<%server.execute "isdev.asp"%> Adolescent prolapsed lumbar intervertebral disc: Management strategies and outcome Sarma P, Thirupathi RT, Srinivas D, Somanna S - J Pediatr Neurosci
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Year : 2016  |  Volume : 11  |  Issue : 1  |  Page : 20-24

Adolescent prolapsed lumbar intervertebral disc: Management strategies and outcome

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Web Publication27-Apr-2016

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DOI: 10.4103/1817-1745.181259

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Objective: Lumbar intervertebral disc herniation (LIVDH) is rare in children and adolescents when compared to adults. In literature, children generally constitute around 0.5–3% of surgically treated LIVDH. Though much rarer, they are less likely to respond to conservative treatment than adults. In this study, we analyze our experience in the management of adolescent LIVDH (ALIVDH) (age group 12–18 years) including the demographic, clinico-radiological features; surgical management strategies and outcome. Materials and Methods: This retrospective analysis constituted all patients between 12 and 18 years, who underwent surgery for LIVDH at our institute over a period of 15 years from January 1999 to June 2014. The records of these patients were retrieved, and demographic features, clinical picture, radiological features, operative findings, and postoperative events were evaluated. Follow-up data were obtained either through direct clinical evaluation or mailed self-report questionnaire and telephone conversations. The long-term outcome was analyzed by using standardized and condition specific outcome scales in addition to routine clinical follow-up evaluation. The long-term outcome was analyzed by using the short form-36 (SF-36).Results: There were a total of 32 patients (26 males, eight females) with an average age of 15.64 years. Trauma was a significant etiological factor 57.14% (n = 16/28). Vertebral anomalies were present in 35.7% (n = 10/28) cases. Majority had a neurological deficit at presentation (n = 20/28). The most commonly involved level was the L4–L5 level (n = 18/128) in this series. Multiple level disc degeneration was present in eight patients (28.6%). Immediate postoperative relief was achieved in all but one patient. At long-term follow-up twenty patients were pain-free (71.4%). At follow-up, the physical functioning scale of SF-36 was significantly lower in patients with gross motor deficit prior to surgery. Conclusions: Early diagnosis and adequate management contribute to a good outcome. In our study, trauma and presence of preexisting vertebral anomalies were significant factors in the etiogenesis of ALIVDH.

Keywords: Adolescent, child, discectomy, intervertebral disc, lumbar disc herniation, outcome of surgery

How to cite this article:
Sarma P, Thirupathi RT, Srinivas D, Somanna S. Adolescent prolapsed lumbar intervertebral disc: Management strategies and outcome. J Pediatr Neurosci 2016;11:20-4

How to cite this URL:
Sarma P, Thirupathi RT, Srinivas D, Somanna S. Adolescent prolapsed lumbar intervertebral disc: Management strategies and outcome. J Pediatr Neurosci [serial online] 2016 [cited 2022 Jul 5];11:20-4. Available from: https://www.pediatricneurosciences.com/text.asp?2016/11/1/20/181259

   Introduction Top

Lumbar disc herniation (LDH) is one of the most common vertebral column diseases of elderly people leading to back pain, radicular pain, and subsequently neurological deficit due to nerve root compression.[1] Intervertebral disc herniation is a rare condition in children and adolescents. In published literature, children generally constitute only 0.5–3% of all patients of surgically treated LDH.[2] Though, there are quite a few series on surgical management of pediatric lumbar disc, a closer examination reveals that the reviewed series were heterogeneous and the number of true pediatric patients (<18 years) was generally small. Moreover, the length of follow-up varied greatly. Evidently, it is still not possible to draw very decisive conclusions regarding the long-term prognosis of surgical treatment in children. Our study is an attempt to study the long-term results of surgery in adolescent lumbar intervertebral disc herniation (LIVDH) and compare these with available literature.

   Materials and Methods Top

This retrospective examination was performed on all adolescent patients (12–18 years) who underwent surgery for LIVDH at our tertiary care center, one of the busiest in South Asia, from January 1999 to June 2014. Patients having a diagnosis other than lumbar disc disease viz., spondylolisthesis, congenital malformation, infection of spine, inflammation, and neoplastic pathology were excluded. The records of these patients were retrieved, and demographic features, clinical picture, radiological features, operative findings, and postoperative events were evaluated. Follow-up data were obtained, either through direct clinical evaluation or mailed self-report questionnaire and telephone conversations. The long-term outcome was analyzed by using standardized and condition specific outcome scales in addition to routine clinical follow-up evaluation. The short form-36 (SF-36) was selected for use as a general measure of health and quality of life. This 36-question survey measures eight health scales: Physical functioning, social functioning, role limitations due to physical problems, role limitations due to emotional problems, mental health, vitality, bodily pain, and general health. In each of these scales, the scores range from 0 to 100, with higher numbers reflecting greater health.

   Results Top

Patient characteristics

Of a total of 3107 patients, who underwent surgery for LIVDH during the study period, there were a total number of 32 adolescent patients (1.03%). Among them, there were 26 males and six females. The age of patients ranged from 14 years and 2 months to 17 years and 8 months (mean 15.64 years). Four patients were excluded from analysis due to nonavailability of follow-up. Pain was the predominant presenting complaint in all patients in our series; radicular type alone was seen in 26 patients, while 22 patients had both radicular and local back pain. The back pain duration ranged from 7 days to 180 days (mean 77.3 days). Sixteen (57.14%) patients at the time of presentation had a motor deficit, ten had mild weakness while six presented with foot drop. The duration of weakness in these ranged from 3 days to 30 days (Mean 9.46 days). Twenty (71.4%) patients had sensory disturbance at presentation, 14 had hypoesthesia, and six had paresthesia. Only two patients had bladder disturbance at presentation both were catheterized outside before referral to our institute. The clinical presentation is summarized in [Figure 1] and [Figure 2].
Figure 1: Dermatome wise distribution of radicular pain

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Figure 2: Incidence of presenting complaints

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There was a positive history of trauma in 16 out of the 28 patients (57.14%). Sixteen out of the 28 patients had undergone a trial of conservative line of management for at least 6 weeks without relief of pain. Four patients had received epidural steroid injection without much relief of symptoms, prior to referral to our center. Twelve patients were operated on an emergency and semi-emergency basis due to the presence of significant neurological deficit. None of the patients had any comorbid conditions.


All the patients underwent plain X-ray (anterior-posterior and lateral view) and magnetic resonance imaging prior to surgery. Ten patients had scoliosis while 16 had straightening of lumbar spine (loss of lordosis). Disc space reduction at the concerned level was present in only two patients. Structural anomalies were seen in ten cases (35.7%) of patients. Sacralization of the L5 vertebra was present in six patients, two patients had spina bifida at L5 level, and two patients had grade one L5–S1 listhesis with pars defect. Disc degeneration characterized by T2 signal loss (hypointensity) was seen at the prolapsed disc level in eight patients, multiple level disc desiccation was seen in eight patients, and there was no T2 signal change in 12 patients even at the prolapsed level.

Disc prolapse was at a single level in 22 patients and in six patients there was a two level consecutive disc prolapse. The level of the disc prolapse is detailed in [Table 1]. Four patients had extruded discs, while two patients had a migrated disc. The disc was of a central type in 18 patients and paracentral in four patients. Posterior longitudinal ligament was intact in twenty patients and breached in eight patients. Intervertebral foramen compromise was seen in all patients. About 18 patients had a disc prolapse at L4–L5 level, six patients had at L3–L4 level, and four patients at L5–S1 level. Of the six patients who had two level disc prolapse, the level with significant prolapse and that corresponding to clinical findings were operated. The disc prolapse at the consecutive level was insignificant in all six cases.
Table 1: Level wise incidence of prolapsed disc

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Treatment details

All patients underwent posterior discectomy at one level. Laminectomy was performed in 12 patients, fenestration was in 14 patients, and hemilaminectomy in two patients. Ligamentum flavum was found to be hypertrophied in six patients. None of the patients had osteophytes. During surgery the prolapsed disc material was soft and degenerated in ten patients, calcified in four and in the rest was of normal nondegenerated texture. There was no intraoperative complication such as dural tear, root injury, or difficulty in identifying the disc. Two patients had postoperative wound infection which responded to antibiotics and dressing. There were no other complications.

Immediate postoperative pain relief

All patients were asked to grade their pain on a visual analog scale. The grade of pain before surgery and immediately after surgery (after 48 h) was obtained from the patient. The mean score of the patients in the preoperative period was 8, with a range from 7 to 10 [Table 2]. Postoperative period pain relief was taken as complete if the pain score was 0, 1, to 2 was taken as significant relief of pain and 3–4 as moderate relief of pain. Two patients had complete relief of pain, 24 patients had significant relief, and two patients had moderate relief [Table 3].
Table 2: Visual analog score of patients in preoperative period

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Table 3: Postoperative pain relief at the time of discharge

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Follow-up data were obtained, either through direct clinical evaluation or mailed self-report questionnaire and telephone conversations. The follow-up duration ranged from 6 months to 70 months, with a mean follow-up of 26.86 months. None of the patients in this study underwent any further surgery or injection for back pain or other spinal problems. Of the twenty patients with a motor deficit, all of them reported improvement in their power except two patients who had a significant weakness (L5 root) at the time of surgery. When the follow-up data for the sensory disturbance was examined, it revealed that 16 out of the twenty patients had improvement in the sensory disturbance. Two patients who presented with hyperesthesia at 40 months follow-up had hypoesthesia in the same dermatome. The two patients in the study who had involvement of bladder and motor weakness showed good improvement in motor power at 12 months follow-up, but bladder incontinence had not improved. Both were on clean intermittent self-catheterization at the time of follow-up. Back pain or discomfort was graded using the same visual analog scale at last follow-up [Table 4]. All patients in the study were independent of all activities at the time of follow-up, the only exception were the patients with bladder involvement as they had significant impairment of quality of life due to incontinence.
Table 4: Visual analog score at last follow-up

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The short form-36 health survey score

The physical functioning scale of SF-36 score in the patients during follow-up ranged from 55 to 90. The least score was obtained in two patients who had presented with bilateral foot drop with disc prolapse at L3–4 level. The best score was in the patients who had no deficit preoperatively. The mean score of all the patients in the study was 78.56. The three lowest scores were found in patients who had a gross motor deficit before surgery. The mean score of patients who had presented with the significant motor deficit was 62.33. The mean score of patients who had no motor deficit or mild deficit before surgery was 83. The difference between the two groups was statically significant (P < 0.05).

   Discussion Top


LIVDH is a common disorder among adults, with reported lifetime occurrence as high as 40%. However, in published literature, children generally constitute only 0.5–3% of all patients surgically treated for LDH.[2] In our series, the incidence was 1.03%. The real incidence of adolescent disc herniation is difficult to establish, one reason being that published series adopted different age ranges. Many factors have been cited as the potential causes for pediatric LDH. Trauma (mostly sport-related or self-reported injury, i.e., heavy lifting, extreme flexion-extension, fall, etc.,) is commonly considered as the most likely cause because as many as 30–60% of children and adolescents with symptomatic LDH have a history of trauma before the onset of pain.[3] In our series, trauma preceded the symptoms in 57.14% of cases. This is in contrast to adult patients who usually do not have any predisposing trauma before the onset of symptoms.

However, more recent studies suggest that instead of being a primary contributory factor, trauma is likely to be an inciting event in the exacerbation of the preexisting lesion in the discs, for example, microdamage, degenerative changes, etc.[4] Though genetic predisposition is generally recognized as studies have shown that between 13% and 57% of adolescents with LDH have a first-degree relative with the same disorder, in our series we did not find any such association. Vertebral anomalies such as scoliosis and transitional vertebra (lumbarization and sacralization) are known to be associated with LDH in children and adolescents, and our study found about 28.6% patients having scoliosis even though their influence has not been quantified in other studies.[5]

Clinical characteristics

Clinical presentations of pediatric LDH are generally similar to those seen in adults.[4] One distinctive feature is that up to 90% of patients have a positive straight leg raising test (SLRT), a finding which was similar with our study (SLRT present in 92.7% and crossed SLRT in 7.1%). This can be explained by the finding that children and adolescents tend to have a greater nerve root tension than adults. However, children and adolescents are less often seen with neurological symptoms such as numbness and weakness [6] which was in contrast to our series in which only 16 cases had a gross motor weakness.

Management strategies

Conservative treatment: At the onset or acute phase of the disease, 1–2 weeks bed rest can be recommended for patients with severe pain [7] followed by the use of a brace for a few weeks afterward. Nonsteroidal anti-inflammatory drugs are always prescribed as an adjunct therapy to bed rest. There were also reports of successful results from the use of epidural steroid injections as a part of conservative treatments for pediatric LDH.[8] A search of the literature indicates that the short- to long-term success rate of conservative treatment for pediatric LDH without neurological deficits varied from 25% to 50%. Regardless of the controversy between conservative and surgical options, it has been widely agreed by most authors that conservative treatment is not as effective for pediatric LDH as it is for adults.[1],[6] There may be several explanations for the disappointing result of conservative treatment: (1) The herniated nucleus pulposus of children, as compared with adults, is less degenerated, more hydrated, soft, and viscous,[1] it does not dry up and resorb like a degenerated adult disc might, (2) pediatric LDH is often associated with trauma where the annulus fibrosus could be severely ruptured, (3) the epiphyseal cartilage of the vertebral body in children and adolescents is not fully fused; hence, severe trauma could rupture the epiphyseal ring forming a large implastic mass along with the herniated disc, and (4) children and adolescents are active and less likely to comply to strict bed rest. Nevertheless, conservative treatment is still generally recommended as the first-line treatment for LDH in children and adolescents without neurological deficits.[6],[8] This may be due to the concern that a growing spine is vulnerable to surgical trauma, and iatrogenic deformities can develop after surgical intervention in children and adolescents.[9] In our series, we have operated the cases which did not improve with conservative management except those operated as emergency or semi-emergency setting.

Surgical treatment


Indications for surgical intervention on pediatric LDH appear to be generally agreed upon in the literature. These include: (1) Severe pain refractory to 4–6 weeks of conservative treatment, (2) disabling pain affecting one's daily activities, (3) cauda equina syndrome, (4) progressive neurological deficits, and (5) associating spinal deformities.[8] Like adults, modalities of surgical treatment for pediatric LDH consist of percutaneous endoscopic discectomy (also known as microendoscopic discectomy) and open discectomy including microsurgical discectomy or microdiscectomy, discectomy with laminotomy or laminectomy and spinal fusion. The outcomes in various series are outlined in [Table 5].
Table 5: Long-term outcome of discectomy as reported in the literature

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Postoperative complications

Early postoperative complications found in pediatric patients include wound hematoma (1–4%) and delayed wound healing (3%). Postoperative infection, for example, wound infection and discitis secondary to lumbar spine surgery are rare in children and adolescents with only a few cases being reported in the literature.[2],[4],[10],[11] Although there have been reports of narrowing of disc space, foraminal stenosis, and adjacent disc degeneration from few months to several years after discectomy, the clinical outcome was not affected accordingly.[2] It was also found that multiple level laminectomy, particularly at thoracolumbar region and damage to the facet joints could result in spinal instability and deformity. None of the patients in our series had an intraoperative complication such as dural tear, root injury, or difficulty in identifying the disc. Two patients had postoperative wound infection which responded to antibiotics and dressing. None of the patients had a cerebrospinal fluid leak or needed redo surgery.

   Conclusions Top

Pediatric LDH is a rare entity leading to hospitalization of approximately 0.1–0.2% of children and adolescents. Diagnosis of pediatric LDH is, by and large, similar to that of adults. Conservative treatment is less effective for pediatric patients as compared with adults, even though it remains the first-line treatment for pediatric LDH. Surgical treatment for pediatric LDH is associated with the excellent short-term outcome regardless of which modality is chosen. Although the outcome begins to deteriorate in the mid-term follow-up, it remains good in the long run. Surgical treatment of lumbar disc disease in children does not appear to have a negative impact on overall health and well-being except in patients with significant deficits prior to surgery.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Kumar R, Kumar V, Das NK, Behari S, Mahapatra AK. Adolescent lumbar disc disease: Findings and outcome. Childs Nerv Syst 2007;23:1295-9.  Back to cited text no. 1
Luukkonen M, Partanen K, Vapalahti M. Lumbar disc herniations in children: A long-term clinical and magnetic resonance imaging follow-up study. Br J Neurosurg 1997;11:280-5.  Back to cited text no. 2
Durham SR, Sun PP, Sutton LN. Surgically treated lumbar disc disease in the pediatric population: An outcome study. J Neurosurg 2000;92 1 Suppl: 1-6.  Back to cited text no. 3
Parisini P, Di Silvestre M, Greggi T, Miglietta A, Paderni S. Lumbar disc excision in children and adolescents. Spine (Phila Pa 1976) 2001;26:1997-2000.  Back to cited text no. 4
Smorgick Y, Floman Y, Millgram MA, Anekstein Y, Pekarsky I, Mirovsky Y. Mid- to long-term outcome of disc excision in adolescent disc herniation. Spine J 2006;6:380-4.  Back to cited text no. 5
Ozgen S, Konya D, Toktas OZ, Dagcinar A, Ozek MM. Lumbar disc herniation in adolescence. Pediatr Neurosurg 2007;43:77-81.  Back to cited text no. 6
Ippolito E, Versari P, Lezzerini S. The role of rehabilitation in juvenile low back disorders. Pediatr Rehabil 2006;9:174-84.  Back to cited text no. 7
Slotkin JR, Mislow JM, Day AL, Proctor MR. Pediatric disk disease. Neurosurg Clin N Am 2007;18:659-67.  Back to cited text no. 8
Revuelta R, De Juambelz PP, Fernandez B, Flores JA. Lumbar disc herniation in a 27-month-old child. Case report. J Neurosurg 2000;92 1 Suppl: 98-100.  Back to cited text no. 9
Lee DY, Ahn Y, Lee SH. Percutaneous endoscopic lumbar discectomy for adolescent lumbar disc herniation: Surgical outcomes in 46 consecutive patients. Mt Sinai J Med 2006;73:864-70.  Back to cited text no. 10
Papagelopoulos PJ, Shaughnessy WJ, Ebersold MJ, Bianco AJ Jr., Quast LM. Long-term outcome of lumbar discectomy in children and adolescents sixteen years of age or younger. J Bone Joint Surg Am 1998;80:689-98.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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