Lower Back Pain Fundamentals
By far the most common cause of lower back pain among young athletes is a strain of the lumbar musculature, a sprain of the lumbosacral ligaments, or a combination of the two. Perhaps the most important concept to keep in mind, however, is the possibility of other less common but potentially more serious conditions that can masquerade as a routine lower back pain problem. In order to label an athlete as having a lumbosacral strain, the conditions listed below must be excluded:
- Herniated Lumbar Disc
The herniated lumbar disc includes severe lumbosacral spasm, increased leg pain when raising a straight leg, and usually a positive neurological finding such as diminished reflex, muscle weakness, or an area of numbness. The majority of these individuals will respond to a period of rest and rehabilitation, although at times surgical excision of the extruded disc is required.
Defects of the pars interarticularis (spondylolysis) are being found with increasing frequency in particular types of athletes. It is especially common in those individuals whose activity requires repeated hyperextension of the spine, such as in gymnastics. Most of these individuals can be managed with rest and specific flexibility exercises. However, since this lesion commonly represents a stress fracture, there is some evidence that an extended period of rest in the early development of a spondylolysis may actually enable the lesion to heal. In addition, spondylolysis may be associated with a forward slipping of one vertebrae on another (spondylolisthesis). Spondylolisthesis is particularly vulnerable to progressive slipping during the adolescent growth spurt period. At times, a spinal fusion is indicated to control a significant or progressive spondylolisthesis. These two conditions, however, do not exclude participation in athletics as long as symptoms can be managed conservatively.
The young athlete who presents with lower back pain of a severe nature that is present at rest as well as during activity should alert one to the possibility of a more serious underlying problem. This can include irritative lesions of the spine such as tumor or infection. These diagnoses are frequently difficult to establish and require thorough physical and radiological investigations. Bone scans are helpful in detecting and localizing inflammatory or neoplastic lesions. Treatment is dependent upon the particular lesion present.
Fractures of the lumbar spine, excluding spondylolysis, are infrequent. They usually involve significant trauma and are detected by X-ray examination. Treatment is dependent upon the neurological status of the patient and the inherent stability of the fracture.
- Infection of the Disc (Discitis)
In this condition, the adolescent has persistent and severe back pain that is fairly constant although markedly aggravated by any sort of activity. X-rays initially may be entirely normal. Laboratory studies that reflect an inflammation, such as an elevated sedimentation rate, are usually present. A bone scan and, at time, tomograms of the spine may be helpful in localizing and defining the problem. The true infectious nature can be difficult to establish although at least 50% of the time it is bacterial in origin. The primary treatment for discitis is prolonged rest. This can involve strict bed rest for several weeks until the symptoms subside and at times a body cast is applied. This disease is usually self-limiting and results in a spontaneous fusion between the adjacent vertebral bodies.
What are the symptoms?
- Lower back pain
- Exacerbation of pain associated with activity
- Relief during periods of rest
- Some pain in the buttocks and back of legs
What are my child’s treatment options?
Physical examination may demonstrate some mild to moderate spasm of the lumbosacral musculature, some reversal of the normal lumbar lordosis, inability to fully forward flex and touch one’s toes, and a normal neurological examination. X-rays may appear normal.
Treatment of this condition involves, above all else, a period of rest. This rest may only involve the elimination of that particular activity or exercise that aggravates the symptoms or, in more severe cases, strict bed rest for a week or two.
If the aggravating activity is continued, the back pain may also continue. Medication plays a secondary role in the management of acute lower back pain. Of more importance is the management of this condition; that is prevention of recurrence. This primarily involves the institution of an exercise program that stresses postural techniques for the lumbosacral spine, increased abdominal tone, and enhanced flexibility. Specific techniques in lifting or performing one’s particular activity are individualized.
What are the risks of surgery?
Risks include nerve injury, infection, bleeding, and stiffness.