Acute Backache Secondary to a Congenital Anomaly in a Young Man

Spina bifida, a neural tube defect characterized by failure of fusion of vertebral bodies, is seen in 1 per 1000 pregnancies [1]. The commonest and the least severe form is spina bifida occulta (SBO), characterized by an intact overlying skin and has an incidence of up to 20% [2]. Commonly, this type is found incidentally on X-rays performed for other purposes.

A 30-year-old soldier presented with one week history of low backache starting after unaccustomed physical exertion. The pain did not radiate down the legs and was not associated with any weakness or sensory symptoms in the legs. Physical examination revealed normal vital signs. There was mild tenderness over the lower back but no neurological deficit in the legs. X-ray of the lumbosacral spine revealed fusion defects in bodies of all lumbar vertebrae and the last thoracic vertebra (Figure 1), and reduced joint space between third and fourth lumbar vertebrae. The latter was confirmed on lateral view, which also showed straightening of lumbar spine. The patient was managed with acetaminophen, oral tizanidine, topical NSAIDs and bed rest. He responded well to treatment and declined further assessment with MRI scan.

Common causes of reduced disk space in lumbar spine include prolapsed or herniated intervertebral discs, disc degeneration, and to a lesser extent, arthritides especially ankylosing spondylitis. Backache resulting from disc prolapse is due to compression of adjacent nerve roots. Mechanisms for pain in disc degeneration are much more complex, with emphasis being laid on inflammation and abnormal micromotion instability. Treatment for both of these problems is largely supportive, consisting of analgesics, patient education, exercise and physical modalities including the use of ice packs/heat and electrical stimulation. Surgical treatments, such as decompression and spinal fusion, are used in a very small percentage of patients.

The aim of presenting this image is twofold. Firstly, it is important to remember that spina bifida occulta is usually asymptomatic and almost never has any consequences [3, 4]. Therefore, back problems, particularly backache, should not be attributed to spina bifida occulta. Secondly, the detailed inspection of radiographs in clinical practice is very important. Recognition of a gross abnormality should not stop a keen observer from looking for other anomalies, especially when the first one does not sufficiently explain the clinical picture.

1. Short KR,Frimberger A review of the potential for cardiometabolic dysfunction in youth with spina bifida and the role for physical activity and structured exercise.Int J Pediatr 2012; 2012:541363.
2. Fidas A, MacDonald HL, Elton RA, Wild SR, Chisholm GD, Scott R. Prevalence and patterns of spina bifida occulta in 2707 normal adults. Clin Radiol 1987; 38: 537–542.
3. Iwamoto J, Abe H, Tsukimura Y, Wakano K. Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school rugby players: a prospective study. Scand J Med Sci Sports 2005; 15:163–168.
4. Foster MR. Spina Bifida Clinical Presentation [Internet]. New York (NY): WebMD LLC; 1994-2012 [updated 2011 Jun 7; cited 2012 Sep 27]. Available from: http://emedicine.medscape.com/article/311113-clinical#a0216