Back Pain

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.  Back pain is a relatively uncommon chief complaint for trips to pediatric emergency departments, accounting for only 0.4 percent of visits in one study.  Persistent back pain requires attention from the pediatrician as one study demonstrated that 32 out of 61 children presenting to an orthopedist for persistent back pain had serious pathology.

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
    6. Age less than four years
    7. Nocturnal 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 - Pain caused by 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.
  2. Osteomyelitis – These children are more likely to have systemic systems such as fever and toxic appearance compared to discitis
  3. Epidural Abscess - Classically presents with fever, spinal pain, and neurologic deficitis.
  4. Muscular Pain – May be due to diverse causes such as a heavy backpack, overly soft mattress, improper soft mattress, and large breasts.
  5. Disc Herniation - uncommon in childhood. Pain worse with leg raising because associated with tight hamstrings.
  6. Spondylolysis - Defect of the pars interarticularis usually in the lower lumbar vertebrae. May have fracture. Seen frequently in gymnasts, weight lifters, hockey players, and football linemen.  Usually an acquired defect caused by excessive lumbar hyperextension or repeated flexion and extension. Presents with lumbosacral tenderness
  7. Spondylolithesis - Slippage of vertebrae anteriorly due to bilateral defects. Significant cause of back pain in adolescents. Increased with hyperextension activities such as gynastics, ballet, skating.  May present with a prominent palpable spinous process

  8. Scoliosis- presence of pain doesn't necessarily indicate underlying pathology but back pain is more common in children with scoliosis.

  9. Scheurmann's Kyphosis –Anterior wedging of more than five degrees in at least three adjacent vertebral bodies. Treatment is weith corrective exercises

  10. Tumors - Rare cause, may be characterized by nocturnal pain and a rapid increase in pain.  Causes include primary malignancies (neuroblastoma, lymphoma, leukemia), metastatic disease (neuroblastoma, rhabdomyosarcoma, Wilm's tumor, retinoblastoma, teratoma), benign tumors (osteoma, osteoblastoma), other sarcomas (Ewing sarcoma, osteosarcoma), or Langerhans Cell Histiocytosis.

  11. Disc calcification – Idiopathic disorder hypothesized to be secondary to a post inflammatory condition. This condition most often involves the cervical and/or thoracic discs.

  12. Pyogenic and tuberculosis osteomyelitis

  13. Pyelonephritis

  14. Sickle Cell disease

  15.  Retrocecal appendix

  16. Pancreatitis

  17. JRA

  18. Ankylosing spondylitis

  19. Conversion reaction

Treatment

Treatment is symptomatic with modification of activites. Bracing has also been successful. The need for surgery is rare.

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. Nigrovic P. Back Pain in Children and Adolescents: Overview of Causes. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2012.
  3. Payne,W. and Oglivie, J. Back Pain in Children and Adolescents. Pediatric Clinics of North America August 1996.
  4. Fernandez,Marisol, Carroll,Clark, and Baker, Carol  Discitis and Vertebral Osteomyelitis in Children: An 18 Year Review.  Pediatrics Vol 105 No. 6 June 2000
  5. DeWolfe Craig. Back Pain.  Pediatrics in Review Vol 23 No.6 June 2002
  6. Kronberg J. and Small E. Tackling back pain in a young athlete. Contemporary Pediatrics November 2005

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