Nonoperative Management of Multilevel Lumbar Disk Herniations in an Adolescent Athlete
1992; Elsevier BV; Volume: 67; Issue: 2 Linguagem: Inglês
10.1016/s0025-6196(12)61314-7
ISSN1942-5546
AutoresAllen M. Weinert, Thomas D. Rizzo,
Tópico(s)Shoulder Injury and Treatment
ResumoHerniated lumbar nucleus pulposus is rare in the pediatric age-group; for surgically proven cases, the estimated prevalence is between 0.8 and 3.2%. Most of the current literature indicates that herniated nucleus pulposus in pediatric patients differs from that in adult patients in epidemiologic characteristics, clinical manifestations, and frequency of associated neurologic findings. To our knowledge, the current case is the first published report of lumbar disk herniations at three levels in a 15-year-old male adolescent, whose abnormalities were verified by computed tomography and myelography. Most investigators recommend surgical treatment; however, our patient had good results with nonoperative management that consisted of nonsteroid anti-inflammatory drugs, passive extension, lumbar traction, segmental mobilization, and a progressive program of dynamic lumbar stabilization exercises. The patient is now asymptomatic and able to participate in selected limited contact sports and most farm activities; however, contact sports are prohibited for 1 year. If follow-up computed tomographic imaging of the lumbar spine demonstrates no progression of the disk abnormalities and if the patient remains asymptomatic, he could consider participation in contact sports after necessary conditioning. Herniated lumbar nucleus pulposus is rare in the pediatric age-group; for surgically proven cases, the estimated prevalence is between 0.8 and 3.2%. Most of the current literature indicates that herniated nucleus pulposus in pediatric patients differs from that in adult patients in epidemiologic characteristics, clinical manifestations, and frequency of associated neurologic findings. To our knowledge, the current case is the first published report of lumbar disk herniations at three levels in a 15-year-old male adolescent, whose abnormalities were verified by computed tomography and myelography. Most investigators recommend surgical treatment; however, our patient had good results with nonoperative management that consisted of nonsteroid anti-inflammatory drugs, passive extension, lumbar traction, segmental mobilization, and a progressive program of dynamic lumbar stabilization exercises. The patient is now asymptomatic and able to participate in selected limited contact sports and most farm activities; however, contact sports are prohibited for 1 year. If follow-up computed tomographic imaging of the lumbar spine demonstrates no progression of the disk abnormalities and if the patient remains asymptomatic, he could consider participation in contact sports after necessary conditioning. A 15-year-old male high school football and basketball athlete was referred to our institution because of pain in the low-back area and left leg. The patient had been in good health until approximately 2 months before referral, when intermittent low-back pain had developed, unrelated to any specific incident. Six weeks later, after a particularly active day that involved weight lifting, farm chores, and snowmobiling, the low-back pain increased on the left side and extended to the left buttock and posterior aspect of the thigh. The patient also experienced subjective numbness and weakness of the left leg. Assessment in the emergency department disclosed left paraspinal spasm and a positive response to left straight leg raising at 10 degrees. Findings on motor examination and sensory examination were normal, as were the deep tendon reflexes. Roentgenograms of the anteroposterior and lateral lumbar spine also showed normal findings. A regimen of naproxen and chlorzoxazone was initiated in conjunction with bed rest. At follow-up 1 week later, the patient's condition had substantially improved. The pain and numbness in the left leg had resolved, but he still experienced mild low-back pain on the left side. Findings on physical examination were remarkable for left paraspinal spasm and back pain when the left leg was straight and raised. He was instructed to apply ice, perform flexibility and strengthening exercises, and modify his activities. One week later, the patient returned because of increased pain in the left leg and low-back area (60% and 40%, respectively) after a day of snowmobiling. The leg pain increased when he sneezed, coughed, or strained. No incontinence of bowel or bladder functioning was noted. Pertinent family history was unremarkable for herniated nucleus pulposus in first-degree relatives. On physical examination, the 188-cm-tall, muscularly well-developed patient was in moderate discomfort. He demonstrated a prominent right lateral lumbar shift, limited lumbar flexion, and left lateral flexion. Paraspinal spasm was evident, and straight leg raising was positive for pain in the left leg when the right leg was raised to 70 degrees and the left to 40 degrees. Findings on motor examination were normal for manual testing of muscles; however, a relative weakness of the left gastrocnemius and soleus muscles was noted with repetitive toe raises. A sensory examination disclosed decreased sensation on the dorsal aspect of the left foot when pinpricked, and deep tendon reflexes were remarkable for an absent left ankle jerk. Computed tomography of the lumbar spine showed extradural defects at the third and fourth lumbar interspaces. After a neurosurgical consultation, the patient underwent computed tomographic myelography to delineate further the nature of the disk abnormalities. Three discrete disk herniations were identified: a central and right protrusion at L3-4, associated with minimal displacement of the right L-4 nerve root; a large central and left L4-5 extrusion that displaced the left L-5 and S-1 nerve roots posteriorly with nonfilling of the left L-5 nerve root; and a small central and left protrusion at the L5-S1 interspace in conjunction with impingement of the left S-1 nerve root (Fig. 1, Fig. 2, Fig. 3, Fig. 4). Free-flowing contrast medium was noted from the cul-de-sac to the upper cervical spine.Fig. 2Computed tomography of the lumbar spine, showing large extrusion of central portion and left side of L4-5 intervertebral disk and displacement of left L-5 nerve root. L = left; R = right.View Large Image Figure ViewerDownload (PPT)Fig. 3Computed tomography of the spine, showing small protrusion of central portion and left side of L5-S1 intervertebral disk and impingement of left S-1 nerve root. L = left; R = right.View Large Image Figure ViewerDownload (PPT)Fig. 4Series of computed tomographic-myelographic slices from L-3 vertebral body through L5-S1 intervertebral disk. Note large extrusion of L4-5 disk both above and below level of the disk. L = left; R = right.View Large Image Figure ViewerDownload (PPT) After we reviewed the findings with the patient and his family, we recommended surgical treatment; however, the patient chose a nonoperative approach because of his age and personal preference. Naproxen therapy was continued. A program of modification of activity with frequent periodic supine positioning in “90/90 posture” (90 degrees of flexion at both the hips and the knees) was begun, as well as temporary symptomatic use of a soft lumbar corset, ice, and passive extension exercises. With use of the aforementioned treatments, the leg pain gradually diminished, but the pain “centralized” to his left hip and low-back area. The patient's condition further improved with lumbar traction while he was in the prone position and nonballistic segmental mobilization; these measures increased the lumbar motion and diminished the lateral shift. As the pain decreased, a dynamic lumbar stabilization program was initiated (as described by Saal and Saal1Saal JA Intervertebral disc herniation: advances in nonoperative treatment.Phys Med Rehabil. June 1990; 4: 175-190Google Scholar, 2Saal JS The role of inflammation in lumbar pain.Phys Med Rehabil. June 1990; 4: 191-199Google Scholar, 3Saal JA Saal JS Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study.Spine. 1989; 14: 431-437Crossref PubMed Scopus (444) Google Scholar) in conjunction with progressive flexibility exercises. The patient also was instructed in dynamic posture and back mechanics and was advised to avoid activities that would increase pressure within the disks. A 7-month follow-up computed tomographic scan of the lumbar spine showed minimal change from the previous scan. The patient, however, had resumed farm activities and selected sports (such as basketball) without recurrence of symptoms. Herniated nucleus pulposus is rare in the pediatric age-group; the estimated prevalence is between 0.8 and 3.2% for surgically proven protrusions.4Rugtveit A Juvenile lumbar disc herniations.Acta Orthop Scand. 1966; 37: 348-356Crossref PubMed Scopus (43) Google Scholar, 5O'Connell JEA Intervertebral disk protrusions in childhood and adolescence.Br J Surg. 1960; 47: 611-616Crossref PubMed Scopus (44) Google Scholar Investigators estimate that only 2% of all herniated lumbar intervertebral disks occur in children and adolescents.6Bunnell WP Back pain in children.Orthop Clin North Am. July 1982; 13: 587-604PubMed Google Scholar, 7Love JG The disc factor in low-back pain with or without sciatica.J Bone Joint Surg [Am]. 1947; 29: 438-447PubMed Google Scholar Multiple protrusions of disks are even rarer. In a study by Fisher and Saunders8Fisher RG Saunders RL Lumbar disc protrusion in children.J Neurosurg. 1981; 54: 480-483Crossref PubMed Scopus (28) Google Scholar of 43 pediatric patients who had protrusions of disks, 1 patient had them at 2 levels. Of 37 pediatric patients with herniated nucleus pulposus, Clarke and Cleak9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar noted that 2 patients had lesions at 2 levels. In a series of 70 operative disk herniations in children, Kurihara and Kataoka10Kurihara A Kataoka O Lumbar disc herniation in children and adolescents: a review of 70 operated cases and their minimum 5-year follow-up studies.Spine. 1980; 5: 443-451Crossref PubMed Scopus (111) Google Scholar encountered only 1 patient with involvement at 2 levels. In the medical literature, we found no reports of pediatric patients with protrusion of a disk at three separate levels. Although several studies in the literature show an almost equal prevalence of disk herniations among male and female adolescent patients,11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar, 12Børgesen SE Vang PS Herniation of the lumbar intervertebral disk in children and adolescents.Acta Orthop Scand. 1974; 45: 540-549Crossref PubMed Scopus (59) Google Scholar other studies reveal a slightly increased prevalence in male patients, especially in those older than 15 years of age.5O'Connell JEA Intervertebral disk protrusions in childhood and adolescence.Br J Surg. 1960; 47: 611-616Crossref PubMed Scopus (44) Google Scholar, 9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar, 13DeOrio JK Bianco Jr, AJ Lumbar disc excision in children and adolescents.J Bone Joint Surg [Am]. 1982; 64: 991-996PubMed Google Scholar, 14Bradford DS Garcia A Herniations of the lumbar intervertebral disk in children and adolescents: a review of 30 surgically treated cases.JAMA. 1969; 210: 2045-2051Crossref PubMed Scopus (57) Google Scholar, 15Bulos S Herniated intervertebral lumbar disc in the teenager.J Bone Joint Surg [Br]. 1973; 55: 273-278PubMed Google Scholar The study by Kurihara and Kataoka10Kurihara A Kataoka O Lumbar disc herniation in children and adolescents: a review of 70 operated cases and their minimum 5-year follow-up studies.Spine. 1980; 5: 443-451Crossref PubMed Scopus (111) Google Scholar demonstrated the prevalence to be 3 times greater in Japanese male adolescents than in female adolescents. Because of cultural biases, however, this finding may not be applicable in other countries. The L4-5 and L5-S1 disk levels are the most frequently involved (in approximately equal numbers).9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar, 11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar, 14Bradford DS Garcia A Herniations of the lumbar intervertebral disk in children and adolescents: a review of 30 surgically treated cases.JAMA. 1969; 210: 2045-2051Crossref PubMed Scopus (57) Google Scholar The study by Kurihara and Kataoka,10Kurihara A Kataoka O Lumbar disc herniation in children and adolescents: a review of 70 operated cases and their minimum 5-year follow-up studies.Spine. 1980; 5: 443-451Crossref PubMed Scopus (111) Google Scholar however, showed that protrusions at the L4-5 level were 6 times more common than were protrusions at the L5-S1 level. Many investigators agree that the initial clinical manifestation of herniated nucleus pulposus in children differs from that in adults.4Rugtveit A Juvenile lumbar disc herniations.Acta Orthop Scand. 1966; 37: 348-356Crossref PubMed Scopus (43) Google Scholar, 5O'Connell JEA Intervertebral disk protrusions in childhood and adolescence.Br J Surg. 1960; 47: 611-616Crossref PubMed Scopus (44) Google Scholar, 9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar, 13DeOrio JK Bianco Jr, AJ Lumbar disc excision in children and adolescents.J Bone Joint Surg [Am]. 1982; 64: 991-996PubMed Google Scholar, 16Ghabrial YAE Tarrant MJ Adolescent lumbar disc prolapse.Acta Orthop Scand. 1989; 60: 174-176Crossref PubMed Scopus (14) Google Scholar Although low-back pain is an almost universal initial symptom, leg pain is more varied. Unlike in adults, overt neurologic deficits due to radiculopathies in adolescents are rare. Some investigators have attributed this discrepancy to the greater mobility of the spine in adolescents, which allows relief of pressure of the nerve root.4Rugtveit A Juvenile lumbar disc herniations.Acta Orthop Scand. 1966; 37: 348-356Crossref PubMed Scopus (43) Google Scholar, 12Børgesen SE Vang PS Herniation of the lumbar intervertebral disk in children and adolescents.Acta Orthop Scand. 1974; 45: 540-549Crossref PubMed Scopus (59) Google Scholar, 14Bradford DS Garcia A Herniations of the lumbar intervertebral disk in children and adolescents: a review of 30 surgically treated cases.JAMA. 1969; 210: 2045-2051Crossref PubMed Scopus (57) Google Scholar This factor may explain why abnormal lumbar posture and motion in the absence of pain of the lower extremities are common features in herniated nucleus pulposus in adolescents. Kurihara and Kataoka10Kurihara A Kataoka O Lumbar disc herniation in children and adolescents: a review of 70 operated cases and their minimum 5-year follow-up studies.Spine. 1980; 5: 443-451Crossref PubMed Scopus (111) Google Scholar described a case of cauda equina syndrome due to herniated nucleus pulposus in an adolescent; however, this occurrence is extremely rare. In herniated nucleus pulposus, range of motion of the spine is almost always limited, including limited flexion, restricted ipsilateral bending, and decreased lumbar lordosis. The straight leg test is positive in more than 90% of patients studied.4Rugtveit A Juvenile lumbar disc herniations.Acta Orthop Scand. 1966; 37: 348-356Crossref PubMed Scopus (43) Google Scholar, 5O'Connell JEA Intervertebral disk protrusions in childhood and adolescence.Br J Surg. 1960; 47: 611-616Crossref PubMed Scopus (44) Google Scholar, 9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar, 10Kurihara A Kataoka O Lumbar disc herniation in children and adolescents: a review of 70 operated cases and their minimum 5-year follow-up studies.Spine. 1980; 5: 443-451Crossref PubMed Scopus (111) Google Scholar, 11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar, 14Bradford DS Garcia A Herniations of the lumbar intervertebral disk in children and adolescents: a review of 30 surgically treated cases.JAMA. 1969; 210: 2045-2051Crossref PubMed Scopus (57) Google Scholar Many patients demonstrate a lateral shift. The frequency of objective neurologic findings, including motor, sensory, and reflex changes, varies widely, depending on the study.4Rugtveit A Juvenile lumbar disc herniations.Acta Orthop Scand. 1966; 37: 348-356Crossref PubMed Scopus (43) Google Scholar, 5O'Connell JEA Intervertebral disk protrusions in childhood and adolescence.Br J Surg. 1960; 47: 611-616Crossref PubMed Scopus (44) Google Scholar, 9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar, 10Kurihara A Kataoka O Lumbar disc herniation in children and adolescents: a review of 70 operated cases and their minimum 5-year follow-up studies.Spine. 1980; 5: 443-451Crossref PubMed Scopus (111) Google Scholar, 11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar, 12Børgesen SE Vang PS Herniation of the lumbar intervertebral disk in children and adolescents.Acta Orthop Scand. 1974; 45: 540-549Crossref PubMed Scopus (59) Google Scholar, 13DeOrio JK Bianco Jr, AJ Lumbar disc excision in children and adolescents.J Bone Joint Surg [Am]. 1982; 64: 991-996PubMed Google Scholar, 14Bradford DS Garcia A Herniations of the lumbar intervertebral disk in children and adolescents: a review of 30 surgically treated cases.JAMA. 1969; 210: 2045-2051Crossref PubMed Scopus (57) Google Scholar, 15Bulos S Herniated intervertebral lumbar disc in the teenager.J Bone Joint Surg [Br]. 1973; 55: 273-278PubMed Google Scholar, 16Ghabrial YAE Tarrant MJ Adolescent lumbar disc prolapse.Acta Orthop Scand. 1989; 60: 174-176Crossref PubMed Scopus (14) Google Scholar The cause of herniated nucleus pulposus in children remains unknown. Bradford and Garcia,14Bradford DS Garcia A Herniations of the lumbar intervertebral disk in children and adolescents: a review of 30 surgically treated cases.JAMA. 1969; 210: 2045-2051Crossref PubMed Scopus (57) Google Scholar O'Connell,5O'Connell JEA Intervertebral disk protrusions in childhood and adolescence.Br J Surg. 1960; 47: 611-616Crossref PubMed Scopus (44) Google Scholar Epstein and colleagues,11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar and Fisher and Saunders8Fisher RG Saunders RL Lumbar disc protrusion in children.J Neurosurg. 1981; 54: 480-483Crossref PubMed Scopus (28) Google Scholar found trauma to be an important factor in more than half of the cases; however, other investigators refute this finding.9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar, 16Ghabrial YAE Tarrant MJ Adolescent lumbar disc prolapse.Acta Orthop Scand. 1989; 60: 174-176Crossref PubMed Scopus (14) Google Scholar Certain structural anomalies including transitional vertebrae, spondylolisthesis, spina bifida occulta, and increased angulation at the L5-S1 level were noted to be more prevalent in pediatric patients with herniated disks than in the general pediatric population.9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar, 11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar, 13DeOrio JK Bianco Jr, AJ Lumbar disc excision in children and adolescents.J Bone Joint Surg [Am]. 1982; 64: 991-996PubMed Google Scholar Except for spondylolisthesis in childhood and adolescence, these same findings have been shown to have no relationship to back pain in adults.17Frymoyer JW Newberg A Pope MH Wilder DG Clements J MacPherson B Spine radiographs in patients with low-back pain: an epidemiological study in men.J Bone Joint Surg [Am]. 1984; 66: 1048-1055PubMed Google Scholar, 18Nachemson AL The lumbar spine: an orthopaedic challenge.Spine. 1976; 1: 59-71Crossref Scopus (468) Google Scholar O'Connell5O'Connell JEA Intervertebral disk protrusions in childhood and adolescence.Br J Surg. 1960; 47: 611-616Crossref PubMed Scopus (44) Google Scholar found that the most frequent age when injuries occur correlated with the period of rapid growth in children—ages 11 to 15 years in female and 13 to 16 years in male subjects. DeOrio and Bianco13DeOrio JK Bianco Jr, AJ Lumbar disc excision in children and adolescents.J Bone Joint Surg [Am]. 1982; 64: 991-996PubMed Google Scholar showed that size, especially height, was a risk factor for herniated nucleus pulposus in children and adolescents. In their study, approximately half the subjects were above the 80th percentile in height and between a third and a half were above that percentile in weight. Gunzburg and co-workers19Gunzburg R Fraser RD Fraser GA Lumbar intervertebral disc prolapse in teenage twins: a case report and review of the literature.J Bone Joint Surg [Br]. 1990; 72: 914-916PubMed Google Scholar described twin sisters who were tall and actively involved in sports who had similar two-level disk abnormalities. Clarke and Cleak9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar noted a high prevalence of family history positive for herniated nucleus pulposus (57%); this finding could possibly indicate a hereditary predisposition to early disk or connective tissue failure. A recent study by Varlotta and associates20Varlotta GP Brown MD Kelsey JL Golden AL Familial predisposition for herniation of a lumbar disc in patients who are less than twenty-one years old.J Bone Joint Surg [Am]. 1991; 73: 124-128PubMed Google Scholar suggested a 4 to 5 times greater risk for disk herniation in persons younger than 21 years of age whose family history is positive for disk herniation. The pathologic description of herniated disks in the pediatric age-group varies. In the study by Clarke and Cleak,9Clarke NMP Cleak DK Intervertebral lumbar disc prolapse in children and adolescents.J Pediatr Orthop. 1983; 3: 202-206Crossref PubMed Scopus (34) Google Scholar typical degenerative changes in disks were commonly encountered. Other investigators have described herniated disks in adolescents that have resulted from an apophyseal vertebral fracture and posterior displacement without extrusion or sequestration; these abnormalities differ distinctly from degenerative disk disease in adults.11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar, 21Bartolozzi P Lombardini G Floris G Herniated lumbar disc in the child: a description of two cases.Ital J Orthop Traumatol. 1989; 15: 115-120Google Scholar, 22Callahan DJ Pack LL Bream RC Hensinger RN Intervertebral disc impingement syndrome in a child: report of a case and suggested pathology.Spine. 1986; 11: 402-404Crossref PubMed Scopus (25) Google Scholar, 23Clark JE Apophyseal fracture of the lumbar spine in adolescence.Orthop Rev. 1991; 20: 512-516PubMed Google Scholar The treatment of herniated nucleus pulposus in pediatric patients remains controversial. Although most investigators initially recommend conservative measures, many believe that operative management is the most effective.8Fisher RG Saunders RL Lumbar disc protrusion in children.J Neurosurg. 1981; 54: 480-483Crossref PubMed Scopus (28) Google Scholar, 10Kurihara A Kataoka O Lumbar disc herniation in children and adolescents: a review of 70 operated cases and their minimum 5-year follow-up studies.Spine. 1980; 5: 443-451Crossref PubMed Scopus (111) Google Scholar, 11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar, 12Børgesen SE Vang PS Herniation of the lumbar intervertebral disk in children and adolescents.Acta Orthop Scand. 1974; 45: 540-549Crossref PubMed Scopus (59) Google Scholar, 15Bulos S Herniated intervertebral lumbar disc in the teenager.J Bone Joint Surg [Br]. 1973; 55: 273-278PubMed Google Scholar, 21Bartolozzi P Lombardini G Floris G Herniated lumbar disc in the child: a description of two cases.Ital J Orthop Traumatol. 1989; 15: 115-120Google Scholar The operation usually consists of a unilateral laminotomy, foraminal decompression (if needed), and partial diskectomy.10Kurihara A Kataoka O Lumbar disc herniation in children and adolescents: a review of 70 operated cases and their minimum 5-year follow-up studies.Spine. 1980; 5: 443-451Crossref PubMed Scopus (111) Google Scholar, 11Epstein JA Epstein NE Marc J Rosenthal AD Lavine LS Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.Spine. 1984; 9: 427-432Crossref PubMed Scopus (79) Google Scholar Other investigators have had good results with nonoperative treatment; however, no controlled studies have been done.16Ghabrial YAE Tarrant MJ Adolescent lumbar disc prolapse.Acta Orthop Scand. 1989; 60: 174-176Crossref PubMed Scopus (14) Google Scholar, 24Key JA Intervertebral-disc lesions in children and adolescents.J Bone Joint Surg [Am]. 1950; 32: 97-102Google Scholar The only published randomized controlled study that assessed the outcome of surgical versus nonoperative treatment of herniated lumbar disk disease was conducted among adults in Norway.25Weber H Lumbar disc herniation: a controlled, prospective study with ten years of observation.Spine. 1983; 8: 131-140Crossref PubMed Scopus (952) Google Scholar Its applicability to adolescents with herniated lumbar disk disease is uncertain. The study showed a better outcome in the surgically treated group at 1 year after treatment. At 4- and 10-year follow-up, the difference between the two groups was not statistically significant. One could argue that the nonoperative care that consisted of 1 week of bed rest followed by 1 week of “partial bed rest,” “exercises,” and “back school” may not be state-of-the-art practice, but the satisfactory outcome in both groups was encouraging. In that study, the use of patient satisfaction without a functional correlate as a measure of outcome may have led to potential biases. In a randomized surgical versus nonsurgical comparative study, nonoperative patients may perceive that a potentially beneficial surgical therapeutic option was not exercised. This perception may account for a lower level of patient satisfaction. Surgical patients may be less likely to consider their treatment suboptimal. The absolute indications for surgical intervention of herniated nucleus pulposus are neurogenic bladder or bowel dysfunction (cauda equina syndrome) and progressive neurologic deficits. Relative indications include intractable radicular pain and lateral spinal stenosis. The rationale for nonoperative treatment of herniated intervertebral disks is supported by the recent work of Saal and Saal1Saal JA Intervertebral disc herniation: advances in nonoperative treatment.Phys Med Rehabil. June 1990; 4: 175-190Google Scholar, 3Saal JA Saal JS Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study.Spine. 1989; 14: 431-437Crossref PubMed Scopus (444) Google Scholar in adults. Nonoperative management of a herniated lumbar disk necessitates a comprehensive goal-oriented program as outlined in Table 1.Table 1Goal-Oriented Comprehensive Nonoperative Management of Herniated Nucleus Pulposus 1.For reduction of pain and spasm Bed rest in 90/90 position (90 degrees of flexion at both hips and knees) Analgesics: nonsteroid anti-inflammatory drugs, narcotic agents, and muscle relaxants Stool softener (docusate sodium) Lumbar corset Local modalities Ice Superficial or deep heat Transcutaneous electrical nerve stimulation Passive lumbar extension Trial of lumbar traction Segmental manual mobilization 2.For reduction of inflammation Nonsteroid anti-inflammatory drugs Orally administered corticosteroids Epidurally or caudally administered corticosteroids Selective nerve root injections 3.For improved flexibility Exercise hamstrings, quadriceps, iliopsoas muscle, hips, internal and external rotators, and lumbar spine 4.Education and back skills Posture Body mechanics Anatomy Fitness and nutrition 5.Dynamic lumbar stabilization program “Neutral curve” Supine Bridging Prone Quadruped Lunges 6.Progressive aerobic fitness Walking Upper body ergometer Bicycling Swimming Cross-country ski simulator 7.Progressive strengthening exercises (no Valsalva maneuver) Abdominals Squats and inclined leg presses (strengthens gluteus maximus and quadriceps) Lateral pulldowns (strengthens latissimus dorsi and thoracolumbar fascia) Weight lifting to build upper extremities Open table in a new tab In our patient with lumbar disk herniations, a comprehensive nonoperative rehabilitation program, including nonsteroid anti-inflammatory drugs, passive extension, lumbar traction, segmental mobilization, and a progressive program of dynamic lumbar stabilization exercises, was effective in controlling symptoms and allowing him to return to selected noncontact physical activities gradually. Most physicians believe that an initial nonoperative approach is indicated in all but a few selected cases. Some physicians report that operative management for herniated nucleus pulposus in the pediatric age-group is more effective than a nonoperative approach. To date, no controlled studies have been performed to support this hypothesis.
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