Back Pain
Back Pain: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Although less common in children than inadults, a specific cause can frequently be identified.
Principal Causes of Back Pain
- Congenital
- Spineanomalies
- Developmental
- Scoliosis
- Scheuermann disease
- Trauma
- Musculoskeletal
- Herniated disc
- Spondylolysis
- Spondylolisthesis
- Slipped vertebral epiphysis
- Spinal epidural hematoma
- Infection/inflammation
- Discitis
- Disc space calcification
- Osteomyelitis
- Sacroiliac joint infection
- Juvenile rheumatoid arthritis
- Ankylosing spondylitis
- Spinal epidural abscess
- Sickle cell disease
- Neoplasm
- Vertebral tumors
- Intraspinal tumors
- Referred pain
- Psychogenic
Clinical Features and Diagnosis
Congenital
Congenitalspine anomalies, including absence of lumbar pedicle, spinal fusion,or spinal stenosis, are unusual causes of back pain.Plain radiographs are useful for diagnosis.In some cases, MRI is necessary for diagnosis. Developmental
Scoliosis
Idiopathic scoliosis may be associated withmild back pain, particularly after long activity. When scoliosisis associated with more severe back pain, other underlying disordersshould be considered (e.g., infection, herniated disc, spondylolysis,spondylolisthesis, and tumor).
Scheuermann Disease
Disorderof unknown cause that usually occurs in older children and adolescentsinvolved in athletics.Most common site is thoracolumbar area,although thoracic or lumbar spine may be affected alone. Pain isusually worse with forward flexion and relieved by rest.Spine radiographs show increased kyphosiswith anterior wedging of ≥1 vertebrae, irregular vertebral endplates, and disc herniation upward or downward into adjacent vertebra(Schmorl node). Trauma
Musculoskeletal
Muscle strainis common cause of back pain and is usually result of improper conditioning,heavy lifting, overuse in sport-related activity, or contusion.History of trauma followed by spasmof paraspinous muscles and limited range of motion of spine suggestdiagnosis. Tenderness over vertebrae may indicate fracture.Although spine radiographs are usuallydiagnostic, some fractures may not be visible, and technetium bonescan can be useful in localization of occult fracture. Herniated Disc
Most commonin individuals who participate in vigorous athletic activities.Trauma is often predisposing factor.Most commonly involved discs are thosebetween L4 and L5 and L5 and S1.Intermittent or constant lower backor buttock pain with radiation down the leg is most common presentation.Limp and disturbed gait are frequent findings.Sneezing, coughing, or laughing mayaggravate pain.There is limitation of movement oflumbosacral spine and often spasm of paraspinous muscles.Straight leg raising test is usuallyabnormal.Decreased sensation in L4–S1dermatome and motor weakness are variable findings.MRI confirms diagnosis. Spondylolysis
Definedas fracture of pars interarticularis of vertebral arch, which occursprimarily in older children and adolescents, especially in thoseparticipating in gymnastics, dance, or weight lifting.Usual location is lumbar spine, andless commonly thoracic spine.Pain is especially aggravated by extensionmovements of leg. There is localized tenderness and limited rangeof motion of spine.Plain radiographs usually demonstratedefect. Spondylolisthesis
Involvessame defect as spondylolysis, but there is also forward slippageof 1 vertebra on the other, usually L5 on S1.Plain radiographs are usually diagnostic. Slipped Vertebral Epiphysis
Posteriorrim of inferior epiphysis, usually L4, and adjacent disc are displacedinto spinal canal.Pain usually occurs after heavy lifting.Diagnosis may be confirmed by plainradiographs or CT. Spinal Epidural Hematoma
May occurafter a fall, another injury, or spontaneously in children withbleeding disorders.Pain is usually followed by signs ofspinal cord compression.CT or MRI is diagnostic. Infection/Inflammation
Discitis
Thoughtto result from bacterial or low-grade viral infection and usuallyoccurs in preschool or school-age children.Most common sites of infection aredisc spaces in lumbar region.Affected children may have low back,hip, or lower abdominal pain; limp or reluctance to walk; and sometimesfever. Localized tenderness over involved disc space, spasm of adjacentmuscles, and pain with straight leg raising are usually found.Early in course of illness, plain radiographsare normal; later, they show narrowing of disc space with irregularerosions and sclerosis of vertebral end plates. Nuclear scintigraphyshows increased uptake in vertebral bodies on each side of involveddisc space. CT or MRI may be useful in atypical or questionablecases by confirming presence of disc space narrowing and vertebralend-plate destruction.Although controversy exists about whetherdisc space aspirate should be performed, in some cases S. aureuscan be cultured from disc space aspirate or blood. Disc Space Calcification
Rare lesionin pediatric population. Although pathogenesis is uncertain, itmay follow nonspecific inflammatory reaction of disc space. Mostcommonly involved area is cervical spine.There is cervical or thoracic pain,localized tenderness over disc space, muscle spasm, and occasionalfever.Plain radiographs show calcification. Osteomyelitis
Most commonpathogen causing osteomyelitis of spine is S. aureus. Other pathogens includeS. pneumoniae, group A Streptococcus, E. coli, P. aeruginosa, andSalmonella species.Localized back pain, tenderness overinvolved vertebrae, restriction of spine motion, and fever are commonfindings. There is usually leukocytosis and increased sedimentationrate.Plain radiographs may be normal earlyin course of illness, but after about 10 days, radiologic findingsinclude disc space narrowing, decreased height of vertebra, andsclerotic/lytic lesions of vertebral body, pedicles, orneural arches. Extension into soft tissues can produce paravertebralmass. Nuclear scintigraphy usually shows increased uptake earlyin illness.Bone aspirate or biopsy may revealpathogen, and blood cultures also may be positive. Tuberculosis of Spine
Much lesscommon than pyogenic infection.Thoracic spine is most common siteof involvement, with pain radiating to intercostal areas. Involvementof cervical spine may produce neck pain and torticollis, whereaslumbar spine involvement may produce lower back pain and limp. Feveralso may occur.Plain radiographs show destructionand collapse of vertebrae with narrowing of disc spaces.Involvement of spinal cord at any levelmay produce extremity weakness.Diagnosis should be considered in childrenwho have history of exposure or who live in endemic area and whohave persistent back or neck pain.CBC, sedimentation rate, chest radiograph,Mantoux test, early morning gastric aspirates, and bone biopsy foracid-fast bacilli and culture should be performed. Iliac Osteomyelitis
Uncommoninfection.Clinical manifestations include lowback pain, fever, and tenderness over ilium.Nuclear scintigraphy shows increaseduptake. Bone aspirate or biopsy is diagnostic. Sacroiliac Joint Infection
Most commonpathogen is S. aureus. Prior pelvic fracture is risk factor.Usually presents with pain in lowerback, hip, or buttock; limp; and fever. Flexion, abduction, andexternal rotation of leg cause sacroiliac pain if joint is involved.Plain radiographs may be normal earlyin illness, but within 10 days, lytic and sclerotic changes of bonemargins and widening of joint space are usually seen. Nuclear scintigraphyshows increased uptake in affected bone.Aspiration or open biopsy is usuallyrequired to establish specific diagnosis. Blood culture also mayreveal pathogen. Juvenile Rheumatoid Arthritis
Can affectthe spine at any level and cause persistent back pain and decreasedrange of motion. Most commonly involved area is cervical spine.Plain radiographs of cervical spinemay show atlantoaxial displacement, ankylosis of apophyseal joints,and narrowing of disc spaces.See Chap.37, Limp Ankylosing Spondylitis
Disorderof unknown cause that primarily affects boys >8 yrs.Most common feature is arthritis oflower extremity joints, which may include hips, knees, ankles, andfeet. Back pain and limitation of motion of lumbosacral spine orsacroiliac joints also can occur.Diagnostic clue is presence of enthesitis,especially involving heel.Plain radiographs of lumbosacral spineand sacroiliac joints may show changes consistent with sacroiliitis.Slit-lamp exam should be performedbecause uveitis can occur.HLA-B27 antigen is positive in about90% of cases. Antinuclear antibody and rheumatoid factorare usually negative. Spinal Epidural Abscess
Rare infectionin childhood that can be acute or chronic.Most common pathogen is S. aureus.Predisposing factors include local wound infection, decubitus ulcer,or spine surgery.Back pain, localized spine tenderness,tender spinal mass, and fever are common findings. Lumbosacral involvementmay produce buttock and leg pain with leg weakness, impaired sensation,decreased deep tendon reflexes, and impaired bowel and bladder function.Radiographs of spine are usually normalbut sometimes show evidence of osteomyelitis. CT or MRI may be diagnostic.Diagnosis is confirmed at surgery. Sickle Cell Disease
Back painmay occur in sickle cell vasoocclusive episode and is usually musculoskeletalin origin. Infarction of posterior ribs or vertebrae may cause backpain and bone tenderness.Can usually be demonstrated by bonescintigraphy. Neoplasm
Tumors ofthe spine or spinal cord are uncommon in pediatric population.Clinical features include persistentpain sometimes waking child during night, sciatic pain, painfulscoliosis, localized tenderness, palpable mass, lower extremityweakness, sensory changes, and bowel or bladder disturbances.Histologic diagnosis is necessary exceptfor perhaps osteoid osteoma. Vertebral Tumors
Most commonbenign tumor of spine is osteoid osteoma.Pain often awakens child from sleep.Localized tenderness and scoliosisalso may occur.Spine radiograph shows small radiolucentarea surrounded by sclerosis. Osteoblastoma has same histology asosteoid osteoma but is larger.Aneurysmal bone cyst may affect posteriorelements of spine, vertebral bodies, or ribs, causing pain and sometimespalpable mass.Commonlyoccurs in adolescence.Spine radiograph shows cyst with finetrabeculae and thin cortex.MRI shows extent of tumor and any neuralcompression. Eosinophilic granuloma commonly presentswith persistent thoracic back pain in adolescence. Radiographs showcircumscribed area of osteolysis and any vertebral collapse.Most common primary malignant bonetumors affecting spine are osteogenic sarcoma and Ewing sarcoma.Common metastatic lesions include neuroblastoma, Wilms tumor, leukemia,and lymphoma. Usual findings are persistent pain, bone tenderness,fever, and weight loss. Spine radiographs, nuclear scintigraphy,CT, and MRI are useful in locating and defining the extent of thetumor. Intraspinal Tumors
May arisewithin spinal cord (astrocytoma, ependymoma), within dura but outside spinalcord (neurofibroma, lipoma, dermoid), and outside dura (commonly,extension of paravertebral neuroblastoma).May present with spinal pain with radiationto specific dermatome, leg or arm weakness, limp or difficulty walking,and bowel or bladder disturbance. Clinical findings include weaknessor spasticity of extremities, decreased sensation, pathologic reflexes,relaxation of anal sphincter, and scoliosis.Spine radiographs are useful, but CTand MRI help locate and define extent of lesion. Referred Pain
Infection/inflammationor mass in abdominal, thoracic, retroperitoneal, or pelvic regionscan cause referred back pain. Examples are pneumonia, pyelonephritis,pancreatitis, appendicitis, cholecystitis, and hydronephrosis.History and physical exam suggest thesediagnoses, which are discussed in other chapters. Psychogenic
Back paincan be due to anxiety, depression, hypochondriasis, or conversionreaction.Pain is nonspecific and nonlocalizing.Physical and neurologic exams, CBC,sedimentation rate, and spine radiographs are normal.Psychosocial history provides cluesto diagnosis. Diagnostic Approach
History,physical exam, and spine radiographs are usually diagnostic of congenital spineanomalies, fractures, Scheuermann disease, spondylolysis, and spondylolisthesis.MRI is procedure of choice to confirmdiagnosis of herniated disc.Fever usually occurs with inflammatorydisorder or infection affecting spine. When fever accompanies backpain, CBC and erythrocyte sedimentation rate should be performed.Nuclear scintigraphy is useful, especiallywith suspected osteomyelitis, discitis, or sacroiliac joint infection.Aspirate or biopsy of lesion shouldbe strongly considered with suspected osteomyelitis. Blood culturemay reveal organism, but yield is often low.Spine radiographs are useful in diagnosisof vertebral spine and intraspinal masses.CT and MRI are valuable in diagnosingtumors as well as spinal epidural abscess.For all tumors except possibly osteoidosteoma, histologic exam is necessary for diagnosis. References
- Ball WS Jr, ed. Pediatric neuroradiology.Philadelphia: Lippincott-Raven, 1997.
- Cassidy JT, Petty RE. Textbook of pediatric rheumatology,4th ed. New York: Churchill Livingstone, 2001.
- Corneli HM. Pain–back. In: Fleisher GR, LudwigS, eds. Textbook of pediatric emergency medicine, 4th ed. LippincottWilliams & Wilkins, 2000:429–433.
- Crawford AH, Bagamery N. Handbook of pediatric orthopedics,3rd ed. Cincinnati: Children's Hospital Medical Center,1996.
- Hollingsworth P. Back pain in children. Br J Rheumatol1996;35:1022–1028.
- McIntire SC. Back pain. In: Gartner JC Jr, ZitelliBJ, eds. Common & chronic symptoms in pediatrics. St. Louis:Mosby-Year Book, 1997:15–31.
- Payne WK, Ogilvie JW. Back pain in children and adolescents.Pediatr Clin North Am 1996;43:899–917.
- Sponseller PD. Back pain in children. Curr Opin Pediatr1994;6:99–103.
- Thompson GH. Back pain in children. J Bone Joint Surg [Am] 1993;75:928–938.
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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