Basic Evaluation Process for Back Pain in Children

While back pain is perhaps the most common pain complaint of adults, and all adults have had back pain at some time in their life, back pain is much rarer in children and adolescents. In this population, back pain may be the initial symptom of an underlying disease process. This is especially true in younger children (pre-teenagers) who are less likely to experience an overuse injury such as those that occur during strenuous exercise. The exact incidence of back pain in children is not known, however there is a gradual increase with age. Unlike adults, children are rarely if ever disabled by back pain, and in more than half of patients, a definable cause for the back pain can be found.

The cornerstone of evaluating the pediatric patient with back pain is a thorough history and physical exam, including a complete musculoskeletal and neurologic evaluation. Importance is placed on determining the nature of onset, as well as character, location, duration and radiation of symptoms. Note should be made of spinal posture (including any excessive or abnormal curves), range of motion (including any restriction), areas of tenderness, and muscle spasm. Assessment of gait, muscle strength, reflexes and sensation also are part of the initial physical. Special tests like straight leg raise and presence of pathologic reflexes like Babinski contribute more useful information.

More extensive investigation may be in order if pain does not improve within several weeks or if there are objective findings on exam, pain worsens or new symptoms develop. Because effective treatment begins with an accurate diagnosis of the condition, a prompt diagnosis may increase the likelihood of a successful outcome. Important warning signs have been identified that if found on history and physical exam should alert the clinician that there is a high probability for a serious cause of back pain. Further evaluation and potential significant underlying etiology are suggested with:

• persistent or increasing pain
  
• pain with associated fever, malaise or weight loss
  
• neurologic symptoms or exam findings
  
• bowel or bladder dysfunction
  
• symptom onset at young age (4 years or younger is suspicious for tumor)
  
• painful left thoracic scoliosis

Initial X-ray evaluation may typically include anterior-posterior and lateral views of the area involved. Oblique view X-rays often are useful to evaluate for spondylolysis. Further studies would be carried out if indicated by the previous evaluation. A CBC, sedimentation rate and urinalysis may be part of the original screening tests beyond the H&P and X-rays. An elevated CBC or sedimentation rate suggests the presence of an inflammatory or infectious process. Results of initial evaluation should be used to direct further imaging studies, which may include MRI, CT scan, tomogram or bone scan. The use of these studies is dictated by differential diagnosis.

Treatment of back pain in children is diagnosis-specific. Conservative treatment (activity modification, mild analgesics) is appropriate initially if there are no neurologic signs or symptoms (radicular pain, muscle weakness, gait abnormalities, sensory changes, bowel and bladder abnormalities). Regardless of the cause, some form of pain reliever may be required in most cases. Treatment may begin with simple analgesics like acetaminophen (Tylenol) and ibuprofen (Advil).

A targeted differential diagnosis can be generated by dividing children into two age groups: pre-pubertal and pubertal. In pre-pubertal children, the differential includes infection, in the form of diskitis or osteomyelitis, or tumor of the spinal column or spinal cord. In pubertal children, the differential includes tumor of the spinal column or spinal cord, spondylolysis or spondylolisthesis, herniated disk, lumbar strain from overuse or Scheuermann’s Disease. Specific symptom associations that are important to identify include fever and back pain (possible underlying infection, neoplasm, or inflammatory disease); neurological symptoms (may signify underlying disc herniation); excessive lordosis (possible spondylolysis or spondylolisthesis); and excessive kyphosis (possible Scheuermann’s disease).

Another useful classification is the separation of back pain and its causes into one of four categories: mechanical problems, developmental abnormalities, infectious/inflammatory conditions and neoplasm.

Mechanical problems include overuse injury, backpack syndrome, direct trauma and herniated discs.Mechanical problems are more common in adolescents than in pre-teens. Herniated discs are rare causes of back pain in children (especially under age 10). Although treatment is usually non-surgical, 1 percent to 2 percent of disc excisions are done on children under 16. The so-called backpack syndrome is considered in children with back pain but is still inconsistent in literature. Education on posture and proper use (potentially less than 10 percent to 15 percent of body weight carried) of backpack may be beneficial. Most overuse syndromes will respond with activity modification and mild analgesics.

Developmental abnormalities include spondylolysis, spondylolisthesis and Scheuermann’s kyphosis. Spondylolysis and spondylolisthesis are among the most common causes of back pain in the lumbar and lumbosacral regions. They are most common in children 10 years and older and rarely seen in children younger than 10. Spondylolysis refers to a defect in the pars interarticularis, which occurs most commonly at the L5 vertebra. This defect is present in about 5 percent to 7 percent of the general population and may be congenital or acquired. The rate of occurrence may be 10 percent or higher in certain athletic populations (divers, hockey players, gymnasts, wrestlers and football linemen). Spondylolisthesis is the presence of a slippage of one vertebral body on another. Treatment depends on presence of symptoms. Beyond activity modification and analgesics, bracing and surgery may be considered. Diagnosis is made from X-rays (particularly oblique and lateral views). If doubt is present, SPECT bone scan or CT may provide additional information.

Another developmental abnormality that results in back pain in adolescents is Scheuermann’s disease or juvenile kyphosis. Scheuermann’s disease is the most common cause of pediatric back pain in the thoracic spine or thoracolumbar spine. Although the exact cause of the disease has not been determined, researchers believe it results from an abnormality or interruption of the blood supply to key areas of the vertebral bodies, which leads to progressive fixed kyphosis of the spine. Parents may notice that their child has “poor posture” and is walking “hunched” over, while the children frequently complain of pain, especially late in the day. The diagnosis is confirmed by simple X-ray examination of the spine. Activity modification, physical therapy and analgesic medications are typical treatments. Bracing and surgery are considered in more severe cases.

Inflammatory and infectious diseases including diskitis, vertebral osteomyelitis, pyelonephritis, juvenile rheumatoid arthritis (JRA), and ankylosing spondylitis (AS) may occur in younger patients (typically pre-teens) and may be associated with fever or laboratory abnormalities. Diskitis is more common in children younger than 8 to 10, while vertebral osteomyelitis is more common in children older than 8 to 10. Infection can cause fever, back pain, irritability (especially in younger children), and muscle spasms in the back. Infection may cause some children to hold their spine straight, and they may limp and/or refuse to stand or walk. The infection also may cause changes on an X-ray (narrowing of the disk space). Diagnosis is aided by bone scan and MRI. Beyond the early treatment, which usually consists of antibiotics and bed rest, surgical exploration for drainage, biopsy or fusion may considered. Kidney infections (pyelonephritis) may be causes of back or flank pain in children. Symptoms may include sharp pain on one side of the back, fever, nausea and dysuria. Treatment is antibiotics for underlying infection. JRA most often affects the cervical spine, whereas AS may present as low back pain and stiffness in boys over 8 years. Treatment consists of medication and physical therapy.

Neoplastic disorders include primary and metastatic lesions. Not all tumors of the vertebral bodies and spine are malignant. Back pain may be caused by benign lesions such as osteoid osteoma, hemangioma and giant cell tumors. Depending on the type of tumor, treatment may include surgical removal of the tumor or radiation and/or chemotherapy. In most cases, a biopsy of the lesion is necessary to determine the type of tumor and its appropriate treatment. Primary osseous neoplasms of the lumbar spine are uncommon, with Ewing sarcoma, aneurysmal bone cyst, benign osteoblastoma and osteoid osteoma being the most common, followed by primary lymphoma. These lesions occur more often in children between the ages of 5 and 20. Osteoid osteoma is characterized by severe night pain that is relieved by salicylates. Symptoms of spinal tumors generally develop slowly and worsen over time. The main symptom is chronic back pain that may be worse at night and unaffected by rest or activity. Other symptoms may include sciatica, numbness, weakness, fever and bowel/bladder issues. Imaging (X-rays, bone scans using CT and MRI) is useful in diagnosis.

Another category of consideration may be the psychosocial or psychological components or contributions to back pain. Children may mimic the behavior and symptoms of adults and older children in the family. Symptoms may indicate other problems in the home or at school. Children sometimes respond to stress with physical symptoms. There is even a population of pediatric fibromyalgia. However, these diagnoses should be made with caution after ruling out other diagnosable conditions.

If a child presents with persistent back pain that is not relieved by rest, decrease in activities, and simple analgesics and anti-inflammatory drugs, consider referring the child to a spine specialist. If there are associated constitutional symptoms, referral should not be delayed.

DeMicco R. Basic Evaluation Process for Back Pain in Children. Spinal Column. Summer 2005. Cleveland Clinic Spine Institute (CCSI)
http://cms.clevelandclinic.org/spine/documents/Spinal%20Column%20Su05.pdf

Copyright (C) 2005. Cleveland Clinic Foundation. All rights reserved.