Pediatric emergency medicine trisk 3978 3978
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indications for, and effectiveness of surgical therapy is not well studied. When
cultures demonstrate particular organisms with known antimicrobial
susceptibilities, antibiotic therapy can be individualized.
Spondylolysis and Spondylolisthesis
Current Evidence
Spondylolysis, with or without spondylolisthesis, occurs in 2% to 5% of children,
but the majority are asymptomatic. Most children presenting with low back pain
will not receive a definitive diagnosis, but of those that do, spondylolysis is the
most common condition identified. Adolescents involved in sports are at highest
risk.
Spondylolysis is a defect in the pars interarticularis of the vertebral body.
Spondylolisthesis is displacement of the vertebral bodies, usually involving L5
slipping anteriorly on S1. Spondylolisthesis may result from structural
abnormalities of the vertebral bodies (dysplastic type) or acquired defects of the
pars interarticularis (isthmic type) that allow slippage. There is a genetic
predisposition to spondylolysis and spondylolisthesis. Parents of children with
spondylolisthesis are found to have this condition in 28% of cases.
The cause of the defect of the pars interarticularis in spondylolysis is not fully
understood. Repeated stress, such as occurs in gymnasts with frequent
hyperextension of the spine, causes stress fracture. One side of the pars
interarticularis fractures overtly, which adds to the stress on the contralateral side.
Fracture becomes bilateral. Displacement may or may not occur. Children who
play sports that stress the spine, such as gymnastics, football, rowing, diving,
weight lifting, and high jumping, are at particular risk.
Clinical Considerations
Clinical Recognition. Patients who develop symptoms generally present during
the adolescent growth spurt. Back pain usually has an insidious onset and
worsens with activity, improves with rest. Over time, there may be pain in the
buttocks and posterior thighs. Symptoms radiating down the legs suggest
significant nerve root irritation. Parents may describe an increase in the lumbar
lordosis or a change in the child’s gait. If back pain in an adolescent athlete
persists for more than 2 weeks there is an approximately 40% chance that
spondylolysis or spondylolisthesis will be noted on MRI.
Initial Assessment/H&P. Physical examination in the prone position shows
tenderness with hyperextension of the lumbar spine and with deep palpation. The
