Disc protrusion in the child : Particular features and comparison with neoplasms

Lumbar intervertebral disc herniation, although common in adults, is infrequent in the young, and especially in patients under 17 years old. In this work we review clinical data pertaining to two pediatric groups of patients whose main complaint was low back pain and/or sciatica, trying to identify factors that might contribute to their earlier referral and to the differential diagnosis of protruded disc and spinal neoplasm in this population. Group A comprises 17 youngsters diagnosed as having lumbar herniated nucleus pulposus and group B, 16 children with neoplasms of the lower thoracic and lumbosacral regions. Both groups were similar in sex distribution and symptoms of pain and numbness. However, there was a striking difference in age at presentation. No patient in group A was younger than 11 years, while most of those in group B were in their first decade of life (P = 0.018). The classic clinical onset in the children with herniated discs started with low back pain and sciatica, as in the children with neoplasms, although in subgroup B leg pain tended to be bilateral. The usual examination findings in both groups were spinal rigidity and sensory loss, but motor weakness and impaired reflexes were found to be more frequent in the group with spinal growths (P = 0.02). Children with lumbosacral neoplasms also tended to present with atypical symptoms (acute onset, intracranial hypertension, subarachnoid hemorrhage and abdominal pain), while this was the exception in the group with herniated discs. Plain radiographs of the pediatric spine showed that X-ray examination is still a good tool for diagnosing spinal growths compared with their scant utility in disc herniations (P = 0.001). During the survey we were impressed by the children's apparent good tolerance to pain, which is probably due to the lack of the emotional component of pain in adults and explains their delayed referral for neurosurgical consultation. However, all modalities of treatment seemed to be effective in children, chemonucleolysis and surgery being extraordinarily effective in this age group. Accordingly, we see no reason for long-term conservative therapy in children with lumbar and sciatic pain; on the contrary, we believe these patients should be offered earlier neurosurgical treatment.