Back Pain 

Case

A 12 year old female comes to the office complaining of lower back pain of 4 days duration. She participates in gymnastics 3 times a week at the club level. She denies any trauma. How should you precede to evaluate this young woman?
Complaints of back pain are not common reasons for visits to the pediatrician's office and compared to adults, children will usually have a cause identified. 

History

  1. Duration of the pain, frequency, location, nature, association with activity,  what makes it better, and radiation.
  2. What does the patient do when they have the pain and must they stop their activities?
  3. Was there any trauma?
  4. What type of activities is the child involved in?
  5. Family and social history
  6. Indications to do a more rapid and extensive workup
    1. Fever, weight loss, and feeling sick
    2. Persistent pain
    3. Radicular pain and neurologic changes-tingling, weakness gait changes
    4. Bladder and bowel habit changes
    5. Night pain
Physical Findings
  1. Palpate along the spine and bony tissues of the back
  2. Have the patient bend over to inspect the spine and do rotation activities to attempt to reproduce the pain
  3. Check DTR's, strength, sensation, Babinski reflex, hamstring tightness
  4. Observe gait
  5. Abdominal exam and check for CVA tenderness
  6. Skin examination for cafe au lait spots, hairy patches around the spine, bruising and petechiae
  7. Evidence of trauma
  8. Presence of scoliosis, kyposis, and lordosis
Differential Diagnosis
  1. Discitis of Childhood- have a narrow disc space. May have fever and child will often refuse to stand and walk. May be bacterial etiology and blood culture may reveal organism. ESR may be elevated and few systemic symptoms. Usually treat for Staphyloccocus aureus. If doesn't respond to IV antibiotics, consider needle aspiration. Diagnosis aided by bone scan and MRI.

  3. Disc Herniation- uncommon in childhood. Pain worse with leg raising because associated with tight hamstrings.

  5. Spondylolysis- Defect of the pars interarticularis. May have fracture. Seen frequently in gymnasts, weight lifters, hockey players, and football linemen. 

    6. Spondylolithesis- Slippage of vertebrae anteriorly. Significant cause of back pain in adolescents. Increased with hyperextension activities such as gynastics, ballet, skating.
    Treatment- symptomatic and modification of activites. Bracing hasalso been successful. Surgery rarely indicated.

  6. Tumors
    1. Malignant- neuroblastoma, lymphoma, leukemia
    2. Metastatic- neuroblastoma, rhabdomyosarcoma, Wilm's, retinoblastoma, teratomas
    3. Benign- osteomas, osteoblastomas
    4. Nocturnal pain and rapid increase in pain. 
  7. Pyogenic and tuberculosis osteomyelitis
  8. Pyelonephritis
    9. <> Retrocecal appendix
    Pancreatitis
  9. Scoliosis- presence of pain doesn't necessarily indicate underlying pathology.
  10. Scheurmann's disease-Kyphosis
  11. JRA
  12. Ankylosing spondylitis
  13. Conversion reaction

    14. If a child presents with persistent back pain that is not relieved by rest, decrease in activities, and simple analgesics and anti-inflammatory drugs, referral to an orthopedic surgeon should be considered. If there are associated constitutional symptoms, referral should not be delayed. 
References
  1. King HA. Back Pain in Children. Orthopedic Clinics of North America. 1999; 30(3):467-474.
  2. Payne,W. and Oglivie, J. Back Pain in Children and Adolescents. Pediatric Clinics of North America August 1996.
  3. Fernandez,Marisol, Carroll,Clark, and Baker, Carol  Discitis and Vertebral Osteomyelitis in Children: An 18 Year Review.  Pediatrics Vol 105 No. 6 June 2000
  4. DeWolfe Craig. Back Pain.  Pediatrics in Review Vol 23 No.6 June 2002
  5. Kronberg J. and Small E. Tackling back pain in a young athlete.  Contemporary Pediatrics November 2005