Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

Introduction. Epidural steroid injection is an established treatment modality for intervertebral disc prolapse. It is a low-risk alternative to surgical intervention in some patients for whom noninvasive treatment has failed. Caudal epidural steroid injection is one of the most widely used methods for pain relief. The aim of this study was to determine the significance of same dose in different volume of caudal epidural steroid injection in the treatment of lumbar degenerative disc disease. Material/Methods. Prospective study was conducted during 2007 to 2009. 100 Patients were randomized in to two groups, of which 50 % (group A) received 4 ml of steroid with isotonic saline and remaining 50 % (group B) received 12 ml. Injection was given in prone position through a 22-G needle in to the epidural space through the sacral hiatus. The average follow-up was 18 months. Outcomes scores included the SF-36, Oswestry disability index and pain VAS and were recorded in the pre and post injection periods. Results. In group A, 18 patients had significant pain relief and 32 had no relief during the early period. Whereas in group B, 22 had significant pain relief and 28 had no relief. The quality of pain relief of 50% or greater was considered as significant. Follow up after 1 year does not show much difference. Group B had significant decrease in symptoms in the initial post injection period (P<0.05). Conclusions. The volume of steroid solution in the treatment of lumbar degenerative disc disease is significant in the early post injection period only

Introduction: The cervical spine can be severely loaded in bending during sporting injuries and ‘whiplash’. Compressive loading could also be high if some advanced warning of impact stimulated vigorous (‘protective’) contraction of the neck muscles. Combined bending and compression can cause some lumbar discs to herniate in-vitro (. 1. ) but the outcome depends on spinal level, and may not be applicable to cervical discs. We test the hypotheses: a) that cervical discs can prolapse in-vitro, and b) that prolapse leads to irregular stress distributions inside the disc. Material and methods: Human cervical ‘motion segments’ (two vertebrae and intervening soft tissues) were obtained from cadavers aged 51–88yrs. Specimens were secured in cups of dental stone and subjected to static compressive loading (150N) for 20s. During this time, the distribution of vertically-acting compressive ‘stress’ was recorded along the postero-anterior diameter of the disc by pulling a 0.9mm-diameter pressure transducer through it (. 2. ). Injury was induced by compressing each specimen at 1mm/s while positioned in 20 deg of flexion, 15 deg of extension, or 8 deg of lateral bending. The distribution of compressive stress within the disc was then re-measured. Specimens were sectioned at 2mm intervals in order to ascertain soft tissue disruption. Results: In all six specimens tested to date, one or both of the apophyseal joint capsules were ruptured by the complex loading. Intervertebral disc prolapse also occurred in all six specimens, with the herniated nucleus appearing on the anterior, posterior and postero-lateral disc surface in extension, flexion and lateral bending respectively. All modes of failure affected intradiscal stresses: on average, nucleus pressure decreased by 75% (STD 7%), while stress concentrations in the annulus increased by 130% (STD 21%). Discussion: These preliminary results confirm that severe complex loading can cause cervical discs to prolapse. No particular state of disc degeneration is required, provided the loading is sufficiently severe. Indeed, the altered stress distributions suggest that cell-mediated changes would probably follow prolapse

Study design: To investigate the effects of muscle atrophy on back muscle fatigue:. Objective: To assess fibre type atrophy in patients undergoing surgery for pro-lapsed lumbar intervertebral disc, and to determine its effect upon EMG measures of fatigue. Methods: Intra-operative biopsies were obtained from the erector spinae muscles of patients undergoing microdiscectomy. Mean fibre area of type I and II fibres were determined after myosin ATPase staining. Prior to surgery, EMG activity of the erector spinae muscles was recorded bilaterally at T10 and L3 whilst subjects performed the Biering-Sorensen fatigue test. Power spectral analysis indicated the initial median frequency and its rate of decline (median frequency gradient) at each recording site. Fibre type area was compared with the median frequency measures. Subjects: 34 subjects (20 male) with intervertebral disc prolapse. Results: Mean fibre area of type I and II fibres was 5890 ± 1947μm. 2. and 3461 ± 1946μm. 2. in men, and 5144 ± 1692μm. 2. and 1945 ± 1039μm. 2. in women, indicating marked type II fibre atrophy. Type II MFA was positively correlated with initial median frequency at L3 on the operated side (R=0.445) and negatively correlated with the maximum median frequency gradient of the four recording sites (R= −0.430). Conclusion: Type II fibre atrophy influences EMG measures of fatigue. The decrease in initial median frequency with type II fibre atrophy probably reflects a reduced conduction velocity in these small fibres. The less negative median frequency gradient with decreased type II fibre size indicates a lower rate of fatigue which may be explained by an increased contribution to force generation from type I fibres which occupy a greater proportion of the muscle

Aims: To assess the effectiveness of intra-articular facet joint injections in controlling disability in patients with low back pain. Methods: 100 consecutive patients admitted in our day case unit for facet joint injections were included in the study. Fluoroscopically controlled intra-articular facet joint block with injection of a local anaesthetic and corticosteroid suspension was performed after clinical and radiological assessment. Disability due to back pain was assessed by determining a revised Oswestry Low Back Pain Disability Index (Oswestry Score). The patients completed a questionnaire immediately prior to treatment, two weeks following injection and three months following injection. Results: Facet joint injections were performed for intervertebral disc prolapse (66%), spondylolysthesis (13%), spinal stenosis (10%), spondylosis (7%), and sacro-iliac joint pain (4%). The mean Oswestry Score prior to injection was 40.6% (95% conþdence interval 4.4), at two weeks following injection was 26.6% (95% conþdence interval 4.9) and at three months following injection was 21.5% (95% conþdence interval 4.8). 78% of the patients found the facet joint injections useful at 2 weeks following treatment and this þgure was maintained (79%) at 3 months after injection. No complications were reported following treatment. Conclusions: We have found intra-articular facet joint block for the treatment of low back pain a valid therapeutic option, acceptable by the patients and with negligible risks

We report the cases of teenage twin girls presenting within months of each other with severe symptoms from lumbosacral disc prolapses, requiring laminectomy in one and chemonucleolysis in the other. CT scans showed similarities in spinal configuration, including the presence of disc bulges at the L4-5 level. This suggests a strong hereditary factor in prolapse of intervertebral discs, but a review of the literature showed little information on that aspect

Computerised tomography of the lumbar spine was performed on 22 patients with clinical evidence of prolapse of an intervertebral disc and normal or equivocal radiculograms. Of 11 patients with positive scans who had an operation the presence of pathology was confirmed in 10. Although CT scanning is always helpful in diagnosing disc disorders, where facilities are scarce (as in Great Britain) it is best employed in patients with negative or non-contributory radiculography.

Doubt remains as to the safest surgical approach to the prolapsed thoracic intervertebral disc. Laminectomy, lateral rhachotomy and the transthoracic approach all have their protagonists. Twenty-two patients from the National Hospital for Nervous Diseases, Queen Square, and Atkinson Morley's Hospital have been reviewed. Their clinical presentation is discussed and the ancillary aids to diagnosis assessed. The diagnostic value of disc space calcification is stressed, and the use of air myelography as an adjunct to positive contrast myelography is noted. Fifteen patients were subjected to laminectomy, and seven to lateral rhachotomy. Each group contained patients with a wide range of neurological deficit. Six of the patients who underwent laminectomy were improved, two were unchanged, six deteriorated and one died. Of the patients who had lateral rhachotomy, six were improved, one was unchanged and none deteriorated. The conclusion is drawn that lateral rhachotomy is a safer procedure

Two groups of intervertebral discs, one normal, as obtained from the post-mortem room, the other prolapsed, as removed at operation, have been compared by chemical analysis of their principal constituents. There is a progression of chemical changes associated with the ageing of the normal disc. This shows not only the expected slight increase in collagen as age advances, but also, surprisingly, that the polysaccharide content rises to a maximum in the fourth decade, in the same way as does polysaccharide in costal cartilage. In prolapsed discs the ageing process is superseded by a different and distinctive progression, which advances, not according to age, but according to the duration of the prolapse. There is a critical level to which the polysaccharide content must apparently fall, irrespective of the normal level for the patient's age, before a prolapse occurs. Normal ageing probably consists in the breakdown of a particular polysaccharide/protein linkage, with coincident "maturation" of collagen. In the prolapsing disc multiple, and possibly different, linkages are rapidly broken down. This depolymerisation of a gel structure must be presumed to be the basis of the decreased imbibition capacity of the nucleus pulposus, and to be the source of the hydrostatic abnormalities which result in disc prolapse.

In both normal and prolapsing discs the products of mucopolysaccharide breakdown appear to participate in the metabolism of collagen.