Back Pain

Thomas H. Chun, MD

Back Pain - BASICS

Back Pain - description

Any condition causing pain of the thoracic, lumbar, or sacral spine area(s).

Back Pain - general prevention

• Back muscle strengthening and hamstring stretching exercises may be helpful.
• Maximum backpack load: 10–15% body weight
• Sports participation:
  • Emphasize appropriate protective equipment and proper technique.
  • Training >15 h/wk is associated with increased risk of injury.
• Lumbar supports: Do not appear to be effective (adult studies).

Back Pain - epidemiology

Back Pain - incidence

30–50% lifetime incidence

Back Pain - prevalence

• Recurrent/chronic back pain: 8% of adolescents
• Discitis and osteomyelitis: Usually in children <10 years of age
• Spondylolysis, spondylolisthesis, Scheuermann kyphosis, herniated disc, tumors, and apophyseal ring fractures: Usually in children >10 years of age

Back Pain - risk factors

Back Pain - genetics

Inheritance patterns for some congenital (e.g., scoliosis, Scheuermann kyphosis) and inflammatory/rheumatologic causes have been described.

Back Pain - etiology

Back pain can result from a variety of causes involving the bony or muscular structures of the back, intervertebral discs, spinal cord, or peripheral nerves.

Back Pain - DIAGNOSIS

Back Pain - signs & symptoms

Back Pain - history

• Fleeting or short duration of pain (rarely serious)
• Interference with activity) often a marker of severe disease)
• Physical activity and trauma history:
  • Spondylolysis and spondylolisthesis are more common in those who repeatedly twist, bend, or hyperextend their spine (e.g., in gymnastics, diving, tennis, contact sports, weightlifting).
  • Heavy lifting may contribute to Scheuermann kyphosis.
  • Trauma causes 1/3 of herniated discs.
• Pain aggravated by activity and/or relieved by rest: Consider overuse conditions, spondylolysis, or spondylolisthesis.
• Pain radiating down legs: Consider herniated disc, spondylolisthesis, epidural abscess, or osteoid osteoma.
• Neurologic symptoms: Consider syringomyelia, spinal cord abnormalities (e.g., congenital, tumors, herniated disc).
• Adolescent growth spurt: More prone to musculotendinous strain
• Idiopathic scoliosis: Rarely painful or functionally limiting
• Pain that awakes the child from sleep, and/or relief with NSAIDs: Consider osteoid osteoma and osteoblastoma.
• Pain aggravated by prone position: Consider epidural abscess.

Back Pain - physical exam

• Inspect for occult abnormalities (sacral dimples, hair tufts, vascular anomalies, café-au-lait spots, or discrepancies in limb length).
  • If head not midline, consider syringomyelia, tumor, spondylolisthesis, herniated disc
  • Shortened waistline and flattened or “heart shaped” buttocks: Consider spondylolisthesis.
• With feet together and knees and hips straight, observe patient from back and side, both standing and through full range of motion of spine:
  • Evaluate for scoliosis, kyphosis, and range of motion
  • Lumbar lordosis should “reverse” when child bends over; if it does not, consider significant pathology.
  • During forward flexion: If thoracic kyphosis accentuates, suspect Scheuermann kyphosis; if stiffness observed, consider inflammatory, infectious, or neoplastic causes.
  • Extension: Stiffness typical of discitis; if it reproduces pain, consider spondylolysis.
• Point or focal tenderness: Consider fracture.
• Assess neurologic function:
  • In young children: Observe gait, heel- and toe-walking, rising from a squat.
  • Include tests of sensation and rectal tone.
  • Lack of abdominal reflexes: Consider syringomyelia.
  • Abnormal neurologic findings need urgent, thorough investigation.
• Abnormal gait: Consider spondylolisthesis (short stride or “pelvic waddle”), herniated disc.
• Hamstring tightness and/or decreased hip flexion: Consider spondylolisthesis, discitis.
• Straight leg raise (patient supine): If limited leg raise and/or radiating pain, consider neurologic abnormality.
• Bony “ledge”/step-off on palpating lumbar spine or anterior bony mass on rectal exam: May be seen in spondylolisthesis.
• Asymmetric lower-extremity muscle circumference: Consider nerve impingement due to herniated disc.

Back Pain - tests

Back Pain - lab

• Blood tests (e.g., ESR, HLA-B27, ANA, rheumatoid factor, blood culture) are indicated only if infectious or rheumatologic etiologies are considered.
• Discitis: Bacterial cultures (needle aspiration or open biopsy):
  • Positive in only 25–50%; biopsy thus not routinely recommended
  • Staphylococcal species most common organism

Back Pain - imaging

Plain x-rays (AP and lateral; oblique and flexion/extension if warranted) of the spine:

• Indicated if any worrisome signs or symptoms are present
• Spondylolysis is a “collar” (lucent line) on the “Scottie dog’s” neck

• Plain x-rays are often normal, even in cases with serious causes.
• Bone or SPECT scan:
  • More sensitive for occult/subtle lesions
  • Obtain if serious etiology is suspected.
• MRI: Preferred examination for suspected neurologic or disc injury

Back Pain - differencial diagnosis

• Congenital:
  • Tethered cord
  • Syringomyelia (may also be traumatic)
• Inflammatory:
  • Ankylosing spondylitis
  • Enteropathic arthritis
  • Intervertebral disc calcification
• Infectious:
  • Tuberculosis
  • Discitis
  • Epidural abscess
• Trauma:
  • “Musculotendinous” strain
  • Spondylolysis (stress fracture of posterior vertebral elements, usually a repetitive-stress injury)
  • Spondylolisthesis (anterior displacement/“slip” of vertebral body, associated with bilateral spondylolysis)
  • Herniated disc
  • Apophyseal ring fracture (fracture separating the vertebral body and cartilaginous ring apophysis)
  • Epidural hematoma (traumatic or due to bleeding diathesis)
• Neoplastic:
  • Bony:
    • Osteoid osteoma, osteoblastoma
    • Osteosarcoma
    • Ewing sarcoma
    • Aneurysmal bone cyst
  • Metastatic/other
  • Leukemia, lymphoma
  • Eosinophilic granuloma
  • Glioma
  • Neuroblastoma
  • Rhabdomyosarcoma
• Developmental:
  • Scheuermann kyphosis (excessive kyphosis/”hunchback” due to abnormal ossification causing “wedging” of the vertebral bodies)
  • Painful scoliosis
• Referred:
  • Pyelonephritis
  • Pancreatitis
• Psychogenic

Warning signs of potentially serious causes of back pain in children include:

• Young age (<4 years old)
• Chronic interference with normal activity (e.g., school, sports, play)
• Duration of pain >4 weeks
• Associated fever, weight loss, or other systemic symptoms
• Postural shift of trunk
• Any neurologic abnormality
• Limitation of spinal motion (e.g., bending forward, straight leg raise)
• Painful or left thoracic scoliosis

Back Pain - TREATMENT

Back Pain - general measures

• If warning signs are absent, conservative management of rest/activity modification, ice or heat, acetaminophen or ibuprofen, muscle relaxants, physical therapy, and close follow-up are appropriate.
• Back brace: May be helpful with spondylolisthesis and Scheuermann kyphosis.
• Spondylolysis/spondylolisthesis:
  • <50% slip: Conservative medical treatment
  • >50% slip/persistent back pain: Surgical treatment
• Discitis: Antistaphylococcal medications indicated; PO vs. IV depends on severity of symptoms.
• Bed rest/activity limitation: Adult data do not support this strategy.
• Lumbar supports: Limited adult evidence supporting their efficacy in treating low back pain.

Back Pain - FOLLOW UP

• Patients managed conservatively should be re-evaluated within 2 weeks.
• All patients should follow up immediately for any worsening symptoms, especially pain or neurologic symptoms.

Back Pain - prognosis

• Dependent on the underlying cause
• The majority, when properly diagnosed and treated, do well, without significant sequelae.
• Not possible to predict future course of spondylolysis, spondylolisthesis, or Scheuermann kyphosis.

Back Pain - complications

Complications of missed diagnosis or improper management include paralysis, other permanent neuromuscular injury, and neoplastic/paraneoplastic or infectious syndromes.

Back Pain - bibliography

1. Cardon G, Balagué F. Low back pain prevention’s effects in schoolchildren. What is the evidence? Eur Spine J. 2004;13:663–679.
2. Cavalier R, Herman MJ, Cheung EV, et al. Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management. J Am Acad Orthop Surg. 2006;14:417–424.
3. Ginsburg GM, Bassett GS. Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg. 1997;5:67–78.
4. Hagen KB, Jamtvedt G, Hilde G, et al. The updated Cochrane review of bed rest for low back pain and sciatica. Spine. 2005;30:542–546.
5. Jellema P, van Tulder MW, van Poppel MNM, et al. Lumbar supports for prevention and treatment of low back pain. Spine. 2001;26:377–386.
6. Payne WK, Ogilvie JW. Back pain in children and adolescents. Pediatr Clin North Am. 1996;43:899–917.
7. Mackenzie WG, Sampath JS, Kruse RW, Sheir-Neiss GJ. Backpacks in children. Clin Orthop Rel Res. 2003;409:78–84.
8. Mason DE. Back pain in children. Pediatr Ann. 1999;28:727–738.
9. Trainor TJ, Wiesel SW. Epidemiology of back pain in the athlete. Clin Sports Med. 2002;21:93–103.
10. Waicus KM, Smith BW. Back injuries in the pediatric athlete. Curr Sports Med Reports. 2002;1:52–58.

Back Pain - CODES

Back Pain - icd9

• 724.5 Backache (postural)
• 307.89 Psychogenic pain
• 724.6 Sacroiliac instability

Back Pain - FAQ

• Q: Which children should have activity restrictions?
• A: High-risk” children (e.g., those with spinal or bony abnormalities or familial histories of spondylolysis) should avoid hyperextension and contact sports.
• Q: When can/should the child resume normal activities?
• A: “Low-risk” children, with a normal neurologic exam, can resume activity or sports when they are pain free.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Middle back pain: Introduction (review 31 causes)
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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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