Although a commonly recognized condition in adults, herniated nucleus pulposus (HNP) is often an unrecognized cause of back and leg pain in the pediatric/adolescent population. This often leads to a delay in diagnosis and/or inappropriate treatment. HNP is distinct from a "bulged disc", an MRI finding often cited as a cause of pediatric /adolescent back pain. With HNP, patients generally have some element of back pain, but it is the leg pain (radiculopathy) or sciatica that often leads to their presentation to a health care provider.
It is not uncommon for children to present with "sciatic scoliosis", a spinal deformity that is a response to the patient's nerve root irritation. This condition can have a sudden presentation from a traumatic event of occur spontaneously with no known cause.
Join Dr. Anderson and Transformational Pediatrics as we discuss HNP, associated conditions, presentation, and treatment.
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"What a Pain" - Appreciating Pediatric, Adolescent Lumbar Disc Herniation Pain
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Learn more about John T. Anderson, MD
John T. Anderson, MD
John T. Anderson, MD, is a pediatric orthopaedic surgeon at Children’s Mercy, Assistant Professor of Pediatric Orthopaedic Surgery, University of Missouri-Kansas City School of Medicine, and Assistant Professor of Orthopaedic Surgery, University of Kansas School of Medicine. He received his medical degree from the University of Kansas in Kansas City, KS, completed residency in Orthopaedic Surgery at the University of Kansas – Wichita in Wichita, KS and completed fellowships in Pediatric Orthopaedic Surgery and Spine Surgery, Baylor College of Medicine, Houston, TX. He is a fellow of the American Academy of Orthopaedic Surgeons, board certified by the American Board of Orthopaedic Surgeons and is a member of various state and national orthopaedic associations. He was rated one of the Top Doctors in Kansas City, by 435 Magazine and KC Business Journal in 2016.Learn more about John T. Anderson, MD
Transcription:
"What a Pain" - Appreciating Pediatric, Adolescent Lumbar Disc Herniation Pain
Dr. Michael Smith (Host): Alright. Today’s topic is, “What a Pain: Appreciating Pediatric, Adolescent Lumbar Disc Herniation Pain”. My guest is Dr. John Anderson. He is the Assistant Professor of Pediatric Orthopedic Surgery at the University of Missouri-Kansas City School of Medicine, and also Assistant Professor at the University of Kansas School of Medicine. Dr. Anderson, welcome to the show.
Dr. John Anderson (Guest): Good morning. Thanks for having me.
Dr. Mike: So, in the title, we have “appreciating the pediatric disc herniation pain”. So, that leads me to think that we must often under-recognize pediatric disc herniation. So, what’s going on there?
Dr. Anderson: Well, I think, part of the problem is that many people equate disc herniations with an older age population. So, a lot of my kids that I see have been having pain for, it’s not uncommon for up to two years at times, before someone recognizes the fact that their leg pain is related to their spine and not their leg. The average time to diagnose this is, I believe, in the range of almost 10 months, and that’s an average, of course, but a lot of these kids go a long time with this pain before anyone recognizes the fact that it’s a disc herniation that’s the source.
Dr. Mike: For a pediatrician, we just have to change the way we think a little bit when we’re presented with chronic pain. I guess, we’re just not used to thinking of herniated discs in kids, right? It’s an adult thing.
Dr. Anderson: Sure. Absolutely. Yes.
Dr. Mike: So, what are some of the related? Let’s back it up for a second. Let’s just define things a little bit here.
Dr. Anderson: Sure.
Dr. Mike: When we talk about disc herniation pain, are there any associated conditions that we also need to be aware of, ready to recognize when a child presents with classic sciatic pain?
Dr. Anderson: Yes, there are some risk factors. Children that have six lumbar vertebra rather than five seem to be at some predisposition. I’m not quite sure why, but certainly kids that are very athletic and active, constantly in sports, are also at some risk. But, oddly enough, a lot of the kids that I see have no history of a specific event or an incidence of trauma that predisposes or starts their symptoms. It just tends to be a random occurrence, oddly enough. But, I think that the main thing is, if you see a child complaining of back pain that’s radiating into their legs particularly their buttocks down the posterior aspect of their thigh, down to their knee or even down into their foot area, it’s certainly something to consider, specifically if they present with stiffness of their spine. Most of these kids really try to avoid flexing their trunk, so if you ask them to bend forward and touch their toes, they’re going to give you a pretty limited amount of effort because it’s just so painful. And they also might--
Dr. Mike: And what about…
Dr. Anderson: Oh, go ahead.
Dr. Mike: Yes. So, thinking of how they’re presenting, so you mentioned they have a lot of the same symptoms. If it’s truly a herniated disc, pain down the leg, right? It’s almost the same presentation we see in adults but, with children, how do you distinguish, say, between a true lumbar disc herniation versus something like scoliosis causing some of the problem?
Dr. Anderson: Sure. Well, typically, the most common form of scoliosis we see is adolescent idiopathic scoliosis which affects our pre-adolescent age group. We don’t really consider scoliosis to be that much of a pain generator. When you look at the natural history studies of scoliosis, it’s not really a disease that causes much as morbidity as you’d think. In majority of the kids with scoliosis that we have, their incidence of back pain isn’t really much different than kids without scoliosis and I wouldn’t expect scoliosis to be causing that classic sciatica type pain. The one thing that is different with kids versus adults is they tend to have more back pain with their disc herniations than adults do. When you see adults, their primary complaint would be their leg pain. With a child or an adolescent, a lot of times their complaint is back pain with leg pain and sometimes the back pain component of it is fairly large and a significant burden to them. So, that’s one way that they're different than adults.
Dr. Mike: Do you think the presentation with back pain in kids versus adult is more children or the inflammatory response is greater, maybe not as well controlled in a child as in an adult, so we’re just having a lot of inflammatory pain. Is that maybe one of the reasons for the difference in presentation?
Dr. Anderson: It could be. And I think one of the other things is that, if you see a child with a disc herniation, especially if it’s a large disc herniation on MRI, there’s a good chance that child actually has what we call an “apophyseal ring avulsion” where they’ve actually avulsed some of the cartilage in the bone off of the end plate of their vertebra with the disc herniation and that can be a source of significant back pain. So, I think that’s another reason you see more back pain in kids versus adults. Now, I want to take you back to this. You alluded to scoliosis. Now, the other thing to keep in mind is a lot of these kids will present with what we call “sciatic scoliosis” where they’ll look like they have a significant amount of trunk shift and they’ll be leaning away from the side of the disc herniation in order to decompress the nerve route that’s being impinged upon. So, if you see a teenage boy or girl that all of a sudden has an acute onset of scoliosis, and they’re having leg pain, that scoliosis is probably not true scoliosis. It could certainly be from their disc herniation.
Dr. Mike: So, let’s talk and maybe walk us through a little bit how you approach this if a child is referred to you, you’re suspecting that there is a disc herniation. What’s the workup for you?
Dr. Anderson: Typically, a lot of times when I see a kid, they’ve already had an MRI. If they haven’t had an MRI, that’s certainly probably diagnostic imaging of choice although most of the time you can just tell from your physical examination that the child has a disc herniation. But, obviously, confirming which level it’s a because usually it’s going to be at L4-L5 or L5-S1. So, I get the imaging oftentimes to confirm the diagnosis, and also to figure out which level is affecting them. If they don’t have neurologic symptoms, if they’re not weak, they don’t have sensory loss, their bowel and bladder function are normal, you can certainly try a course of short rest, anti-inflammatories such as ibuprofen, and then, eventually if they can get their symptoms under better control, a course of therapy is certainly a reasonable next approach. If they don’t get better, because in the adult world, the majority of the patients will get better within a month of presentation whereas that doesn’t seem to be the case in kids. It’s actually the one thing that kids seem to recover from more poorly than adults do. So, I give them the short period of conservative measures of therapy and rest and anti-inflammatories. If they’re not better at some point within a month or six weeks, I think it’s not an unreasonable thing to consider an epidural steroid injection to see if you can alleviate their symptoms. There’s not a lot of good literature out there looking at the effects of steroids in this age group, but I usually try because I've had a handful of kids that respond very well and avoid an operation. But, if they fail all these non-operative measures including steroid injections and things like that, then we consider doing, what they call, a “microdiscectomy”.
Dr. Mike: Right. Any plans from your practice or Children’s Mercy to maybe look into steroid use in children so we can understand it a little bit better? I mean, it sounds like you’ve had some success with it?
Dr. Anderson: Yes, absolutely. I usually have my kids that come in fill out an outcomes instrument just so I can follow their progress more objectively. I think, sometimes as the physician, it’s easy to become a little biased on how you perceive the patient’s doing. So, I generally have them fill out an outcomes instrument and, a lot of times, I’ll have them do it before they have the injection. I’ll have them repeat the instrument after they’ve had the injection so I can get some objective way of measuring how well these kids are responding to steroids.
Dr. Mike: Yes. You’ve had some success with it and I imagine some other practitioners have had success as well. In the last question, Dr. Anderson, what about when it comes to educating the patient, the child and the parents about how they can help manage the pain as well, like when they go home?
Dr. Anderson: Absolutely. One of the things that I oftentimes will have to tell my athletes, in particular, is they need to take a break. They got to stop their activity that’s exacerbating their symptoms. But, also, I think, the parents just need to maintain a positive attitude and be encouraging but, at the same time, obviously, sympathetic and empathetic towards their child. I think you just have to be helpful and, the other thing is, the parents can be very key in helping the child manage their activities of daily living. If you’re just being helpful, it’s oftentimes hard for these kids forward and pick things off the floor, grab their backpack and things like. So, the parents can be helpful as far as just helping the child while they’re really symptomatic.
Dr. Mike: Yes. Maybe decrease the sizes of some of those backpacks those kids carry around a lot.
Dr. Anderson: Yes, certainly decreasing the burden of the weight they’re carrying but certainly the parents can be key as to administering the anti-inflammatory medication with food and water and things like that, making it a more safe environment.
Dr. Mike: Well, Dr. Anderson, listen, I want to thank you for coming on this show, and thank you for the work that you are doing at Children’s Mercy Kansas City. You’re listening to Transformational Pediatrics with Children’s Mercy. For more information, you can go to www.childrensmercy.org. That’s www.childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.
"What a Pain" - Appreciating Pediatric, Adolescent Lumbar Disc Herniation Pain
Dr. Michael Smith (Host): Alright. Today’s topic is, “What a Pain: Appreciating Pediatric, Adolescent Lumbar Disc Herniation Pain”. My guest is Dr. John Anderson. He is the Assistant Professor of Pediatric Orthopedic Surgery at the University of Missouri-Kansas City School of Medicine, and also Assistant Professor at the University of Kansas School of Medicine. Dr. Anderson, welcome to the show.
Dr. John Anderson (Guest): Good morning. Thanks for having me.
Dr. Mike: So, in the title, we have “appreciating the pediatric disc herniation pain”. So, that leads me to think that we must often under-recognize pediatric disc herniation. So, what’s going on there?
Dr. Anderson: Well, I think, part of the problem is that many people equate disc herniations with an older age population. So, a lot of my kids that I see have been having pain for, it’s not uncommon for up to two years at times, before someone recognizes the fact that their leg pain is related to their spine and not their leg. The average time to diagnose this is, I believe, in the range of almost 10 months, and that’s an average, of course, but a lot of these kids go a long time with this pain before anyone recognizes the fact that it’s a disc herniation that’s the source.
Dr. Mike: For a pediatrician, we just have to change the way we think a little bit when we’re presented with chronic pain. I guess, we’re just not used to thinking of herniated discs in kids, right? It’s an adult thing.
Dr. Anderson: Sure. Absolutely. Yes.
Dr. Mike: So, what are some of the related? Let’s back it up for a second. Let’s just define things a little bit here.
Dr. Anderson: Sure.
Dr. Mike: When we talk about disc herniation pain, are there any associated conditions that we also need to be aware of, ready to recognize when a child presents with classic sciatic pain?
Dr. Anderson: Yes, there are some risk factors. Children that have six lumbar vertebra rather than five seem to be at some predisposition. I’m not quite sure why, but certainly kids that are very athletic and active, constantly in sports, are also at some risk. But, oddly enough, a lot of the kids that I see have no history of a specific event or an incidence of trauma that predisposes or starts their symptoms. It just tends to be a random occurrence, oddly enough. But, I think that the main thing is, if you see a child complaining of back pain that’s radiating into their legs particularly their buttocks down the posterior aspect of their thigh, down to their knee or even down into their foot area, it’s certainly something to consider, specifically if they present with stiffness of their spine. Most of these kids really try to avoid flexing their trunk, so if you ask them to bend forward and touch their toes, they’re going to give you a pretty limited amount of effort because it’s just so painful. And they also might--
Dr. Mike: And what about…
Dr. Anderson: Oh, go ahead.
Dr. Mike: Yes. So, thinking of how they’re presenting, so you mentioned they have a lot of the same symptoms. If it’s truly a herniated disc, pain down the leg, right? It’s almost the same presentation we see in adults but, with children, how do you distinguish, say, between a true lumbar disc herniation versus something like scoliosis causing some of the problem?
Dr. Anderson: Sure. Well, typically, the most common form of scoliosis we see is adolescent idiopathic scoliosis which affects our pre-adolescent age group. We don’t really consider scoliosis to be that much of a pain generator. When you look at the natural history studies of scoliosis, it’s not really a disease that causes much as morbidity as you’d think. In majority of the kids with scoliosis that we have, their incidence of back pain isn’t really much different than kids without scoliosis and I wouldn’t expect scoliosis to be causing that classic sciatica type pain. The one thing that is different with kids versus adults is they tend to have more back pain with their disc herniations than adults do. When you see adults, their primary complaint would be their leg pain. With a child or an adolescent, a lot of times their complaint is back pain with leg pain and sometimes the back pain component of it is fairly large and a significant burden to them. So, that’s one way that they're different than adults.
Dr. Mike: Do you think the presentation with back pain in kids versus adult is more children or the inflammatory response is greater, maybe not as well controlled in a child as in an adult, so we’re just having a lot of inflammatory pain. Is that maybe one of the reasons for the difference in presentation?
Dr. Anderson: It could be. And I think one of the other things is that, if you see a child with a disc herniation, especially if it’s a large disc herniation on MRI, there’s a good chance that child actually has what we call an “apophyseal ring avulsion” where they’ve actually avulsed some of the cartilage in the bone off of the end plate of their vertebra with the disc herniation and that can be a source of significant back pain. So, I think that’s another reason you see more back pain in kids versus adults. Now, I want to take you back to this. You alluded to scoliosis. Now, the other thing to keep in mind is a lot of these kids will present with what we call “sciatic scoliosis” where they’ll look like they have a significant amount of trunk shift and they’ll be leaning away from the side of the disc herniation in order to decompress the nerve route that’s being impinged upon. So, if you see a teenage boy or girl that all of a sudden has an acute onset of scoliosis, and they’re having leg pain, that scoliosis is probably not true scoliosis. It could certainly be from their disc herniation.
Dr. Mike: So, let’s talk and maybe walk us through a little bit how you approach this if a child is referred to you, you’re suspecting that there is a disc herniation. What’s the workup for you?
Dr. Anderson: Typically, a lot of times when I see a kid, they’ve already had an MRI. If they haven’t had an MRI, that’s certainly probably diagnostic imaging of choice although most of the time you can just tell from your physical examination that the child has a disc herniation. But, obviously, confirming which level it’s a because usually it’s going to be at L4-L5 or L5-S1. So, I get the imaging oftentimes to confirm the diagnosis, and also to figure out which level is affecting them. If they don’t have neurologic symptoms, if they’re not weak, they don’t have sensory loss, their bowel and bladder function are normal, you can certainly try a course of short rest, anti-inflammatories such as ibuprofen, and then, eventually if they can get their symptoms under better control, a course of therapy is certainly a reasonable next approach. If they don’t get better, because in the adult world, the majority of the patients will get better within a month of presentation whereas that doesn’t seem to be the case in kids. It’s actually the one thing that kids seem to recover from more poorly than adults do. So, I give them the short period of conservative measures of therapy and rest and anti-inflammatories. If they’re not better at some point within a month or six weeks, I think it’s not an unreasonable thing to consider an epidural steroid injection to see if you can alleviate their symptoms. There’s not a lot of good literature out there looking at the effects of steroids in this age group, but I usually try because I've had a handful of kids that respond very well and avoid an operation. But, if they fail all these non-operative measures including steroid injections and things like that, then we consider doing, what they call, a “microdiscectomy”.
Dr. Mike: Right. Any plans from your practice or Children’s Mercy to maybe look into steroid use in children so we can understand it a little bit better? I mean, it sounds like you’ve had some success with it?
Dr. Anderson: Yes, absolutely. I usually have my kids that come in fill out an outcomes instrument just so I can follow their progress more objectively. I think, sometimes as the physician, it’s easy to become a little biased on how you perceive the patient’s doing. So, I generally have them fill out an outcomes instrument and, a lot of times, I’ll have them do it before they have the injection. I’ll have them repeat the instrument after they’ve had the injection so I can get some objective way of measuring how well these kids are responding to steroids.
Dr. Mike: Yes. You’ve had some success with it and I imagine some other practitioners have had success as well. In the last question, Dr. Anderson, what about when it comes to educating the patient, the child and the parents about how they can help manage the pain as well, like when they go home?
Dr. Anderson: Absolutely. One of the things that I oftentimes will have to tell my athletes, in particular, is they need to take a break. They got to stop their activity that’s exacerbating their symptoms. But, also, I think, the parents just need to maintain a positive attitude and be encouraging but, at the same time, obviously, sympathetic and empathetic towards their child. I think you just have to be helpful and, the other thing is, the parents can be very key in helping the child manage their activities of daily living. If you’re just being helpful, it’s oftentimes hard for these kids forward and pick things off the floor, grab their backpack and things like. So, the parents can be helpful as far as just helping the child while they’re really symptomatic.
Dr. Mike: Yes. Maybe decrease the sizes of some of those backpacks those kids carry around a lot.
Dr. Anderson: Yes, certainly decreasing the burden of the weight they’re carrying but certainly the parents can be key as to administering the anti-inflammatory medication with food and water and things like that, making it a more safe environment.
Dr. Mike: Well, Dr. Anderson, listen, I want to thank you for coming on this show, and thank you for the work that you are doing at Children’s Mercy Kansas City. You’re listening to Transformational Pediatrics with Children’s Mercy. For more information, you can go to www.childrensmercy.org. That’s www.childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.