Trauma and overuse
In cases of a traumatic fracture, dislocation, or ligamentous tear, a history of a traumatic injury is not always apparent when the patient is unconscious, demented, psychotic, under the influence of alcohol or drugs, or a nonverbal child.3 On the contrary, a history of injury does not necessarily mean that the pain has a traumatic etiology, and it may be a ”red herring” that distracts from the real cause. Strains and sprains of the spine are defined as low-energy injury, overuse, or stretching of muscles or tendons and ligaments.19 Whiplash injury is well described and can lead to neck and back pain.20 A “clay shoveler’s fracture” is an avulsion injury of the spinous processes of the cervical-thoracic junction that can appear after injury or overuse.21 SCIWORA (spinal cord injury without radiographic abnormality) is a syndrome of traumatic injury/myelopathy without radiological findings that was described in the 1970s’,22 was revealed as being a contusion of the spinal cord by magnetic resonance imaging (MRI) scanning. Central cord syndrome is defined by muscle weakness that is greater in the upper extremities, as well as by urinary retention and various sensory abnormalities.23 It is caused by hyperextension of the neck that compresses the spinal cord, and can appear without predeceasing spondylosis and narrowing of the spinal canal.23 Pathological fractures due to osteoporosis, infection, or a tumor can appear without injury or after only a minor trauma.6 Stress fractures of the pars-interarticularis (spondylolysis) are typical to adolescents that are physically active, they appear more often in volleyball players and weightlifters, and the pain is typically ”mechanical”24. Stress fractures of the sacrum appear in osteoporotic patients and may be responsible for low back pain.25 Apophysitis of the vertebrae (Scheuermann’s disease/osteochondrosis) will appear in the thoracic spine (75%) or in the lumbar spine in adolescents without apparent history of overuse. Only 20-60% will have pain, and the rest will develop a painless kyphotic deformity.24 Neurological abnormalities are rare. Brown-Sequard syndrome is caused by injury to a hemicord that can be traumatic or due to a tumor: ipsilateral paralysis with loss of proprioception will typically be observed, with contralateral loss of pain and temperature sensation.26