tight and in spasm. schedule an interim check at 3 weeks. Roughly 30% of all cases of back For student athletes, this includes pain in adolescents is muscular in ori- A word about scoliosis return to sports as soon as they can. gin. When an adolescent comes to the Although scoliosis does not directly More activity does not typically cause offi ce with a complaint of back pain, produce back pain, muscular back increased problems with muscular what clues would suggest muscular pain is a common secondary fi nding back pain, so these patients can be pain? in adolescents who have a scoliotic encouraged to use their judgment. Muscular pain in the adolescent curve, which is why it is important to back tends to occur on one or both rule out scoliosis if a diagnosis of mus- Bone-related back pain sides of either the thoracic or lum- cular back pain is entertained. Patients Bone-related back pain accounts for bar spine, most often during or after with both scoliosis and pain are can- roughly 25% to 50% of back pain in didates for referral because one cannot adolescents and is most often seen in assume the pain is due to scoliosis and more athletic teens. The most com- Keys to Diagnosis and Treatment of Muscular must therefore pursue other causes. mon scenario for this presentation is Back Pain: Evaluation for possible scoliosis is the adolescent athlete who comes in best done by performing the forward- complaining of pain in the lumbar 1) Location of pain is generally para- fl exion maneuver known as the Adams spine with extension. This is gener- spinous, not midline 2) Radicular symptoms are absent test, described above. If physical fi nd- ally an athlete who uses the spine for 3) Scoliosis has been ruled out ings suggest scoliosis, a Scoliometer repetitive extension maneuvers, such as 4) Physical therapy should be started can help to confi rm the diagnosis. An the gymnast, fi gure skater, ballerina, or as soon as possible inclination reading between 5 and 7 volleyball player. degrees indicates that further evalua- Bone-related back pain is most

3 often a result of overuse. In overuse or pain-free require no treatment. interarticularis (often described as the repetitive stress injury, edema in the The most common location for neck of the “Scotty dog”), the hallmark bone signals stress that may progress spondylolysis is in the fi fth lumbar of long-standing spondylolysis.4 to an overt stress fracture known as a vertebrae at the base of the spine. X-ray and physical examination spondylolysis, a crack in the pars inter- Either through congenital causes or are usually suffi cient for diagnosis of articularis. through bilateral spondylolysis, the spondylolysis, but if in doubt an MRI Micheli and Wood found that affected vertebrae can slip. When this can show edema in the bone before it nearly half of young athletes who pre- occurs, the patient has a condition cracks. The quality of MRI magnets sented to a sports medicine clinic with known as spondylolisthesis. can vary, which is why SPECT (CT back pain had spondylolysis.2 However, plus bone scan) is sometimes used to spondylolysis is often asymptomatic. A Physical examination, work-up, confi rm the diagnosis. study of 145 Indiana University football and treatment Treatment is indicated when the players screened for spondylolysis in The specifi c physical exam fi ndings patient has persistent pain bending the 1970s revealed that 47% of those of an adolescent with suspected bone- backward. If this occurs, the patient with spondylolysis were asymptomatic related back pain include pain with should be referred to a sports medicine when they started college and 40% extension maneuvers (bending back- specialist or sports-oriented pediatric remained pain-free at graduation.3 ward). This is in contrast to muscular orthopedist. Patients with spondy- Spondylolysis is not uncommon and pain, which worsens with twisting. lolysis should also be referred for patients with spondylolysis who are The neurological examination for physical therapy with a sports-oriented patients with bone-related back pain is physical therapist. Physical therapy will usually normal, although abnormali- strengthen abdominal or core muscles, Keys to Diagnosis and ties are seen when the spondylolisthe- correct the mechanical problem of Treatment of Bone- sis has slipped to where it is compress- overloading the spine, and reduce dis- Related Back Pain ing the spinal nerve roots. comfort. If the patient has back pain The work-up and treatment for but not pain when bending backward 1. What seems to make it bone-related back pain in the adoles- and the x-ray indicates spondylolysis, worsen? Pain on bending backward cent depends upon the type of pain. many clinicians will allow a month of (extension) should be considered bone-related pain until proven other- In the case presented at the beginning physical therapy before referring the wise. of this article, an adolescent volleyball patient for evaluation by a specialist. 2. Back pain that awakens an player came in with a complaint of Treatment for spondylolysis de- adolescent from sleep and worsens back pain with extension that had pends upon the age of the patient at night but does not worsen with ac- worsened over the past several months and age of the lesion. It may include tivity is suspicious for neoplasm, most until she could no longer play volley- a period of bracing, physical therapy, commonly benign osteoid osteoma. 3. The treatment of bone-related ball without signifi cant pain. The his- and the use of a bone stimulator to back pain most commonly involves tory of pain with extension that limits bracing, physical therapy, and the adolescent’s ability to participate in TALKING POINT rarely, surgery. sports should immediately trigger the 4. Patients are most often referred presumptive diagnosis of spondylolysis Explaining the plan to a sports medicine specialist or in the mind of the health practitioner. for diagnosis and sports-oriented pediatric orthopedist. The work-up for suspected spondy- treatment 5. Physical therapy should be initiated promptly. The ideal physical lolysis includesincludes fourfour radiographs:radiographs: AP,AP, To explain spondylolysis, tell therapy referral will be to someone lateral, and two oblique views. The patients that there has been too much who understands the patient’s sport AP view is important to assess the pressure on the bones of their spine and can address the specifi c athletic curvature of the spine and the lateral and those bones have started to crack. Emphasize that their condi- maneuvers that may have precipi- view is important to investigate for tion is not uncommon and can be tated or exacerbated the condition. spondylolisthesis, slip of the vertebrae. 6. In most cases, patients can treated. Stress that complying with The oblique views, taken at 45 degree resume normal activities as soon as the regimen for physical therapy will they are pain-free, with bracing as angles from the midline on either strengthen core muscles so that these indicated. side of the lumbar spine, are used to injuries do not remain symptomatic. investigate for a crack across the pars

4 Table 1 Common Causes of Back Pain Discogenic Clues to Pathophysiology Muscular Bone-Related

Site of pain Localized to paraspinous Localized to center of spine muscles

Pain during activity X X X

Pain after activity X X X

Pain bending forward X

Pain bending backward X

Straight raised leg test elicits pain X

Pain with twisting X

Radiating pain May occur if there is spondylolisthesis and the degree of slip is sufﬁ cient to X impinge on the nerve root

Strength testing Strength tests involving the great toe, inverted foot, thigh, and hip ﬂ exor may show weakness

Unremarkable Refl ex defi ciencies may signal Refl ex defi ciencies may signal disk Neurosensory exam spondylolisthesis that has progressed to herniation; tingling toes may suggest compress spinal nerve roots. spinal cord compression

Radiologic Tests Consider x-ray only if pain persists X-rays - 1 AP, 1 lateral, and 2 oblique X-rays - 1 AP and 1 lateral. MRI more than 6 weeks, occult fracture is views. Consider MRI if concerned about considered gold standard; rarely CT if suspected, or scoliosis is also present fracture. If spondylolysis is suspected MRI not clear. but not clear on x-ray, MRI will reveal edema

Activity modiﬁ cation Patients should be encouraged to return Sports hiatus for younger patients with Bed rest is not recommended to play as soon as they can, using their spondylolysis that may heal with rest. judgment and taking nonsteroidal anti- Older patients can play with or without inﬂ ammatory drugs as needed. a brace once they are pain-free, but must postpone return to play until nerve- related symptoms resolve.

Indications for referral Associated scoliosis Spondylolysis, spondylolisthesis, or Always pain that persists for more than a month despite physical therapy, regardless of x-ray ﬁ ndings

Treatment plan Physical therapy, which may include Referral to a sports-oriented physical Referral to a sports-oriented physical referral to a sports-oriented physical therapist and either a sports medicine therapist and sports medicine specialist therapist specialist or a sports-oriented pediatric or sports-oriented pediatric orthopedist. orthopedist Their options will include bracing or steroid injection and, if all else fails, microdiskectomy

5 facilitate healing. In patients with H.W. Meyerding’s 5-category classifi - presents with thigh weakness and may spondylolysis who are younger than 10 cation system. To measure the degree also be suffering from undiagnosed or 11 years of age, it is possible to at- of slippage, the examiner takes a lateral lumbar radiculopathy. Discogenic back tain bone healing. These patients take view of the lumbosacral junction, then pain can cause radicular pain into the a respite from sports for a few months measures the slip as a percentage of feet as it does in adults, but in adoles- while they continue with physical the length of the superior border of cents, radicular pain more commonly therapy and are followed with CT or the sacrum. Meyerding’s grade I is a stops at the level of the thigh and MRI. Older adolescents can generally 1% to 25% slip. Grade II is a 26% to upper leg. return to sports as soon as they are 50% slip. Slips of 50% or more (grade pain-free. Continued physical therapy, III or more) are considered high-grade. Evaluation and treatment bracing, and judicious use of NSAIDs Grade III is a 51% to 75% slip, grade The evaluation and treatment of will usually be all that is needed to IV is a 76% to 100% slip, and grade V, discogenic lumbar spine pain in the return to their sport. spondyloptosis, is a slip greater than adolescent patient begins with a good The work-up for suspected spondylolis- 100%.5 history. The presence of nerve-re- thesis iiss ggenerallyenerally fi nishednished afterafter thethe ra-ra- The treatment for spondylolisthesis lated fi ndings on the physical exam, diographs. MRI can be used to evaluate is rarely surgical. Symptoms generally classically a worsening of pain with adolescents with discogenic symptoms improve with physical therapy. Oc- forward fl exion, will confi rm clinical that might accompany spondylolisthesis casionally, surgery is necessary if the suspicions. Straight leg testing, raising when spinal stenosis, a narrowing of the symptoms persist and the degree of the leg to an extended position while spinal canal, is present, or when the de- slippage is suffi ciently severe. the patient is seated at the edge of gree of slip is suffi cient to cause nerve the examination table, is the best way root compression. Discogenic (nerve-related) to identify discogenic pain because Spondylolisthesis is a graded entity back pain straightening the affected leg impinges most often described in terms of Discogenic back pain, which the nerve root. The diminution of accounts for 50% of back pain in either the patellar or Achilles refl ex on adults, accounts for roughly 10% of the affected side reinforces a prelimi- Making a Referral back pain in adolescents.2 Discogenic nary determination that the pain is Most adolescents with back pain pain is caused by the herniation of an nerve-related. are ideally referred to sports medi- intervertebral disk and subsequent Radiographs are important. Gen- cine physicians, pediatric orthope- impingement on either a central or pe- erally, AP and lateral views of the dists, and physical therapists who ripheral nerve. These teens will often lumbar spine are suffi cient to show enjoy working with student athletes. present to the offi ce complaining of any underlying bone causes of disco- One way to fi nd these specialists is to fi nd out who helps out with the lumbar spine pain that worsens with genic back pain. The classic fi nding is school teams, cares for the instructors bending forward, and may sometimes spondylolisthesis, in which slippage of at the local dance studio, or advises be accompanied by radiating pain into the vertebra weakens the disk, mak- volunteer parents for the youth soccer the hip or thigh. league. The most common reasons Unlike muscular or bone-related for referral are as follows: back pain, which is acute, discogenic • To clarify the diagnosis Keys to Diagnosis and • To pursue next steps when an exer- pain tends to wax and wane, and does Treatment of Discogenic cise regimen with physical therapy not always follow a typical activ- Back Pain has not brought improvement of ity-pain correlation. For this reason, 1) Have a proper index of suspicion musculoskeletal pain discogenic back pain can persist for if evaluation reveals pain with for- • When there is evidence of spondy- months and even years without proper ward fl exion and radicular pain lolysis, spondylolisthesis, scoliosis, diagnosis or treatment. 2) Rule out underlying spondylolisthe- or disk herniation on x-ray or MRI The typical patient with adolescent sis with x-rays. 3) Initial management is nonsurgi- Adolescents with evidence of neo- variant discogenic back pain comes to cal. Refer the patient for physical plastic, rheumatologic, or infectious the offi ce complaining of pain with therapy and also to a sports-ori- disease processes should be referred bending forward. Occasionally, nerve ented pediatric orthopedist. to appropriate specialists. impingement symptoms are the cause for concern, as in the patient who

6 ing it prone to herniation and nerve hurts more at night than during the pain. Spondyloarthropathy is signaled root impingement. In higher grades day, and most often occurs in the by sacroiliitis, or infl ammation of the of spondylolisthesis, the spinal canal femur, tibia, extremities, and lumbar sacroiliac space, and peripheral arthri- can become narrowed by the verte- spine. The pain from osteoid osteoma tis, often in the lower extremity. brae themselves, causing unremitting initially responds well to nonsteroidal radicular pain. anti-infl ammatory drugs (NSAIDs); a CONCLUSION Physical fi ndings are corroborated history of night pain that is successful- With a proper history, physical via MRI, the gold standard for diag- ly treated with NSAIDs should raise exam, and testing, diagnosis of ado- nosis. Imaging will show bone, nerve, clinical suspicion for this entity. lescent patients with back pain can be and disc. MRI is used in combination Neoplastic disease should be con- accomplished effi ciently. Successful with physical exam and x-ray fi ndings sidered when the history and symp- treatment will be rewarding for both to chart the best course for treatment. tomatology do not fi t any of the classic the patient and pediatrician. In adolescents, the fi rst step is gener- patterns and the patient’s condition ally physical therapy to strengthen the does not improve over time. There are ACKNOWLEDGEMENT core abdominal musculature. Bed rest a number of uncommon tumors and The editors would like to acknowl- is no longer recommended. Occasion- cysts of the spinal canal and extraspi- edge technical review by David M. ally, a temporary back brace is used nal area that may be present. Although Siegel, MD, MPH, FAAP, University to augment core stability during the MRI evidence is diagnostic, not all of Rochester School of Medicine and strengthening phase. If this treatment MRIs are equally reliable. When Dentistry and Rochester General Hos- fails, epidural spinal injection of ste- symptoms persist over 6 to 8 weeks, pital, Rochester, New York. roids at the level of the disk herniation fi t no pattern, and worsen at night, has been used with moderate success. consider referral to a specialist. REFERENCES AND If this fails, surgical microdiskectomy, RESOURCES in which the surgeon removes a little Systemic causes 1. Olsen TL, Anderson RL, et al. The epidemiol- piece of the disk, is the surgical treat- Systemic causes, such as infectious ogy of low back pain in an adolescent population. Am J Public Health. 1992;82:606-608 ment of choice for most adolescents. or rheumatologic diseases should be It must be stressed, however, that the suspected when the history is unclear, 2. Micheli LJ, Wood R. Back pain in young vast majority of adolescents will not there is no trauma, the pain is not athletes. Signifi cant differences from adults in require surgery. consistent with the physical examina- causes and patterns. Arch Pediatr Adolesc Med. 1995;149:15-18 tion, and systemic symptoms such as LESS COMMON CAUSES fever or fatigue are present. Pain can 3. McCarroll JR, Miller JM, Ritter MA. Lumbar OF BACK PAIN occur with all activities and may not spondylolysis and spondylolisthesis in college football players. A prospective study. Am J Sports Neoplasm-related back pain be limited to the back. The intensity Med. 1986;14:404-406 Back pain can result from bone tu- of the pain experience may seem to mors. A signifi cant aspect of bone pain be out of proportion to the physical 4. Smith JA, Hu SS. Management of spondyloly- caused by neoplasm is that it does not examination. Listen for reports of pain sis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am. seem to worsen after activity. Instead, in multiple joints and the extremities; 1999;30:487-499, ix the pain is constant and worsens at these patients are typically referred night. When adolescents complain of either to a pediatric rheumatologist or 5. Meyerding H. Low backache and sciatic pain back pain that awakens them from infectious disease specialist. associated with spondylolisthesis and protruded intervertebral disc: Incidence, signifi cance and sleep, neoplasm should be strongly X-ray may reveal infl ammation. treatment. J Bone Joint Surg. 1947;23:461-4701947;23:461-470 suspected. These patients should be Laboratory tests should include CBC evaluated with both radiographs and with differential, erythrocyte sedimen- an MRI of the spine, as x-rays alone tation rate, HLA B27, and C-reactive may miss a lesion. Only an MRI is protein. Consider screening patients fully diagnostic for neoplastic disease. who live in or travel to areas endemic An extremely common neoplasm for Lyme disease. Results may show in the adolescent age group is osteoid elevated HLA B27, indicating possible osteoma, a small, benign tumor that spondyloarthropathy, which is the appears in the second decade of life, most common systemic cause of back

7 A Note from the Editor

Adolescent Health Update, now in its 17th year of publication, seeks to provide useful clinical tools for ofﬁ ce-based care of adolescents. Our goals are to enhance the general pediatrician’s ability to care for adolescents and to share our enthusiasm for working with these patients. The Nestlé Nutrition Institute™ has sponsored Adolescent Health Update for more than 2 years now. Their generous educational grant has enabled us to continue to pursue our mission. We greatly appreciate Nestlé’s commitment to the Academy. This summer and fall marked a number of transitions within our editorial and advisory boards and the greater AAP leadership. We bid farewell to Paula K. Braverman, MD, FAAP, who has completed two 3-year terms on our editorial board. It has been a true pleasure working with Paula. We will miss her commitment, expertise, and unfailing sense of humor. With Paula’s departure, we welcome our newest editorial board member, Patricia K. Kokotailo, MD, FAAP. Dr. Kokotailo is an associate professor of pediatrics and head of the adolescent medicine division, University of Wisconsin-Madison Medical School. Pat, who is also a member of the AAP Committee on Substance Abuse, brings a wealth of experience in clinical issues and resident education. Our editorial advisory board is comprised of six general pediatricians who contribute to long-range planning and critique manu- scripts in development. We will miss the unfailingly thoughtful comments of David Y. Rainey, MD, FAAP, who has completed his 6-year term on the advisory board. At the same time, we welcome to our advisory board Paul Neary, MD, FAAP, a clinical associate professor of pediatrics at the University of Wisconsin-Madison Medical School who maintains a private practice in Fort Atkinson, Wisconsin. Finally, we marked a major transition at the executive level of the Academy with the recent retirement of Executive Director Joe Sanders, MD, FAAP. Dr. Sanders, an adolescent medicine specialist, was a founding member of our editorial board. His contributions to this publication and support of its mission have meant a great deal to us. The reader’s satisfaction is the measure of success of any publication. We plan to do our best to continue to satisfy the interests and needs of general pediatricians who care for adolescents. You can help us by sharing any ideas you might have for topics and format. If you have any thoughts to share about Adolescent Health Update, please do write to us at [email protected].

Sheryl A. Ryan, MD, FAAP Editor

Adolescent Health Update Editor Advisory Board The American Academy of Pediatrics, through Sheryl A. Ryan, MD, FAAP Barbara E. Cohen, MD, FAAP its Section on Adolescent Health, offers Ado- Rochester, NY Philadelphia, PA lescent Health Update to all AAP Fellows. David T. Estroff, MD, FAAP Editorial Board Comments and questions are welcome Gig Harbor, WA and should be directed to: Adolescent Robert M. Cavanaugh, MD, FAAP Kari A. Hegeman, MD, FAAP Health Update, American Academy of Manlius, NY Minneapolis, MN Pediatrics, P.O. Box 927, Elk Grove Marc S. Jacobson, MD, FAAP Marc Lashley, MD, FAAP Village, IL 60009-0927, or send an e- New Hyde Park, NY mail to [email protected]. Valley Stream, NY Patricia K. Kokotailo, MD, FAAP Paul Neary, MD, FAAP ©Copyright 2005, American Academy of Pediatrics. Madison, WI Fort Atkinson, WI All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, David S. Rosen, MD, MPH, FAAP Scott T. Vergano, MD, FAAP in any form or by any means, electronic, mechanical, Ann Arbor, MI Chatham, NJ photocopying, recording, or otherwise, without prior Walter D. Rosenfeld, MD, FAAP written permission from the publisher. Printed in the United States of America. Pediatricians are encouraged Morristown, NJ to photo copy patient education materials that appear Managing Editor on the extra pages that wrap around the outside of this Supported through an newsletter. Request for permission to reproduce any ma- Mariann M. Stephens terial that appears in the body of this newsletter should educational grant from be directed to the AAP Department of Mar keting and Publi cations. Current and back issues can be viewed on- AAP Staff Liaison line at www.aap.org. Please go to the Members Only Channel and click on the Adolescent Health Update Karen Smith icon/link. The recommendations in this publication do Division of Developmental Pediatrics and not indicate an exclusive course of treatment or serve as Preventive Services a standard of medical care. Varia tions, taking into ac- count individual circumstances, may be appropriate.