🦴 Section 720.8 · Intervertebral Disk Herniation & Slipped Vertebral Apophysis

Nelson Textbook of Pediatrics 22nd Edition | Disk herniation is rare in children/adolescents (3-5% of all discectomies). Presentation: back pain with radiculopathy (sciatica), positive straight leg raise. Slipped vertebral apophysis (posterior ring apophysis separation) — avulsion fracture of vertebral body apophysis, mimics disk herniation but has bony fragment on CT. MRI is best for disk herniation; CT for apophyseal fragment. Treatment: conservative first (rest, PT, NSAIDs). Surgery (microdiscectomy) for cauda equina syndrome, progressive neurologic deficit, or failure of conservative care (6-8 weeks). Adolescents have higher failure rate with conservative treatment than adults.

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📋 30 Clinical Scenarios — Disk Herniation & Slipped Apophysis

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🩺 Clinical Recognition: Disk Herniation / Apophyseal Injury

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📋 Stepwise Management of Disk Herniation & Slipped Apophysis

🔑 Key Principles — Nelson Section 720.8
• Epidemiology: Disk herniation rare in children (<5% of all discectomies). More common in adolescents (peak 15-17 years).
• Presentation: Back pain (90%), radicular pain (sciatica >30%), positive straight leg raise. Pain worse with flexion, coughing, Valsalva.
• Slipped vertebral apophysis: Avulsion of posterior ring apophysis (skeletally immature). Presents similarly to disk herniation; bony fragment on CT. Does not improve spontaneously.
• Imaging: MRI for disk herniation (soft tissue). CT for apophyseal fragment (bony).
• Treatment: Conservative first (rest, PT, NSAIDs) for 6-8 weeks. Surgery (microdiscectomy/laminotomy) for cauda equina, progressive deficit, or failure of conservative care.

    ⚡ Reflex Prompts — Clinical Decisions

    📖 Summary: Disk Herniation & Slipped Apophysis (Nelson 720.8)