Spine or the spinal column is the central supporting structure of the human trunk. It consists of a series of short, stout bones called vertebrae arranged in a linear fashion. There are 33 vertebrae in humans. Between each vertebra there is an inter-vertebral disc which acts as a shock absorber of the spine. Even though there are 33 vertebrae, there are only 23 discs as the last 8-9 vertebrae are normally joined together as a single block.
The important functions of the spine are the following:
- Protection of spinal cord and nerves which pass through the vertebrae from brain downwards.
- Helping maintain correct posture.
- Facilitating movements of the body in multiple planes.
Spinal health is central to the maintenance of normal musculoskeletal and neurological functioning of our body. Diseases and malfunctioning of spine can tremendously hamper the normal day-to-day functioning and cause significant pain, disability, loss of productivity and in severe cases, result in weakness and total paralysis of limbs and trunk.
We should exercise extreme diligence and caution when it comes to issues related to spinal health as early detection and treatment is very vital to preventing irreversible damage to spinal segments and its neural structures.
It is worthwhile remembering that damage to a single spinal segment can affect the normal functioning of the entire spine. This is in accordance with one of the basic laws of science that “any physical construct or structure is only as strong as its weakest link”.
We shall now look into a few important issues pertaining to the spine in children.
In each age group, the spine is predisposed to a specific set of disorders.
In the paediatric age group (age less than 15), the main issues encountered are musculoskeletal strains, break in the bony linkage between vertebrae (called SPONDYLOLYSIS) and spinal deformities.
The immature spine is peculiar in that it is made up of a large amount of cartilage. Cartilage in spine is precursor of the bone, and is much more soft and pliable than the mature bone. It cannot withstand the kind of load the adult bone does and is more deformable. Further, the ligaments in a child’s spine is much more stretchable than in adults.
We should remember the age-old saying in medicine that “child is no miniature man”. That a 60kg adult can safely lift 50kg weight doesn’t mean a 30kg child can lift 25kg. It doesn’t work out like that.
This is especially important in the context of carrying school bags. School bags are considered primary culprits in the causation of many a spinal ailment in kids. These are lumbosacral strains, sacroiliac strains, dorsal strains, chronic pain syndromes and precipitating cause of other underlying or pre-existent spinal lesions like spondylolysis.
There are many guidelines across the world in connection with the weight of school bags. One common suggestion is that boys carry no more than 15% of their weight and girls 10% as school bags. These recommendations are not strictly implemented in many schools in our country. It is extremely important that parents, teachers, school management and other authorities are enlightened regarding the serious health consequences that can arise as a result of carrying heavy school bags.
The HRD ministry in India very recently gave the following strict instructions to all the States to make sure that their kids do not carry more weight to school. Their recommendations of maximum weight are:
Class I - II -- 1.5kg
Class III - V -- 2 - 3kg
Class VI - VII -- 4kg
Class VIII - IX -- 4.5kg
Class X -- 5kg
According to this order, the students should not be asked to bring additional books, extra materials and the weight of a school bag should not exceed the above limits.
We might have heard about spondylosis which refers to age-related degenerative changes causing spinal pain. While spondylosis is a disease of old age, spondylolysis is a paediatric spinal disorder where the bony hook connecting 2 adjacent vertebrae to each other is disrupted. This is the single most important and commonest identifiable cause of persistent back pain in children. It affects children in adolescent age group.
If an adolescent complains of back pain persisting for more than 4 weeks, he/she has to be investigated for spondylolysis. The investigations include dynamic X-rays and a CT scan. If it confirms a break in the bony hook then a nuclear medicine test called SPECT scan need to be carried out. This is to assess the healing potential of the defect.
If SPECT reveals hot spot, which means that the cells are active and auto repair can be expected, then the child is given a spinal brace to be worn for 6 months. The child is strictly instructed to avoid all heavy activities and sports for a 6-month period. However, routine daily activities and schooling can be continued.
However, if SPECT reveals a cold spot, which means that self-repair of the defect is not possible, then a surgical intervention may need to be contemplated for the child.
Deformities are another important group of spinal disorders in children. They are fortunately rare. Nevertheless, it is important to detect the problems as early as possible so that treatment could be simple and straight forward. If they are detected late, the treatment becomes more complex and risky.
The author has carried out a school survey to determine the incidence of scoliosis in 2006 - 08 in school children of central Kerala where 0.5 per cent of school children in classes 5 - 9 were seen to be affected by scoliosis.
Paediatric spinal deformities can be categorised into 3:
- Scoliosis -- Sideways bending deformity of spine.
- Kyphosis -- Forward stooping deformity of spine.
- Kyphoscoliosis -- A combination of both scoliosis and kyphosis.
Scoliosis is by far the commonest paediatric spinal deformity. Sideway tilting of a few degrees is common and is of no cause for worry. But any sideways bending of more than 10 degrees is classified as scoliosis. Scoliosis is much more prevalent in girls than boys. It most commonly occurs in the age group of 9 - 15 years.
It is very easy to miss the deformities of the spine of the Indian girl child in the initial stages as the body remains more covered under the conventional dressing style, in comparison to those in the western world. Apart from the spinal deformity, they also tend to have asymmetry of the trunk, the shoulder, shoulder blade and the breast.
One very easy method of early detection of scoliosis is to ask the child to bend forward and observe her from the back when one of the shoulder blades will be seen elevated in relation to the other. This is called the Adam’s forward bending test and is extensively used as a screening test to identify scoliosis.
Once a scoliosis deformity is detected, the treatment depends upon a number of factors. The most important factor is the severity (or the magnitude) of the deformity which is expressed in degrees.
The following guidelines could be followed after detection of the deformity:
- Curve 0 - 20 degrees -- observation and follow up with 6 monthly X-rays.
- Curve 20 - 45 degrees -- brace treatments could be beneficial.
- Curve more than 45 degrees -- surgical correction.
However, if deformity occupies the lower portion of spine (lumbar region), surgery is indicated even if the curve is 30 degrees, because here, an uncorrected spine could lead to severe degenerative changes in adulthood, the treatment of which could be much more complicated.