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 Table of Contents  
IMAGES IN RHEUMATOLOGY
Year : 2017  |  Volume : 12  |  Issue : 4  |  Page : 226-227

Bilateral L4 pedicle stress fracture: An unusual cause of low back pain in an adolescent


1 Department of Radiodiagnosis, Meenakshi Medical College Hospital and Research Institute, Kanchipuram, Tamil Nadu, India
2 Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India

Date of Web Publication16-Nov-2017

Correspondence Address:
Venkatraman Indiran
Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, 7 Works Road, Chromepet, Chennai - 600 044, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_85_17

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  Abstract 


Keywords: Adolescent, fracture, stress


How to cite this article:
Sivakumar V, Indiran V. Bilateral L4 pedicle stress fracture: An unusual cause of low back pain in an adolescent. Indian J Rheumatol 2017;12:226-7

How to cite this URL:
Sivakumar V, Indiran V. Bilateral L4 pedicle stress fracture: An unusual cause of low back pain in an adolescent. Indian J Rheumatol [serial online] 2017 [cited 2019 Oct 22];12:226-7. Available from: http://www.indianjrheumatol.com/text.asp?2017/12/4/226/213796



A 17-year-old female athlete presented with back pain for 2 months, which was aggravated by running. The pain was insidious in onset. She first noticed back pain following running activity. She did not have radiating pain or lower limb numbness. There was no fever. There was no significant medical history. On examination, there was mild tenderness in the lower back overlying L4–S1 vertebrae in the midline. There was no muscle spasm. Overlying skin was normal. Magnetic resonance imaging (MRI) was performed to rule out any structural pathology in the vertebrae, intervertebral discs, or sacroiliac joints, in view of subacute pain. MRI revealed lysis involving the bilateral pedicles of L4 vertebra with associated marrow edema [Figure 1]a. There was no abnormality of the vertebral bodies or the posterior elements at other levels. Axial computed tomography (CT) section showed undisplaced fractures in the bilateral pedicles of L4 vertebra [Figure 1]b. Basic blood workup and rheumatological profile were normal. She was advised to stop athletic activity for 6 weeks along with modification of daily activities. She reported a significant resolution of her symptoms at 6 weeks' follow-up.
Figure 1: (a) Sagittal T2-weighted magnetic resonance imaging showing undisplaced fracture line in the right and left pedicles with adjacent marrow edema (arrows). (b) Axial computed tomography section showing undisplaced fracture line in the right and left pedicles (arrows)

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Injuries of the neural arch in the lumbar spine, a common cause of back pain in the adolescents, can be missed on radiographs initially. These injuries are not as common in adults as in the adolescents.[1] Pedicle is the second common site of neural arch injury following pars interarticularis.[2] Although pedicle stress injuries are commonly seen along with unilateral spondylolysis, they may also occur without associated spondylolysis in some young athletes and ballet dancers.[3] Incomplete neural arch ossification and higher elasticity of the intervertebral disc are responsible for higher incidence in adolescents. L5 vertebra is the most commonly affected level, followed by L4 vertebra. MRI is the best modality to assess the low back pain in adolescents as it can exquisitely show marrow edema even before CT identifies a fracture.[4] Conservative treatment is usually adequate for stress injuries or incomplete fractures of neural arch. Bracing may be needed if there is a complete fracture. If untreated, stress injuries or incomplete fractures can lead to complete fractures, nonunion, spondylolisthesis, and degenerative disease.[5],[6] Hence, early detection and treatment of acute neural arch injuries are essential. It is pivotal for the rheumatologists to keep this entity in their list of differential diagnoses for low backache in the adolescent age group and refer them for MRI early as plain radiography may not be helpful early in the disease course.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Garry JP, McShane J. Lumbar spondylolysis in adolescent athletes. J Fam Pract 1998;47:145-9.  Back to cited text no. 1
    
2.
Amari R, Sakai T, Katoh S, Sairyo K, Higashino K, Tachibana K, et al. Fresh stress fractures of lumbar pedicles in an adolescent male ballet dancer: Case report and literature review. Arch Orthop Trauma Surg 2009;129:397-401.  Back to cited text no. 2
    
3.
Parvataneni HK, Nicholas SJ, McCance SE. Bilateral pedicle stress fractures in a female athlete: Case report and review of the literature. Spine (Phila Pa 1976) 2004;29:E19-21.  Back to cited text no. 3
    
4.
Campbell RS, Grainger AJ, Hide IG, Papastefanou S, Greenough CG. Juvenile spondylolysis: A comparative analysis of CT, SPECT and MRI. Skeletal Radiol 2005;34:63-73.  Back to cited text no. 4
    
5.
Herman MJ, Pizzutillo PD, Cavalier R. Spondylolysis and spondylolisthesis in the child and adolescent athlete. Orthop Clin North Am 2003;34:461-7, vii.  Back to cited text no. 5
    
6.
Hajjioui A, Khazzani H, Sbihi S, Bahiri R, Benchekroune B, Hajjaj-Hassouni N. Spondylolisthesis on bilateral pedicle stress fracture in the lumbar spine: A case study. Ann Phys Rehabil Med 2011;54:53-8.  Back to cited text no. 6
    


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