Image Quiz
Low Back Pain in a Fourteen-Year-Old Boy1
A fourteen-year-old boy presented with a sixteen-month history of low-back pain that worsened with activity. He reported no history of trauma, weight loss, fevers, chills, sweats, or night pain. He had no neurological symptoms. Prior to presentation, he had undergone chiropractic treatments that had been ineffective for pain relief and he had been seen by twelve different physicians for evaluation of his complaints. The medical and surgical histories were unremarkable. The patient was taking no medications and had a negative family history for scoliosis and other vertebral deformities. The use of nonsteroidal anti-inflammatory medications had not resulted in substantial pain relief.
Physical examination revealed a left trunk shift and waist asymmetry. In addition, the iliac crest and shoulder on the right side were lower than those on the left side. The patient had hyperlordosis of the lumbar spine and markedly decreased forward and lateral bending as well as tender paraspinal muscles on the concave side of a right lumbar hump. He was only able to forward flex approximately 10° with the knees extended. Neurological examination revealed normal findings, including superficial abdominal reflexes and a negative straight-leg-raising test for both lower extremities. The popliteal angle (measured as the lack of full knee extension with the hips flexed to 90°) was 20° on the right side and 30° on the left.
Plain radiographs (Figs. 1-A and 1-B) were made, and a technetium bone scan (Fig. 2) and a computed tomography scan (Fig. 3) were acquired.
Fig. 1-A |
Fig. 1-B |
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Fig. 2 |
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Fig. 3 |
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