Herniated nucleus pulposus with radiculopathy in an adolescent: successful nonoperative treatment.

ABSTRACT

The following report describes a 17-year old girl with a central herniated nucleus pulposus (HNP) at L4-5. The diagnosis of lumbar disk herniation was based on findings from magnetic resonance imaging (MRI). A decision to use conservative treatment was unanimously agreed upon by a team of orthopedists, a neurosurgeon, and an internist. This report follows the patient's course from the onset of pain through the completion of the nonoperative treatment and shows that HNP of a lumbar intervertebral disk with radiculopathy can be treated successfully with aggressive nonoperative care.

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HERNIATED NUCLEUS PULPOSUS of a lumbar intervertebral disk with radiculopathy is common in adults but is uncommon in children and adolescents, accounting for less than 2% of the reported cases of lumbar disk herniation. (1,2) Although successful surgical treatment is well documented in adolescents, it has been found that in the absence of neurologic deficit, a herniated lumbar disk can be safely treated conservatively. (3)

CASE REPORT

A 17-year-old white girl in excellent health, with no previous history of back pain, presented with severe lower back pain almost immediately after lifting a heavy school backpack. She heard a "pop" in the lumbosacral junction as she attempted to lift the backpack. She described the severe pain that followed as aching and radiating into the buttocks and both lateral thighs.

Examination showed intact motor and sensory findings, with no pain on range of motion for either hip in extension. Reflexes at knees and ankles were 2+, without any obvious pathologic reflexes about the ankles. Only back pain was present during straight leg raising (70[degrees] on the right, 45[degrees] on the left). Evaluation with the patient standing showed no evidence of scoliosis. Neither flank asymmetry nor hairy patches were noted. She had no pain with side bending, though pain was present with rotation, particularly to the left.

Given these observations at this initial examination, the impression was that of a muscle strain in her back. Ibuprofen (800 mg tid) was prescribed, but it caused a headache and did not alleviate the back pain. Muscle relaxants were prescribed but had little or no benefit.

Approximately 5 days after injury, the pain worsened and extended through the low back and into the right leg around the lateral aspect of the right knee. On examination, straight leg raising caused back pain, and dural stretching elicited some lateral right leg pain. Sacroiliac joint maneuvers were negative. The pain in the right leg extended down the posterolateral aspect of the thigh, with no radiation past the knee and no paresthesia associated with the pain. The right leg appeared somewhat weaker than the left. Examination of the lumbosacral spine region revealed that she had limitations due to pain, particularly in flexion. Extension and lateral flexion to the right and left were not as limited but were also painful. She was walking with a flexed hunched-over position in an attempt to relieve the back pain, though further flexing of her head downward caused some increased back discomfort. Neurologically, motor and sensory responses were intact. Pulses were within normal range, no lower extremity edema w as noted, no bowel or bladder changes had occurred, and neither fever nor chills were present.

Radiographs of the lumbar spine, including oblique views, showed no evidence of any spondylosis or spondylolisthesis. Even though it is relatively uncommon to see disk-type pain and disk problems in an adolescent, the patient's symptoms suggested lumbar discogenic pain.

Because the patient's pain was still unimproved approximately 3 weeks after injury, MRI of the lumbar spine was done, showing possible minimal narrowing of the L3-4 disk interspace, as well as minimally decreased fluid in that disk. At L4-5, a central disk herniation was seen compressing the anterior margin of the theca, predominantly midline, but somewhat eccentric to the right. The L4-5 disk herniation appeared to be touching the L5 nerve as it emerged from the theca. The impression was that of lumbar radiculopathy.

Various nonsteroidal anti-inflammatory drugs and analgesics were administered while attempting to manage the pain and minimize the side effects. These included etodolac, oxaprozin, rofecoxib, acetaminophen combinations with codeine, hydrocodone, and oxycodone, and a muscle relaxant. None of these yielded any benefit, and most caused headaches. Additionally, a short course of oral steroids (prednisone) yielded no benefit.

During a subsequent physical examination, spasm of the paraspinal musculature was noticed, but no point tenderness or other abnormalities. Lower extremities continued to show good motor strength (5/5 bilaterally throughout). Reflexes remained symmetric and equal. Findings on straight leg raising were positive on the right, with radiation of pain down the posterolateral thigh and occasional radiation past the knee to midcalf. Straight leg raising on the left was negative.

Treatment by epidural steroid injection was discussed, but put off by the patient since she was seeking the most minimally invasive treatment. Therefore, it was agreed that conservative therapy, consisting of an aggressive physical therapy program, would be the best first approach. The physical therapy program consisted of lumbar traction modalities and moist heat. When her acute pain subsided, a range of motion and strengthening regimen was added to this initial aggressive program.

Coincident with the physical therapy program, a complete blood count with differential and erythrocyte sedimentation rate (ESR) were ordered to rule out any possibility of occult infection. Results of blood studies were within normal limits except for those shown in the Table. The ESR was mildly elevated, but there was no evidence of diskitis or infection. On subsequent reevaluation, the ESR remained mildly elevated. Given the slight thyrotropin (TSH) elevation, a small dose of levothyroxine was administered to evaluate for response to the back pain. Some improvement in the pain was noted.

Because of the patient's immobility and associated inability to sit for any period of time, home schooling was initiated for the next 6 weeks. She responded to the aggressive nonsurgical treatment and had complete resolution of the radicular pain approximately 4 months after the onset.

CONCLUSION

It has been documented that an aggressive physical rehabilitation program for treatment of HNP of a lumbar intervertebral disk with radiculopathy can be treated successfully with aggressive nonoperative care. (4) It has been further substantiated by this particular case and suggests that for adolescents, aggressive nonsurgical treatment is a viable first method of treatment for HNP.

TABLE

Patient's Hematologic Values

Days After     ESR            WBC          Neutrophils  Lymphocytes
   Onset     (mm/hr)   (1,000/[mm.sup.3])      (%)          (%)

    46      29 (0-20)  8.9 (1.5-13.0)      66 (40-62)   23 (27-40)
    68      31 (0-20)  NA                  NA           NA

Days After  Monocytes    Thyrotropin
   Onset       (%)       [micro]IU/mL

    46       9 (0-5)   4.89 (0.27-4.20)
    68       NA        NA

ESR = Erythrocyte sedimentation rate

WBC = white blood cell count

NA = not available.

Values in parentheses are normal ranges.

References

(1.) Hoffman HJ: Childhood and adolescent lumbar pain: differential diagnosis and management. Clin Neurosurg 1980; 27:553-576

(2.) Kurth AA, Rau S, Wang C, et al: Treatment of lumbar disc herniation in the second decade of life. Eur Spine J 1996; 5:220-224

(3.) Zamani MH, MacEwen GD: Herniation of the lumbar disc in children and adolescents. J Pediatr Orthop 1982; 2:528-533

(4.) Saal JA, Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy an outcome study. Spine 1989; 14:431-436

RELATED ARTICLE: KEY POINTS

* Herniated nucleus pulposus (HNP) of lumbar intervertebral disk with radiculopathy is uncommon in adolescents.

* Successful nonsurgical treatment for adolescents is not well documented in the literature.

* An aggressive nonsurgical regimen for HNP is a viable first treatment method.

* For some adolescents, HNP can be treated successfully without surgery.

From Internal Medicine Ltd and Martha Jefferson Hospital, Charlottesville, Va.

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