THE YOUNG ATHLETE

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BACK INJURIES IN THE YOUNG ATHLETE

Injuries to the neck and back occur more frequently in young athletes than in their less athletic peers.49, They also occur more frequently in sedentary 63 children than in those engaged in free play.so Pain may result from a single macrotrauma, repetitive microtrauma, or from certain atraumatic conditions. Although macrotrauma is rarely missed, it may be extremely difficult to distinguish between pain resulting from microtrauma and pain from atraumatic conditions. Because the current trend is toward more single-sport athletics and toward television watching and less recreational fitness,so ever-increasing numbers of back injuries in children can be expected. Spencerand Jackson92 report that spine-related complaints constitute almost 10% of athletes' medical problems. Ferguson, McMaster, and Stanitski found that 75% of high-performance athletes have some sort of back pain}8 Because athletes rarely have secondary gain issues confounding their complaints, it is apparent that back problems need to be accurately diagnosed and aggressively managed in the child athlete before chronic problems can develop. Epidemiologic studies are helping to identify problem maneuvers in at-risk sports and certain individuals who are at-risk because of morphologic or physiologic variances. '

Effective clinical management of these athletes is a six-step process. First, the problem must be understood by knowing the types of injuries that occur in the different areas of the spine and the differences between adult and child pathophysiology. Second,the at-risk populations must be identified. This means knowing the different injuries that can occur based on genetic make-up, body habitus, sport involved, and training demands of the particular athlete. These data provide clues to diagnosis and guidelines for prevention. Third, an accurate diagnosis must be made both generally (macrotrauma, microtrauma, or atraumatic) and specifically. "Wastebasket" diagnoses rarely return the athlete to competition rapidly.

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Next, appropriate child-oriented treatment must be undertaken and monitored.SO, This is a team approach involving clinicians, trainers, therapists, 51 coaches,and parents. The fifth step is rehabilitation and return to sports, which requires sport and patient-specific planning. Again, a team approach is essential. Finally, preventive measures must be planned to avoid recurrence},30
MACROTRAUMA

Macrotrauma to the cervical spine and back is most common in the highspeed collision and acrobatic sports. Each sport has its own particular risks. Data also show that spinal injury patterns differ between pre- and post-adolescent children.65These patterns range from chest and abdominal injuries with referred back pain to soft tissue or bony injury to spinal cord injury. The current literature contains evidence of increased risk of spinal and thoracic macrotrauma in more than 20 different sports (Table 1).
Spinal Cord Injury Without Radiographic Abnormality

Spinal cord injury without radiographic abnormality (SCIWORA) is a welldescribed entity in the pediatric trauma literature.66,95, It was first documented 119 in infants involved in motor vehicle accidents.66 More recently, there have been reports of sports-related injuries that cause spinal cord damage in older children where the radiographs are normal.'~' 108 This condition must be considered when evaluating the child or adolescent athlete with cervical macrotrauma. The athletic population at risk for SCIWORA should be the younger athletes.66 Other risk factors are trauma involving elongation40or hyperextension66 the neck, or of
Table 1. SPORTS ASSOCIATED WITH INCREASED INCIDENCE OF SPINE AND THORAX MACROTRAUMA

Baseball Boxing Cycling Diving Downhill skiing Football American Australian Gymnastics Hockey Horseback riding Lacrosse Parasailing Rugby Swimming Taekwondo Tobogganing Trampoline Water ski jumping Wrestling

Commotio cordis Myocardial contusion C-spine fracture C-spine fracture Spinal cord injury C-spine fracture C-spine fracture C-spine fracture/traumatic Commotio cordis C-spine fracture Commotio cordis C-spine fracture C-spine fracture C-spine fracture Thoracic injury Spinal cord injury C-spine fracture Spinal cord injury C-spine fracture

spondylolysis

11,104,108 101 20,21,22 34,76 41,88,89 17 37 70,83

76 88,90
29

118

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athletes with weak neck muscles'2 or relative stenosis of the cervical canap6,104 Diagnosis is made based on history of neurologic symptoms after trauma, which mayor may not have persisted, and negative plain radiographs, tomograms, and/or computed tomography. MR imaging may show spinal cord edema but may not indicate relevant ligamentous injury.23 Myelography may be the most productive diagnostic tool."9 Treatment is the same as for spinal fractures with cord injury: immobilization and, if care is rendered within a few hours of injury, high-dose steroids. These injuries are rarely unstable requiring surgery.95Rehabilitation involves regaining mobility and improving neck strength. If there is neurologic damage, standard spinal cord injury rehabilitation is necessary. In the neurologically intact athlete, return to sports is controversiaP' 4,46, 72, To our knowledge, no 55, 105 good studies have been done to test for increased susceptibility to further injury. Prevention is not only aimed at improving neck strength, but also avoiding the elongation or hyperextension that can cause the injuries. This involves modifying training techniques, changing rules, and redesigning equipment. American gridiron football is a good example. To help prevent SCIWORA, use of the face mask and forehead as an assaultive device should be discouraged.

Fractures

Although macrotrauma can cause fractures anywhere in the spine, C-spine fractures can have the most devastating consequences.Diving and football are the sports most frequently cited as high-risk for C-spine fracture, but many other sports must be considered as well. Downhill skiing,62horseback riding,41.89 gymnastics,21, 98 88. rugby,70. and most of the sports listed in Table 1 have been 83 associated with increased risk of C-spine fracture. The problem is less common in children than in adolescents or adults but can occur whenever the load exceeds the strength of the C-spine, whether in flexion, extension, distraction, compression, rotation, or a combination of these forces}14 Axial compression (resulting, for example, from spearing in football) is associated with the classic tear drop fracture.IO7 The at-risk athlete for C-spine fracture is the child in an at-risk sport with weak neck muscles, poor supervision, and a body habitus that is known to be of a higher risk. The authors concur with Pizzutillo72 who stated that children with limited C-spine motion in any plane should be further studied for undetected congenital or acquired anomalies. Diagnosis of C-spine fractures is straightforward, but mistakes continue to be made when inadequate radiographs are obtained}5 A lateral C-spine that includes the superior endplate of Tl is mandatory before completing the trauma series. The criteria of White .and Panjabi114 should be used to gauge stability, and we must recall that a child's atlanto-dens excursion can be up to 4.5 mm normally on flexion/extension radiographs and that pseudosubluxation of C3-4 is common in children. Jaffe and colleagues33 have developed a protocol for avoiding excessive radiographs after suspected C-spine injury in children. In their series, 73% of 206 children's C-spine injuries were a result of sports or a fall.33 Rachesky and coworkers advocate a somewhat similar approach to Cspine evaluation in children.75 If an unstable C-spine fracture is found, operative stabilization is required. Crawford14 has published a comprehensive review of operative treatment of spine fractures in children. Once the fracture is healed, a decision must be made

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as to whether the child can be rehabilitated adequately enough to return to the former level of competition and in the sport of injury. Some criteria for returning to activity have been developed,z.46. but each child has to be individually 10S assessedwith risks and benefits determined before play is allowed. Macrotrauma fractures to the thoracic spine are uncommon. The most common injury is costovertebral and costochondral injury. Rib fractures also are uncommon. Sports such as taekwondo in which there are many blows to the thorax are at increased risk,85but any athlete may receive a blow to the chest resulting in injury. Diagnosis is made by palpation of the injured rib. Some of these injuries are costal subluxations and can be reduced with direct pressure.74.103 These injuries also can become chronically painful, and can require corticosteroid injection to relieve symptoms.53.54 Rehabilitation is nonspecific and return to sports occurs when symptopls permit. Chest protectors can prevent some rib injuries, but are presently used to prevent injury to the thoracic viscera} Acute thoracolumbar and lumbar fractures are uncommon in the child athlete as are sacral, sacroiliac, and coccygeal fractures. One entity that must be considered is acute traumatic or isthmic spondylolysis. This is more likely to be the final blow in someone who has had repetitive microtrauma to the posterior elements, but can occur after a single, violent hyperextension of the spine. Diagnosis of traumatic spondylolysis is made on lateral and oblique plain radiographs. Treatment is the same as for the more common microtraumainduced isthmic spondylolysis discussed later in this article. A second injury is traumatic spinous process, transverse process, iliac crest or vertebral end-plate apophyseal fracture from sudden hyperextension, hyperflexion, or twisting maneuvers in, for example, gymnastics.3S, 98 84, This injury may be treated as a softtissue injury but may require bracing for symptoms to resolve.

Disc Herniation

Acute disc herniation may occur in the cervical, thoracic, or lumbar spine. These injuries occur more often in adults but must be considered in the adolescent with sciatica or difficult to diagnose low back or buttock pain. The at-risk groups for herniated nucleus pulposus (HNP) seem to be football players61and gymnasts,48 accurate statistics are unavailable. Current data show that HNP but accounts for less than 10% of young athletes' low back pain.98Once fracture has been ruled out by plain radiographs, MR imaging will confirm the herniated disc. It is important to confirm the diagnosis because treatment of these athletes involves rigid bracing with a 15 deg lordosis lumbar module.57 The authors have found bracing to be far more effective than use of a soft lumbar support. If bracing, anti-inflammatories, and physical therapy are unsuccessful after 12 weeks, epidural corticosteroids may be employed. One study suggests that early surgical HNP excision is required to prevent long-term back problems in this age group}6 Our data using the brace are still being compiled, but our clinical impression is that most of these athletes resolve their back and leg pain without surgery. Repeat MR imaging after 1 year has shown complete absence of the HNP in one of our patients. Although we advocate bracing instead of corset use, the authors otherwise follow the discogenic back pain algorithm described by the Pennsylvania Hospital group;17 modified for the special circumstances of the young athlete. Once cauda equina syndrome is ruled out, nonoperative therapy is all that is required for the majority of athletes with discogenic back pain.

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Soft Tissue

Injury

Muscle and tendon macrotrauma in the form of contusions and strains are far more frequent than fractures or herniated discs. Many, if not most, of these injuries never come to the attention of a medical provider and the athlete resolves his or her symptoms in 4 to 6 weeks. Soft-tissue scarring and shortening may occur, making recovery difficult; physical therapy may be required to regain flexibility. Most importantly, muscular low back strain becomes chronic far less frequently in children than it does in adults and heals far more readily. Muscular back strain in a child athlete should be suspected unless an exact date and mechanism of injury are known. Back pain that does not resolve in a child athlete should not be diagnosed as chronic, mechanical low back pain unless all other diagnoses have been ruled out.

Visceral

Injury

Macrotrauma injury to the spine and trunk also can cause injury to internal organs that may be referred to the spine. Two to three children are estimated to die each year as a result of being struck in the sternum by a baseball}' 79 Other reports link ice hockey and lacrosse with similar deaths}7,34Bellotti and colleagues6have documented cardiac contusion in boxers. The mechanism is believed to be compression of the more mobile young sternum, causing cardiac contusion and structural damage or inducing fatal asystole. Taekwondo has been studied to determine the potential for injury to internal viscera. Because the majority of blows are kicks to the abdomen and thorax, the risks are high if no protective gear is worn.85Other than the heart, the lungs, kidneys, spleen, liver, and intestines are at greatest risk for injury. Specific physical examination and laboratory tests such as electrocardiogram, urinalysis, complete blood count, amylase level, and liver functions tests should be employed to rule out injury to thoracic or abdominal viscera.

MICROTRAUMA

Repetitive microtrauma can cause injury anywhere in the spine but is most likely to be the source of lumbosacral low back pain. No reports are found in the literature of C-spine problems from microtrauma, but it cannot be assumed that this area is somehow protected. Repetitive trauma to the chest wall and scapulothoracic area can lead to painfully unstable subluxating ribs or scapulothoracic articulation fibrosis. Both problems can be difficult to treat, requiring corticosteroid injection, fusion, or resection of the offending rib or multiple injections to scapulothoracic trigger pointS.64, 103 addition, stress fracture of 74, In the ribs from rowing has been well documented.28 The vast majority of microtrauma complaints related to the spine concern the lumbosacral region. Rarely will the history indicate acute macrotrauma. In most cases,the athlete will relate that some aspect of his or her particular sport causes disabling low back pa.in. The incidence is estimated at between 50% to 70% in college football players}8 Fortunately, most injuries are probably minor strains and contusions that resolve within a few weeks. Low back pain that persists longer than 3 weeks in a young athlete warrants further investigation. Five distinct entities must be considered in young athletes subjected to

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repetitive microtrauma. These are spondylolysis and spondylolisthesis (Fig. 1), lordotic low back pain and apophysitis (Fig. 2), degenerative disk disease and small herniated nucleus pulposus (Fig. 3), arthritic degeneration at a transitional vertebra (Fig. 4), and chronic low back strain. The at-risk groups for microtrauma low back pain have been amply identified. The most well-studied groups are football players and gymnasts. Three recent studies used MR imaging to compare spines of gymnasts to controls?' 99.102 fourth study looked at routine spine films.73In the first study, 11 of 35 A young gymnasts had complained of low back pain. Three had MRI evidence of degenerative disc disease}02The second study found a 9%, 43%, and 63% incidence of degenerative changes in pre-elite, elite, and Olympic level female gymnasts respectively. These statistics compared with a 15.8% incidence in swimmers. Greater than 15 hours per week of training seemed to lead to the majority of injuries.22Sward and co-workers99found MR imaging evidence of degeneration in male gymnasts to be 75% versus 31% of controls. A German study evaluating over 300 plain radiographs of swimmers' and gymnasts' spines found large numbers of degenerative changes in the gymnasts.73 These studies dramatically emphasize that intense training in at-risk sports leads to early degenerative back disease. As training begins at younger and younger ages and becomes more intensive, it must be realized that early degeneration and injury will result unless specific steps are taken to prevent these injuries by determining risk factors for injury.

Figure 1. Oblique radiograph showing obvious L5 spondylolysis. When the fracture is this apparent, the process is probably long-standing and less likely to heal with bony union.

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Figure 2. Radiograph showing iliac crest apophysitis. This can be very painful and is always tender to palpation of the involved crest.

Spondylolysis and Spondylolisthesis Rosenberg and coworkers study78of nonambulatory patients convincingly demonstrated that fracture of the pars interarticularis usually occurs as a consequence of activity. Most authors now believe that spondylolysis and prespondylolytic stress reaction are overuse injuries}09,112, These repetitive hyperexten113 sion sequelae are the most common serious back injury seen in gymnasts, figure skaters, and ballerinas (Fig. 5).* Diagnosis of spondylolysis may be difficult on plain radiographs, including obliques, and diagnosis of prespondylolytic pars stress reaction cannot be made with plain films. Instead, studies from Children's Hospital in Boston and elsewhere have firmly established that single photon emission computerized tomography (SPECT)bone scans are necessary to pick up these lesions (Fig. 6).5,13, 68, The authors recommend anteroposterior, 67, 77 lateral, and oblique radiographs in young athletes with low back pain lasting longer than 3 weeks. If these radiographs are negative and there is no clinical evidence of herniated disc, we proceed to SPECTbone scan, especially if repetitive hyperextension is involved in the sport and exacerbatessymptoms. Spondylolysis in the young athlete is not considered an incidental finding as it might be for adults. Spondylolysis is considered a pars interarticularis
*References20, 22, 24, 31, 32, 39, 59, 60.

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Figure 3. Herniation of the L1-2, L2-3, and L4-5 nuclei pulposi into the superior vertebral bodies. These herniations form Schmorl's nodes and are diagnostic of atypical Scheuermann's kyphosis in the thoracolumbar spine.

Figure 4. L5-S1 transitional vertebrae with enlarged right transverse processes forming a painful arthritic pseudarthrosis.

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Figure 5. Figure skater a layback. Repetitive sion is believed to be cause of spondylolysis

performing hyperextenthe primary stress frac-

ture.

Figure 6. SPECT bone scan of L-S spine showing L4 spondylolysis. Plain radiographs, including obliques, were normal.

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stress fracture and treated with bracing and hamstring stretching until it is healed or asymptomatic. This may take up to 9 months. The brace used is the Boston overlapping brace in 0 deg of lordosis.57, Prespondylolytic pars stress 93 reaction is treated the same way. Either diagnosis may require repeat SPECTto confirm healing and may take up to 6 to 9 months to resolve.53, 60, 55-57,93 It is essential to make the diagnosis and initiate protective treatment as early as possible, before frank fracture has occurred. There is an unfortunate tendency in this lesion to withhold treatment unless lysis is evident by plain radiographs. This tendency may be a holdover from the time when this entity was believed to be a developmental defect and not recognized as a stress fracture, No clinician, of course, would use such an approach with a tibial stress fracture; such an approach to stress fracture of the pars must be condemned because of even greater potential for complete fracture and subsequent nonunion. Treatment of spondylolisthesis is similar with antilordotic bracing and hamstring stretching. Occasionally, union may occur in grade I spondylolisthesis; however, the goal here is not to attain union or reduction, but to return the athlete to play without pain. If symptoms persist or increased slippage occurs, repair of the pars defect or in situ fusion must be considered.25, All of these 94 athletes are permitted to compete in the brace if symptoms have been relieved. Return to sport for these athletes is entirely based upon resolution of symptoms. If pain resumes when the brace is removed, the athlete is instructed to compete in the brace. If pain persists in the brace, athletic activities are stopped until they can be resumed painlessly. An athlete with persistent unilateral spondylolysis despite adequate bracing may return to full play out of the brace once symptoms have been resolved. In this case, efforts are made to ensure that the contralateral pars does not fracture.8, 93 57, Prevention takes several forms. In at-risk sports such as football, gymnastics, and volleyball, efforts are undertaken to minimize hyPerextension. In football, use of the blocking sled has been thought to cause an increased incidence of spondylolysis.58 Better extension strength may help.38In gymnastics, training more than 15 hours per week seemsto lead to more injury.22 At-risk individuals are known to be those with a family history of spondylolysis or spondylolisthesis and individuals with other spinal anomalies such as spina bifida occulta or transitional vertebrae.52, In such at-risk individuals, it 72,87 might be prudent to avoid hyPerextension sports such as interior line positions in football or hyPerextension gymnastics or volleyball maneuvers.

Discogenic

Back Pain and Atypical

Scheuermann's

Repetitive microtrauma may lead to degenerative disc disease or insidious onset herniated disc. Although disc problems are less common in the young athlete, occurrence has been demonstrated.22, 99.102 most at-risk athletes for 98, The degeneration are gymnasts,22, 102 for herniation they seemto be the collision 99, and sport athletes and weightlifters.'8 Persistent low back pain and sciatica in any young athlete may have a discogenic cause.Diagnosis is made by physical exam and confirmed by MR imaging. Rarely is disc space narrowing seen on plain radiographs in this age group. MR imaging may show relative spinal canal stenosis as well as the disc herniation. Treatment for discogenic back pain in young athletes rarely requires surgery. Rest, physical therapy, and antilordotic bracing will return most of the athletes to competition. The bracing protocol developed in the authors' clinic is

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based upon empirical evidence and uses the Boston overlapping brace in 15 deg of lordosis. Preliminary results are good and a statistical evaluation of longer term results presently is underway. After pain or neurologic symptoms have resolved, rehabilitation entails establishing normal range of motion, flexibility, and strength. Williams115 type flexion exercisesare stressed.The athlete may then safely return to full activity, including contact sports or weightlifting. To prevent recurrence, proper body mechanics and adequate strength of abdominals and paraspinals must be maintained. Another source of back pain in adolescent athletes involving the anterior spine elements is lumbar or atypical Scheuermann's disease.9.72 Anterior intravertebral disc herniation and Schmorl node formation with the kyphosis seen in these individuals can cause disabling back pain9 (see Fig. 3). The at-risk group for this condition has not been defined, but seems to be divers, gymnasts, and others who have "flatter" spines (thoracic hypokyphosis and lumbar hypolordosis) and are subjected to repeated flexion of the lumbar spine. The deformity occurs in the upper lumbar segments or thoracolumbar junction.9 Forward flexion increases symptoms, and the "flat back" is evident by physical examination or standing lateral radiographs (Fig. 7). Treatment consists of hyperextension bracing (15 deg-30 deg), strengthening and stretching, and intensive hamstring stretching. Here, McKenzie-type48 extension exercises are stressed. If diagnosed early, these athletes become asymptomatic in 4 to 6 weeks and gradually return to sports over 3 to 6 months.119 Strengthening in these children

Figure 7. "Flat back." Lateral radiograph of an individual at risk for atypical Scheuermann's kyphosis.

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should follow guidelines described elsewhere.44, 86,111 51, Without better epidemiologic data, prevention guidelines exist in theory only. Observing athletes with increased or decreased lumbar lordosis and stressing flexibility and perilumbar strengthening may help prevent both types of discogenic low back pain. Lordotic Low Back Pain A major source of microtrauma-induced low back pain is tight lumbodorsal fascia in the growing adolescent. This syndrome is most common during the second growth spurt when increased demands from sports are also likely to be present.44 the skeleton grows, the spanning muscles, tendons, and fascia are As subject to increased tension. If bony growth exceeds the capacity of the soft tissues to remain limber, pathologic tightness occurs. In the lumbar spine, the result is chronic tightness of the lumbar fascia and hamstrings leading to multiple small strains97or apophyseal injuries and inflammation.35.84 The at-risk group is any young athlete undergoing rapid growth.61Diagnosis is made by the finding of tight lumbar fascia and hamstrings in an atrisk individual without other pathology (Fig. 8). Spinous process or iliac crest apophyseal injuries may elicit focal tenderness. Radiographs may show an apophyseal avulsion (see Fig. 2). Treatment is intensive lumbar and hamstring stretching. Most of these athletes can continue to participate in sports during treatment and no long-term disability is expected. Prevention can playa large role by keeping young athletes supple, regardless of the sport. Musculotendinous Low Back Pain

Simple muscle and tendon low back strains and sprains are unlikely to cause long-term low back pain. As previously stated, an isolated strain will

Figure 8. Adolescent athlete with tight lumbar fascia, inability to reverse lumbar lordosis, and compensatory thoracic hyperkyphosis.

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heal in a few weeks, whereas small, repetitive strains are more likely to be a manifestation of lordotic back pain. In a child athlete with back pain longer than 3 weeks, a diagnosis of muscle, tendon, or ligament strain is highly unlikely. Other causes must be sought.

Transitional

Vertebra

Another source of low back pain resulting from repetitive microtrauma is arthritic degeneration. In adults, the facet joints would be the most likely source of pain, but facet degenerative arthritis as a result of microtrauma has not been reported in children. Facet syndromehas been described and may be another hyperextension overuse injury27; this injury is treated as a soft tissue overuse injury . What occasionally may be found is painful degenerative arthritis of the pseudarthrosis formed between a transitional vertebra and the posterior iliac wing or sacral ala (seeFig. 4). Transitional vertebra is a congenital malformation at the lumbosacral junction. The types most predisposed to pseudarthrosis formation are those where there is an enlarged transverse process or laterally fused mass. The mass may directly contact the iliac wing or sacrum leading to degenerative changes and pain with movement.45Originally described by Bertolotti,7 this is a well-known source of low back pain.45, Bracing, rest, and 81 anti-inflammatories can frequently return the athlete to the previous less painful state, but the process is progressive and may persist. Corticosteroid injections to the pseudarthrosis have been used with some success,but definitive treatment may require fusion or, more recently, resection of the bony impingement.81 Once symptoms have resolved, there are no contraindications to gradual return to full activity. If an impinging transitional vertebra is found incidently on radiographs, the athlete can be forewarned of the predisposition. Sacroiliac and coccygeal pain are unlikely to result from repetitive microtrauma, although one report exists of sacroiliac stress reaction!7 If there has been no macrotrauma, one of the atraumatic arthritides should be suspected in theseareas.

ATRAUMATIC

CAUSES

OF BACK AND NECK PAIN

Pain in the spine without antecedentmacro- or microtrauma can result from congenital, metabolic, infectious, or neoplastic processes.In addition, unrecognized microtrauma may present as an atraumatic source of spinal pain. In the cervical spine, congenital and developmental abnormalities include Klippel-Feil syndrome, hypermobility, and congenital cervical stenosis. KlippelFeil syndrome usually manifests as C2-3 vertebral fusion. If there is coexistent occipitalization of the atlas, Cl-2 instability develops 75% of the time. Other anomalies that can coexist with Klippel-Feil are unilateral absence of a kidney and cardiac or hearing anomalies.71 of these conditions must be kept in mind All when permitting an athlete with Klippel-Feil to return to sports. Hypermobility of the cervical spine is a controversial subject. The normal atlanto-dens interval (AD!) in a child is up to 4.5 mm. Anything greater than 5 mm is considered unstable.114 C2-3 and C3-4 pseudosubluxation occurs in up to 40% of children under 8 years of age}OO normal children, these criteria In accurately predict stability, but an increasing body of evidence indicates that

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applying White and Panjabi's criterial14to others is not appropriate. Specifically, the Special Olympics athlete with Down's syndrome seems to defy cervical stability prediction. By standard AD! criteria, 25% of Down's patients are unstable.loo Only 3% of Down's patients have neurologic problems as adults72,suggesting that some radiographically unstable Down's patients are not clinically unstable and may be over-protected by physicians to some extent. Recent discussions have advocated ongoing clinical and radiologic analyses to determine suitability for competition in sports at risk for neck injury, such as soccer.IO,72 Congenital cervical stenosis is a bona fide concern and may account for some of the transient quadriplegia and SCIWORA found in older children.26,I04, 106, The diagnosis is made by measuring the AP diameter of the vertebral 108 body and canal at the level in question. If the canal to body ratio is less than 0.8, stenosis is present!06In any athlete who has experienced transient paralysis or who has cervical stenosis by this criterion, serious consideration must be given to permanent restriction of sports activities}05 In the thoracic spine, Scheuermann's kyphosis and scoliosis are relatively common conditions that may predispose an athlete to back pain, although neither condition precludes athletic activity. Scoliosis is rarely a cause of back pain, but progressive classic Scheuermann's can be painful.9, 96By definition, Scheuermann's kyphosis consists of three or more consecutive thoracic vertebrae with greater than 5 deg of kyphosis per level. Vertebral endplate changes and disc space narrowing also are usually found.91Clinically, patients have a roundback posture with tight lumbar fascia and hamstrings. Symptoms respond to rest and dorsal extension stretching and strengthening of the thoracic musculature. Bracing is sometimes necessary, and these athletes always can return to full activity once symptoms have resolved. Diagnosis and treatment of idiopathic adolescent scoliosis is well described elsewhere.42, In the young athlete, back pain from scoliosis is rare, and athletes 116 with curves requiring bracing may still have complete sports participation, particularly with recent bracing regimens incorporating a maximum of 18 hours per day of bracing. If the spine has been fused, most authors do not permit fullcontact sports. Athletes with single level fusions, such as those for spondylolisthesis, may occasionally return to full-contact sportS.55 Developmental spondylolysis is a condition that mayor may not be symptomatic. If back pain is present, treatment is the same as for isthmic or traumatic spondylolysis described in the previous sections. Transitional vertebrae should not, in and of themselves, cause back pain. Painful pseudarthrosis from a transitional vertebra also has been previously

described.
Metabolic and rheumatologic conditions may lead to back pain in the young athlete. Diffuse pain throughout the spine may result from juvenile rheumatoid arthritis GRA) or ankylosing spondylitis. Radiographic changes mayor may not be present. In JRA, cervical or lumbar pain may be present. Unlike adult onset rheumatoid arthritis, rheumatoid factor is less often present upon serologic testing, but antinuclear antibodies will be found 50% of the time.69 Early on, radiographs will be negative but can show the diffuse osteoporosis of chronic inflammation over time. Late findings in the C-spine can be apophyseal fusion or atlanto-axial instability. Any child with JRA and radiographic evidence of atlanto-axial instability on flexion-extension lateral radiographs should not engage in contact sports. Ankylosing spondylitis (AS) also can present with neck or low back pain. Serologic testing for the HLA-B27gene marker will be positive up to 94% of the

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time.36.82 Physical examination may show only diffuse tenderness in the affected region but also may reveal a positive Patrick test indicating sacroiliac involvement. Radiographs may show early sclerosis of the S-I joints. Treatment for both JRA and AS consists of rest, gentle mobility, and anti-inflammatories. Both conditions are chronic and require long-term rheumatologic management. Athletics are not necessarily contraindicated, but may exacerbate symptoms and accelerate degeneration. Infection can present as back or neck pain. Atraumatic back pain that persists or is accompanied by fever requires infectious disease work-up. This includes complete blood count (CBC), erythrocyte sedimentation rate (ESR),and plain radiographs. A radionucleotide bone scan can identify the infected disc or vertebra. Recentstudies have indicated that MR imaging19and C-reactive protein levelsllo may be helpful diagnostic studies for these patients. Blood cultures may grow the causative organism. The usual pathogen is Staphylococcus aureuswith hematogenous seeding of the disc or vertebral endplate. The diagnosis is either discitis or vertebral osteomyelitis, depending upon which structure is more involved. Tuberculosis of the spine or Pott's disease is rising again in incidence and should be considered among infectious agents. Treatment is dependent upon the organism and whether a sequestrum is present. Antibiotics are definitive treatment, but if a sequestrum is present, surgical debridement may be necessary. Neoplasms of the spine fall into two groups based on location in the vertebral segment. Osteoid osteoma and osteoblastoma occur in the posterior elements while aneurysmal bone cyst, giant cell tumor, Ewing's sarcoma, eosinophilic granuloma, or osteogenic sarcoma usually occurs in the vertebral bodies. Lymphoma has also been reported to cause back pain in a young athlete}2 As in infection, CBC and ESR may indicate the problem, and bone scan, computed tomography scan, or MR imaging may be needed to refine the diagnosis. Once the diagnosis is made, guidance from an orthopaedic spinal specialist or oncologist should be sought.

SUMMARY

Back pain in children and young athletes is very different from back pain in adults. Macrotrauma must be carefully evaluated and managed, even in the absence of definitive radiographic findings. Microtrauma must be suspected in at-risk athletes. These athletes require persistent diagnostic evaluation and may require SPECTbone scan to uncover a posterior element stress reaction. Atraumatic back pain requires the elimination of neoplastic, infectious, rheumatologic, or congenital causes.

References 1. Abrunzo TJ: Commotio cordis: The single, most common cause of traumatic death in youth baseball. Am J Dis Child 145:1279-1282, 1991 2. Akau CK, Press JM, Gooch JL: Sports medicine. IV: Spine and head injuries. Arch Phys Med Rehab 74:5443-5446,1993 3. Arvidson EB, Micheli LJ: Spine and trunk problems in athletes. Current Opinion in Orthopedics 1:361-364,1990 4. Bailes JE, Hadley MN, Quigley MR, et aI: Management of athletic injuries of the cervical spine and spinal cord. Neurosurgery 29:491-497,1991

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5. Bellah RD, Summerville DA, Treves ST, et al: Low-back pain in adolescent athletes: Detection of stress injury to the pars interarticularis with SPECT. Radiology 180:509512, 1991 6. Bellotti P, Chiarella F, Domenicucci 5, et al: Myocardial contusion after a professional boxing match. Am J Cardiol 69:709-710,1992 7. Bertolotti M: Contributo alla conoscenza dei vizi di differenzazione regionale dei rachide con speciale riguardo alla assimilazione sacrale della V lombare. Radiol Med (Torino) 4:113-144, 1917 8. Blanda J, Bethem D, Moats W, et al: Defects of pars interarticularis in athletes: A protocol for nonoperative treatment. J Spinal Disord 6:406-411, 1993 9. Blumenthal SL, Roach J, Herring JA, et al: Lumbar Scheuermann's: a clinical series and classification. Spine 12:929-932,1987 10. Burke SW, Roberts JM, French JJ, et al: Chronic atlanto-axial instability in Down syndrome. J Bone Joint Surg 67A:1356-1360,1985 11. Cantu RC, Mueller FO: Catastrophic spine injuries in football (1977-1989). J Spinal Disord 3:227-231,1990 12. Clark A, Stanish WD: An unusual cause of back pain in a young athlete. A case report. Am J Sports Med 13:51-54,1985 13. Collier BD, Johnson RP, Carrera GF, et al: Painful spondylolysis or spondylolisthesis studied by radiography and single photon emission computed tomography. Radiology 154:207-211,1985 14. Crawford AH: Operative treatment of spine fractures in children. Orthop Clin North Am 21:325-339, 1990 15. Davis JW, Phreaner DL, Hoyt DB, et al: The etiology of missed cervical spine injuries. J Trauma 34:342-346,1993 16. DeOrio JK, Bianco AJ: Lumbar disc excision in children and adolescents. J Bone Joint Surg 64A(7):991-995, 1982 17. Edlich RJ, Mayer NE, Fariss BL, et al: Commotio cordis in a lacrosse goalie. J Emerg Med 5:181-184,1987 18. Ferguson RJ, McMaster JH, Stanitski CL: Low back pain in college football lineman. Am J Sports Med 2:63-69, 1974 19. Garcia FF, Semba CD, Santoris, CC, et al: Diagnostic imaging of childhood spinal infection. Orthop Rev 22:321-327,1993 20. Garrick JG, Requa RK: The epidemiology of women's gymnastics injuries. Am J Sports Med 8:261-264,1980 21. Goldberg MJ: Gymnastics injuries. Orthop Clin North Am 11:717-726,1980 22. Goldstein JD, Berger PE, Windler GE, et al: Spine injuries in gymnasts and swimmers. An epidemiologic investigation. Am J Sports Med 19:463-468,1991 23. Hadley MN, Zabranski JM, Brownen CM, et al: Pediatric spinal trauma. Review of 122 casesof spinal cord and vertebral colunm injuries. J Neurosurg 68:18-24,1988 24. Hall SJ: Mechanical contribution to lumbar stress injuries in female gymnasts. Med Sci Sports Exerc 18:599-602,1986 25. Hardcastle PH: Repair of spondylolysis in young fast bowlers. J Bone Joint Surg 75B:398-402,1993 26. Herzog RJ, Wiens JJ, Dillingham MF, et al: Normal cervical spine morphometry and cervical spine stenosis in asymptomatic professional football players. Spine 16(6S):S178-S186, 1991 27. Hochschuler SH: The Spine Sports. Philadelphia, Hanley & Belfus, 1990 28. Holden DL, Jackson DW: Stress fractures of the ribs in female rowers. Am J Sports Med 13:342-345,1985 29. Home J, Cockshotl WP, Shannon HS: Spinal column damage from water ski jumping. Skeletal RadioI16:612-616, 1987
30. Hresko MT, Micheli LJ: Sports medicine and the lumbar spine. In Homan Y (ed): Disorders of the Lumbar Spine. Rockville, Maryland, Aspen Publishers, 1990, pp 879894

31. Ireland ML, Micheli LJ: Bilateral stress fracture in the lumbar pedicle in a ballet dancer. J Bone Joint Surg 69A:14G-142,1987

BACK INJURIFS IN nrn YOUNG ATHLETE

~R7

32. Jackson DW, Wiltse LL, Dingeman RD, et al: Stress reactions involving the pars interarticularis in young athletes. Am J Sports Med 9:304-312, 1981 33. Jaffe DM, Binns H, Radkowski MA, et al: Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Ann Emerg Med 16:270-276,1987 34. Karofsky PS: Death of a high school hockey player. Physician Sportsmed 18:99-103,
1990

35. Keene JS,Drummond DS: Mechanical back pain in the athlete. Compr Ther 11:7-14,
1985

36. Khan MA, Braun WE, Kushner 1,et al: HLA ~ in ankylosing spondylitis: Differences in frequency and relative risk in American Blacks and Caucasians(Suppl). J Rheumatol 3:39-43, 1977 37. Kruger-Franke M, Pforringer W: Verletzungen beim Gleitschirmsegeln. Eine BOTSSammelstudie. Sportverletzung Sportschaden 5:1-4, 1991 38. Leggett SH, Graves JE, Pollock ML, et al: Quantitative assessmentand training of isometric cervical extension strength. Am J Sports Med 19:65~59, 1991 39. Letts M, Smallman T, Afanasen R, et al: Fracture of the pars interarticularis in adolescent athletes: a clinical biomechanical analysis. J Pediatr Orthop 6:40-46, 1986 40. Leventhal HR: Birth injuries of the spinal cord. J Pediatr 56:447-453,1960 41. Uoyd RG: Riding and other equestrian injuries: Considerable severity. Br J Sports Med 21:22-24, 1987 42. Lonstein JE: Natural history and school screening for scoliosis. Orthop Clin North Am 19:227-237,1988 43. Lutz FU, St. Kreidel H: Fatal bicycle accidents: Causes and legal responsibility. Zeitschrift fur Rechtsmedizin 101:1-8, 1988 44. Maffulli N, King JB,Helms P: Training in elite young athletes (the training of young athletes (TOYA) study): Injuries, flexibility and isometric strength. Br J Sports Med 28:120-136,1994 45. Mann DC, Keene JS,Drummond DS: Unusual causesof back pain in athletes. J Spinal Disorders 4:337-343, 1991 46. Marks MR, Bell GR, Boumphrey FR: Cervical spine injuries and their neurologic implications. Clin Sports Med 9:263-278, 1990 47. Marymount JV, Lynch MA, Henning CE: Exercise-related stress reaction of the sacroiliac joint. An unusual cause of low back pain in athletes. Am J Sports Med 14:320323, 1986 48. McKenzie RA: The Lumbar Spine. Mechanical Diagnosis and Therapy. Lower Hutt, New Zealand, Spinal Publications, 1981 49. Micheli LJ: Back injuries in gymnastics. Clin Sports Med 4:85-93, 1985 50. Micheli LJ: Low back pain in the adolescent: differential diagnosis. Am J Sports Med 7:362-364,1979 51. Micheli LJ: Physiological and orthopedic considerations for strengthening the prepubescentathlete. National Strength and Conditioning Association Journal 7:26-27, 1985 52. Micheli LJ: Spinal deformities and the athlete. In Welch RP, Shephard RJ (eds): Current Therapy in Sports Medicine. Philadelphia, BC Decker, 1985,pp 158-164 53. Micheli LJ: The spine and chest wall. In Johnson RL, Lombardo J (eds): Current Review of Sports Medicine. Philadelphia, Current Medicine, 1994,pp 1-16 54. Micheli LJ: Spine, trunk, pelvis, and hip problems in the athlete. Current Opinion in Orthopedics 2:744-748,1991 55. Micheli LJ: Sports following spinal surgery in the young athlete. Clin Orthop 198:152157, 1985 56. Micheli LJ, Allison G: Lumbar spine injury in young athletes (In Proceedings of Sports Neurology Symposium at the 1992 annual meeting of the American College of Sports Medicine). Med Sci Sports Exerc, In press 57. Micheli LJ, Hall JE, Miller ME: Use of modified Boston brace for back injuries in athletes. Am J Sports Med 8:351-356, 1980 58. Micheli LJ, KasserJR: Case Report 6: Painful spondylolysis in a young football player. In Hochschuler SH (ed): The Spine in Sports. Philadelphia, Hanley & Belfus, 1990, pp 327-330

588

GERBINO & MICHELI

59. Micheli LJ, McCarthy C: Figure skating. In Watkins RG (ed): The Spine in Sports. St. Louis, Mosby-Year Book, In press 60. Micheli LJ, Micheli ER: Back injuries in dancers. In Shell CG (ed): The 1984Olympic Scientific Congress Proceedings, vol 8: The Dancer as Athlete. Champaign, Illinois, Human Kinetics Publishers, 1986,pp 91-94 61. Micheli LJ, Wood R: Back pain in young athletes: Significant differences from adults in causesand patterns. Arch Pediatr Adolesc Med 149:15-18,1995 62. Myles ST, Mohtadi NG, Schnittker J: Injuries to the nervous system and spine in downhill skiing. Can J Surg 35:643-648,1992 63. National Institutes of Health: Publication No. 93-3444. Conference on Sports Injuries in Youth: Surveillance Strategies. Proceedings, April 8-9, 1991, Bethesda, Maryland, National Institutes of Health, 1992 64. Ormandy 1: Scapulocostal syndrome. Va Med Q 12:105-108,1994 65. Osenback RK, Menezes AH: Pediatric spinal cord and vertebral column injury. Neurosurgery 30:385-390,1992 66. Pang D, Pollack F: Spinal cord injury without radiologic abnormality in children: the SCIWORA syndrome. J Trauma 29:654-664,1989 67. Papanicolaou N, Wilkinson RH, Emans JB, et al: Bone scintigraphy and radiography in young athletes with low back pain. AJR 145:1039-1044, 1985 68. Pennell RG, Maurer AH, Bonakdarpour A: Stress injuries of the pars interarticularis: Radiologic classification and indications for scintigraphy. AJR 145:763-766,1985 69. Petty RE, Cassidy IT, Sullivan DB: Clinical correlates of anti-nuclear antibodies in juvenile rheumatoid arthritis. J Pediatr 83:386-389,1973 70. Piggot J: The need to make rugby safer. British Medical Journal-Clinical Research Edition 296:1260,1988 71. Pizzutil1o PD: Klippel-Feil syndrome. In Cervical Spine ResearchSociety Staff (eds): Cervical Spine, ed 2. Philadelphia, J.B. Lippincott, 1989,pp 258-271 72. Pizzutillo PD: Spinal considerations in the young athlete. Instructional Course Lectures 42:463-472, 1993 73. Pollahne W, Teichmuller HI, Ahrendt E: Wirbelsaulenschaden aus radiologischer Sicht bei leistungssporttreibenden Kindem. Radiologia Diagnostica 31:479-487, 1990 74. Porter GE: Slipping rib syndrome: An infrequently recognized entity in children: A report of 3 casesand review of the literature. Pediatrics 76:810--813, 1985 75. Rachesky I, Boyce WT, Duncan B, et al: Clinical prediction of cervical spine injuries in children. Radiographic abnormalities. Am J Dis Child 141:199-201, 1987 76. Reid DC, Saboe 1: Spine fractures in winter sports. Sports Med 7(6):393-399,1989 77. Rosen PR, Micheli LJ, Treves S: Early scintigraphic diagnosis of bone stress and fractures in athletic adolescents. Pediatrics 70:11-15, 1982 78. Rosenberg NJU, Bargar WL, Friedman B: The incidence of spondylolysis and spondylolisthesis in nonambulatory patients. Spine 6:35-38, 1981 79. Rutherford GW Jr, Kennedy J, McGhee 1: Hazard Analysis: Baseball and Softball Related Injuries to Children 5-14 Years of Age. Washington, DC, U.S. Consumer Product Safety Commission, 1984 SO. Salminen JJ,Oksanen A, Maki P, et al: Leisure time physical activity in the young. Correlation with low-back pain, spinal mobility and trunk muscle strength in 15year-old school children. Int J Sports Med 14:406-410,1993 81. Santavirta S, Tallroth K, Ylinen P, et al: Surgical treatment of Bertolotti's syndrome. Follow-up of 16 patients. Arch Orthop Trauma Surg 112:82-87,1993 82. Schaller JG, Ochs HD, Thomas ED, et al: Histocompatibility antigens in childhood onset arthritis. J Pediatrics 88:926-932,1976 83. ScherAT: Rugby injuries of the spine and spinal cord. Clin Sports Med 6:87-99,1987 84. Schwobel MG: Apophyseal fractures in adolescents.Chirurg 56:699-704,1985 85. Serina ER, Lieu DK: Thoracic injury potential of basic competition taekwondo kicks. J Biomech 24:951-960,1991 86. Sewall 1, Micheli LJ: Strength training for children. J Pediatr Orthop 6:143-146, 1986 87. Shands AR, Bundens WD: Congenital deformities of the spine. Analysis of the roentgenograms of 700 children. Bull Hosp Jt Dis 17:110-133,1956 RH. Silver TR: Soinal injuries in sports in the UK. Br J Sports Med 27:115-120,1993

BACK INJURIES IN THE YOUNG AnILEfE

589

89. Silver JR, Parry JM: Hazards of horse-riding as a popular sport. Br J Sports Med 25:105-110,1991 90. Silver JR, Silver D, Godfrey D: Trampolining injuries of the spine. Injury 17:117-124, 1986 91. Sorenson HK: Scheuermann's Juvenile Kyphosis. Copenhagen, Munksgaard, 1964 92. Spencer GW, Jackson DW: Back injuries in the athlete. Clin Sports Med 2:191-216, 1983 93. Steiner ME, Micheli LJ: Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace. Spine 10:937-943,1985 94. Stinson JT: Spondylolysis and spondylolisthesis in the athlete. Clin Sports Med 12:517-528,1993 95. Sullivan JA: Fractures of the spine in children. In Greene NE, Swiontkowski MF (eds): Skeletal Trauma in Children, vol 3. Philadelphia, W.B. Saunders Co., 1994,pp 283-306 96. Sward L: The thoracolumbar spine in young elite athletes. Current concepts on the effects of physical training. Sports Med 13:357-364,1992 97. Sward L, Eriksson B, Peterson L: Anthropometric characteristics, passive hip flexion, and spinal mobility in relation to back pain in athletes. Spine 15:376-382, 1990 98. Sward L, Hellstrom M, JacobssonB, et al: Acute injury of the vertebral ring apophysis and intervertebral disc in adolescent gymnasts. Spine 15:144'-148, 1990 99. Sward L, Hellstrom M, JacobssonB, et al: Disc degeneration and associatedabnormalities of the spine in elite gymnasts: a magnetic resonance imaging study. Spine 16:437-443,1991 100. Swischhuk LE: Anterior displacement of C2 in children: physiologic or pathologic? Radiology 122:759-763,1977 101. Taylor TKF, Coolican MRJ: Spinal cord injuries in Australian footballers, 1960-1985. Med J Aust 147:109-110,1987 102. Tertti M, Paajanen H, Kujala UM, et al: Disc degeneration in young gymnasts: a magnetic resonanceimaging study. Am J Sports Med 18:206-208,1990 103. Thomas PL: Thoracic back pain in rowers and butterfly swimmers-Costovertebral subluxation. Br J Sports Med 22:81, 1988 104. Torg JS: Epidemiology, pathogenesis, and prevention of football-induced cervical spinal cord trauma. Exerc Sport Sci Rev 20:321-338,1992 105. Torg JS, Glasgow SG: Criteria for return to contact activities following spine injury. Clinical Journal of Sports Medicine 1:12-25, 1991 106. Torg JS, Pavlov H, Genuario SE, et al: Neurapraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg 68A:1354-1370,1986
107. Torg JS, Pavlov H, O'Neill MJ, et al: The axial load teardrop fracture: A biomechanical, clinical, and roentgenographic analysis. Am J Sports Med 19:355-364, 1991

108. Torg JS, Vegso D, O'Neill JM, et al: The epidemiologic, pathologic, biomechanical, and cinematographic analysis of football-induced cervical spine trauma. Am J Sports Med 18:5D-57,1990 109. Troup JDG: Mechanical factors in spondylolisthesis and spondylolysis. Clin Orthop 147:59-67,1976 110. Unkila-Kallio L, Kallio MJ, Peltola H: The usefulness of C-reactive protein levels in the identification of concurrent septic arthritis in children who have acute hematogenous osteomyelitis. A comparison with the usefulness of the erythrocyte sedimentation rate and white blood cell count. J Bone Joint Surg 76A:848-853, 1994 111. Webb DR: Strength training in children and adolescents. Pediatr Clin North Am 37:1187-1210,1990 112. Weir MR, Smith DS: Stress reaction of the pars interarticularis leading to spondylolysis. A cause of adolescent low back pain. Journal of Adolescent Health Care 10:573-577,1989 113. Weiss GB: Stressesat the lumbosacral junction. Orthop Clin North Am 6:83-91, 1975 114. White AA, Panjabi MM: Clinical Biomechanics of the Spine. Philadelphia, J.B. Lippincott, 1978 115. Williams PC: The conservative management of lesions of the lumbosacral spine. In Instructional Course Lectures, 10. Park Ridge, Illinois, American Academy of Orthopaedic Surgeons, 1953,pp 90-102

590

GERBINO & MICHEU

116. Winter RB: Spinal problems in pediatric orthopaedics. In Morrissy RT (ed): Lovell and Winter's Pediatric Orthopaedics, ed 3, vol 2. Philadelphia, W.B. Saunders Co, 1990, pp 625-702 117. Wisneski RJ, Rothman RH: The Pennsylvania Plan II: An algorithm for the management of lumbar degenerative disc disease. Instructional Course Lectures 34:17-36, 118. WU WQ, Lewis RC: Injuries of the cervical spine in high school wrestling. Surg NeuroI23:143-147,1985 119. Yancey RA, Micheli LJ: Thoracolumbar spine injuries in pediatric sports. In Stanitski
CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Sports Medicine: Principles and Practice, vol 3). Philadelphia, Medicine (Orthopaedic W.B. Saunders, 1994,

1985

pp 162-174 120. Yngue DA, Harris WP, Herndon WA, et al: Spinal cord injury without osseousspine fracture. J Pediatr Orthop 8:153-159, 1988 Addressreprint requests to Peter G. Gerbino ll, MD Children's Hospital Division of Spor\s Medicine 300 Longwobd Avenue Boston, MA 02115