Consider the differential diagnosis oflow back pain in pre-teens, which may include oncologic diagnoses and infections that cause pain prior tobecoming clinically identifiable in diagnostic studies

Author: Elizabeth Wells, MD

What to Do - Gather Appropriate Data

Unlike in adult medicine, low back pain is an unusual chief complaint in pediatric practice, and the majority of pediatric cases have an identifiable cause. Most cases are caused by musculoskeletal disease or trauma; however, clinicians must consider more systemic conditions, such as infection, noninfectious inflammatory disease, and neoplasm.

The most common cause of back pain is mechanical. Strains and sprains are treated with rest and simple analgesics, and typically improve in 2 to 3 days. Direct traumatic injuries are also common, and the history guides the clinician to these diagnoses.

Spinal developmental abnormalities that may cause back pain include spondylolysis and spondylolisthesis. Spondylolysis is caused by a stress or fatigue fracture or separation of the pars interarticularis, often in L5. It is more common in sports that emphasize hyperextension of the spine, such as gymnastics, tennis, and weight lifting. The defect appears as a radiolucent line around the "Scottie dog's" neck on oblique radiographs. Bilateral spondylolysis can lead to spondylolisthesis in which the proximal or cephalad vertebral body is ventrally subluxed over the next most caudal vertebral body. A patient with negative radiographs but pain on hyperextension and a classic history needs further imaging, such as with a computed tomography scan or bone scan. Treatment of spondylolisthesis includes bracing, for early lesions; and fusion surgery, for patients with progression of the subluxation or neurologic signs; followed by physical therapy with core body exercises.

A child with the sudden onset of severe back pain, fever, and an elevated erythrocyte sedimentation rate may have an infection. Discitis and vertebral osteomyelitis are two conditions to consider, with the former being more common in children older than 8 to 10 years and the latter being more common in children older than 8 to 10 years. As routine radiographs can appear normal early on in the disease, magnetic resonance imaging is the test of choice; a bone scan is also frequently diagnostic. Treatment of both infections includes bed rest and antibiotics.

The rheumatologic diseases juvenile rheumatoid arthritis and ankylosing spondylitis are two causes of noninfectious inflammatory back pain in children. Inflammatory diseases can present with morning stiffness that improves with activity. Sacroiliac tenderness may also be found, and joint changes may be seen on plain radiographs or magnetic resonance imaging. Neoplasticdisordersshouldalsobeincludedinthedifferentialdiagnosis of lower back pain in children. The benign tumors osteoid osteoma and osteoblastoma commonly present with painful scoliosis, stiffness, and night pain, and are relieved by nonsteroidal anti-inflammatory drugs or aspirin. Aneurysmal bone cysts are usually asymptomatic until a fracture, collapse, or hemorrhage occurs with the cyst as the focus. Most benign spinal tumors are cured with tumor excision and bone grafting.

Malignant neoplasms present with intractable back pain, night pain, and constitutional findings, including weight loss, fever, and elevated erythrocyte sedimentation rate. Primary malignant neoplasms of the spine are rare but include Ewing sarcoma, leukemia, and lymphoma. Metastases to the spine can be seen in lymphoma, leukemia, Wilms tumor, retinoblastoma, and teratoma-teratocarcinoma. A bone scan is usually the most appropriate imagingtoolforbonyneoplasm;itcandetectthemultipleossificationcenters seen in metastatic disease.

Abdominal disease can also cause back pain in children. These conditions include retrocecal appendicitis, pleuritis, pyelonephritis or hydronephrosis, and psoas abscess. Wilms tumor, rhabdomyosarcoma, and retroperitoneal masses can also cause back pain. It is important for clinicians to consider the broad differential diagnosis when evaluating children with low back pain. Persistent back pain in a child can have a more serious etiology, and the workup should include the appropriate diagnostic imaging and the swift referral to an orthopedic specialist. The possibility of underlying spinal cord compression should always beconsidered.Sickle celldiseasemustbe ruledout. Chronic pain syndromes are a diagnosis of exclusion. If an underlying pathology, such as infection or tumor, is causing the back pain, early diagnosis may facilitate timely effective treatment.

Suggested Readings

Glancy GL. The diagnosis and treatment of back pain in children and adolescents: an update. Adv Pediatr. 2006;53:227–240.
Grattan-Smith PJ, Ryan MM, Procopis PG. Persistent or severe back pain and stiffness are ominous symptoms requiring prompt attention. J Paediatr Child Health. 2000;36(3):208– 212.
McCleary MD, Congeni JA. Current concepts in the diagnosis and treatment of spondylolysis in young athletes. Curr Sports Med Rep. 2007;6(1):62–66.
Payne WK 3rd, Ogilvie JW. Back pain in children and adolescents. Pediatr Clin North Am. 1996;43(4):899–917.
SelbstSM, Lavelle JM, SoyupackSK, et al. Back pain inchildren who presentto the emergency department. Clin Pediatr (Phila). 1999;38:401–406.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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