DDD common in adolescents with persistent low back pain

MRI evaluations find it may be more common than markers for more serious conditions.

Juvenile degenerative disc disease is not an uncommon cause of low back pain in the adolescent population and may have a co-existent relationship with congenital spinal stenosis, according to Kentucky investigators.

In a retrospective study of juveniles with persistent low back pain followed by MRI, John Dimar, II, MD, and colleagues at the Leatherman Spine Center in Louisville, questioned whether lumbral-sacral degenerative disc disease (DDD), commonly believed to be a disease of middle age, in fact begins in adolescents in select patients.

“Persistent low back pain in juveniles remains a difficult diagnostic challenge for clinicians,” Dimar said.

“Traditionally the pathogenesis of low back pain in this population has in the past been attributed to either serious undetected pathology or psycho-social origins. However, this paradigm of an all-or-nothing diagnosis may be incorrect since numerous patients within this population may have underlying degenerative disc disease, which is an important pathological diagnosis in the corresponding adult population,” he said.

17 year-old population

Dimar presented the study results at the 20th Annual Meeting of the North American Spine Society, here. The review evaluated the charts of 1877 patients less than 21 years old who were referred to a spine practice for low back pain. The evaluation included patients with low back pain for greater than 6 months, who then received MRIs. Researchers excluded patients with scoliosis, kyphosis, Sherman’s kyphosis, spondylolisthesis, previous fractures, tumors, metabolic bone disease or previous surgery.

Overall, investigators identified 76 patients with an MRI that identified DDD. The median age was 17.1 years. Thirty-one patients had associated radiculopathy, and researches identified the others as follows:

smokers, 11 patients;
athletes, 20 patients;
associated comorbidities, 17 patients; and
BMI exceeding 30, nine patients.

“The MRIs demonstrated that 36 patients had one-level involvement and 28 had two-level involvement,” Dimar said. “L4-5 and L5-S1 were the most frequently involved levels, while two patients had a five-level involvement.”

Dimar and colleagues documented spinal stenosis in 13 patients, six of them with severe radiculopathy and or spinal claudicatory symptoms.

Later problems

“Juvenile degenerative disc disease (JDDD) has characteristics similar to adult DDD with circumferential bulging, disc space narrowing, central protrusions and MRI changes,” Dimar said. “This study identified patients where JDDD was coexistent with severe multi-level congenital spinal stenosis. These patients demonstrated shortened pedicles and severe AP canal diameter narrowing. This pathology precedes the development of symptoms secondary to spondylolysis later in life.”

The researchers used conservative treatments consisting of: physical therapy, non-steroidal medications, bracing, epidurals and other modalities in 72 patients. Four patients with congenital spinal stenosis received a lumbar decompression due to the radiculopathy.

“Back pain in a juvenile is considered a serious hallmark of undetected pathologies such as tumors,” Dimar said. “Studies, however, have demonstrated that the complaint of back pain is common in juveniles and have shown a relationship between low back pain and premature degeneration as demonstrated on MRI,” he said.

“This study demonstrates that low back pain is more frequent in patients with JDDD than serious undetected pathology,” he noted.

One of the most interesting findings of this study was the high incidence of associated spinal stenosis, he added. “These data suggest that there is a distinct sub-population within juveniles presenting with both severe lower back pain and radicular symptoms. All of the patients with severe spinal stenosis universally had concurrent JDDD, demonstrating a very clear relationship between these two pathological processes.”

For your information:
Dimar II J. Glassman S. Carreon L. Juvenile degenerative disc disease: a report of 66 cases identified by magnetic resonance imaging. Paper #90. Presented at the 20th Annual Meeting of the North American Spine Society. Sept. 29, 2005. Philadelphia.