BACK PAIN IN CHILDREN

I. Epidemiology: not as uncommon as once thought with 8-30% prevalence

II. Hx

  1. Ask about trauma, activities incl. sport like gymnastics, lifting
  2. Pain that occurs spontaneously at night is more likely to have a significant cause
  3. Causing functional disability? If so, more likely to be serious
  4. Accompanying sx raise level of concern, e.g. fever, weight loss, neurologic sx
  5. Also more concern if pain is constant or age < 11yo

III. Other red flags

  1. Neurologic abnormality on exam
  2. Postural shift of trunk
  3. Limitation of range of motion

IV. Differential diagnosis

  1. Inflammatory
  1. Ankylosing spondylitis
  2. Enteropathic arthritis
  1. Infectious
  1. Discitis (usually young kids; stiff back and won't flex; LGF and malaise; plain films often nl; cultures of bx material often sterile)
  2. TB
  3. SI joint infection
  1. Traumatic
  1. Spondylolysis, spondylolisthesis
  1. Consider if pain is at SI joint
  2. Standing hyperextension of spine often reproduces pain
  1. Musculoligamentous strains
  2. Herniated nucleus pulposus or nucleus pulposis/apophysis (rare in kids)
  1. Neoplastic (most often benign
  1. Bony (osteoid osteoma, osteoblastoma)
  2. Eosinophilic granuloma
  3. Leukemia, lymphoma
  4. Osteosarcoma
  5. Ewing's sarcoma
  6. Glioma
  7. Neuroblastoma
  1. Congenital
  1. Tethered cord
  1. Developmental
  1. Sheuermann diseae
  1. Consists of wedging, irregularity, or growth disturbance of 3 successive vertebrae
  2. Unknown etiology; may be related to excessive lifting or spinal flexion
  3. Most common cause of pain in upper back in kids
  4. Often see an increase of thoracic kyphosis
  5. Causes mild-moderate backache throughout life and poss. worsening thoracic kyphosis as kid grows
  1. Iliac apophysitis
  2. Scoliosis
  1. Idiopathic scoliosis rarely associated with pain
  2. Should be thoracic convex to right; lumbar convex to left ("THOCORI")
  3. Left thoracic scoliosis is unusual and should arouse suspicion of non-idiopathic causes (tumor, spondylolysis, infection, syrinx)
  1. Extraspinal
  1. Abdominal
  2. Renal
  3. Vascular
  4. Gynecologic (hematocolpos from imperforate hymen)
  1. Psychogenic

V. Px-just like adult, also

  1. Check abdomen and for CVAT
  2. Check LE's for muscular symmetry
  3. Check leg lengths though diff. of < 2cm prob. not significant
  4. Check for scoliosis and spine flexibility (should be able to get fingers 10cm or less to floor)