Back Pain

Back pain is an uncommon complaint in children, but relatively more common in adolescents. Although relatively benign causes (such as muscular strain in adolescents) account for the majority of cases, some more severe causes should not be overlooked, especially in younger children. Back pain may be manifested by a refusal to walk in toddlers.

Differential Diagnosis

• Muscular strain, disk herniation
  –Most common in adolescents who are involved in competitive or contact sports; may be occupational
• Spondyloarthropathy
  –Ankylosing spondylitis is found primarily in boys, characterized by sacroiliitis, LE oligoarthritis, and may be associated with IBD
  • Malalignment
    –Scoliosis: Idiopathic form is most common in girls, may be familial, may be secondary to neurologic disorder
    –Hyperlordosis
  • Infectious
    –Diskitis: Characterized by spine stiffness and muscular spasm, Staphylococcus aureus is the usual pathogen, blood culture may be positive
    –Vertebral osteomyelitis: Exquisite point tenderness, pathogen may be S. aureus, Streptococcus pneumoniae, or others such as tuberculosis or brucellosis
    –Acute transverse myelopathy: Generally follows an upper respiratory tract infection; characterized by back pain, distal weakness and paresthesias at the midthoracic level
  • Urinary tract
    –Urinary tract infection: Most common in postpubertal girls, occurrence in boys or prepubertal girls may require evaluation for urinary tract anomalies, especially if recurrent
    –Urolithiasis: Associated with hypercalcuria, cystinuria, Lesch-Nyhan; characterized by intense flank pain and hematuria
  • Malignancy
    –Primary spinal cord or column tumors (osteogenic sarcoma, neuroblastoma)
    –Metastatic tumors (neuroblastoma)
    –Bone marrow infiltration (leukemia, lymphoma)
  • Gynecologic
    –Menstrual cramps
    –PID
    –Endometriosis

  Workup and Diagnosis

  • History
    –Onset, duration, location of symptoms
    –History of trauma, heavy lifting, overuse, athletics
    –Systemic symptoms such as fever, irritability
    –Menstrual and sexual history
    –Past medical history of similar complaints, orthopedic conditions, general medical conditions
    –Family history of scoliosis, rheumatic disease
  • Physical exam
    –General appearance, fever, irritability
    –Spinal contour, symmetry
    –Gait, posture
    –Range of motion limitations
    –Point tenderness, SI tenderness
    –Associated neurologic findings (sensation, strength, DTRs)
  • Labs
    –If rheumatologic condition is suspected, consider CBC, ESR, ANA, RF, HLA typing
    –If infectious process is suspected, obtain CBC, ESR
    –Urine microscopy and culture
  • Studies
    –Plain films can reveal fractures such as spinal compression fractures, disk space abnormalities, and sacroiliac abnormalities associated with spondyloarthrosis
    –MRI may be required to discover disk herniation, disk space infection, tumors

  Treatment

  • Muscular strain: Muscle relaxants, NSAIDs, rest, and reduction of exacerbating activities
    
  • Disk herniation: Physical therapy, surgery is rarely indicated in children and adolescents
  • Spondyloarthropathy: NSAIDs, exercise
  • Scoliosis: Conservative management with observation, NSAIDs, bracing or surgery if more severe
  • Gynocologic etiologies
    –Menstrual cramps: NSAIDs, OCPs for severe cases
    –PID: Appropriate cultures, treatment with antibiotics
    –Endometriosis: hormonal therapy such as OCPs may be effective, surgical ablation is rarely required
  • UTI: Antibiotics
  • Urolithiasis: Pain management followed by high fluid intake
  • Infection: Diskitis requires 4–6 weeks of IV antibiotics
    
  • Tumors: Referral to oncologist

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Upper back pain

• Back to symptom: Upper back pain: Introduction (review 20 causes)
• Next Book Extract About Upper back pain: LOW BACK PAIN (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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