Pediatric Back Pain: Evaluation & Management Guide

1. Neck Back Extremities Floppy infant syndrome Differential diagnosis

2. II. Back pain • requires careful evaluation if lasts more than 1 to 2 weeks (in child) • usually the result of a serious underlying disorder including psychogenic back pain which is often difficult to manage

3. II. Back pain • in the past, unlike adults, children were thought to uncommonly have back pain related to psychogenic causes • children with acute or short-lived back pain: more likely to have muscle and ligamentous strain or pain associated with systemic viral infection

4. II. Back pain • History should include: • location • duration • radiation • character of pain • illness or activity preceding its onset • Interference with normal daily & recreational activities should be determined

5. II. Back pain • Examination should seek other signs such as : • abnormalities in gait • configuration of the back (subtle changes in contour may offer localizing clues) • tenderness on palpation

6. II. Back pain • Skin overlying spine should be carefully inspected for: • dimples • tufts of hair • hemangiomas • other cutaneous changes • Any cutaneous changes may denote developmental defects

7. II. Back pain • Lesions causing back pain may also produce neurologic changes in extremities or bladder or bowel dysfunction • Signs of neuromuscular disease should also be sought

8. Hyperlordotic mechanical back pain Ligamentous or muscle strain Spondylolisthesis Myalgias Psychogenic Spondylolysis Scheuermann disease II. Back pain – Most common causes

9. Herniated disc Spinal dysraphism Urinary tract infection Spinal cord tumors Diskitis II. Back pain – Causes not to forget

10. II. Back pain Trauma • Lordotic mechanical back pain • Reputed to be a common cause in adolescent athletes • Pain: • only in lumbar area • variable hyperextension or hyperflexion testing • inability to fully flex the spine forward

11. II. Back pain Trauma • Lordotic mechanical back pain • Kyphosis of thoracic spine present in compensation for decreased forward mobility of lumbar spine • Some have suggested contractures at the facet joints as site of pain

12. II. Back pain Trauma • Ligamentous or muscle strain • History of fall, unusual exercise or other forms of trauma should be sought • There may be localized tenderness and paravertebral muscle spasm • Strain – probably the most common cause of back pain but it should be short-lived

13. II. Back pain Trauma • Prolapse of intervertebral disc • Uncommon lesion in children • Almost always a history of injury • Lower lumbar area – usually involved • Pain may be local or radiate to the legs • Abnormal straight-leg-raising test – most common physical finding

14. II. Back pain Trauma • Slipped vertebral apophysis • May occur after strenuous activity or heavy lifting • Signs of a herniated disc • A small bone fragment, edge of ring apophysis, may be seen within spinal canal on imaging studies • Lower lumbar spine – most common site

15. II. Back pain Infections • Myalgias • Muscle pain may be associated with a multitude of viral and bacterial infections • Aches not limited to paravertebral muscles • Urinary tract infection • Back pain may be the primary complaint • A urine culture should be done

16. II. Back pain Infections • Referred pain • Other infections must be considered in addition to urinary tract infections including: • pneumonia • appendicitis • pancreatitis • cholecystitis • Urinary tract infection • Back pain may be the primary complaint • A urine culture should be done

17. II. Back pain Infections • Diskitis • Aching pain in lower back radiates to flanks, abdomen and lower extremities • Young child may refuse to walk • Illness may be associated with low-grade fever, irritability and lethargy • Limited back motion

18. II. Back pain Infections • Osteomyelitis of vertebra • Localized tenderness present at a specific level • Spine held rigid because of muscle spasm • Systemic signs often absent • Iliac osteomyelitis, sacroiliac joint infection • Frequently confused with appendicitis or septic arthritis of hip

19. II. Back pain Infections • Tuberculosis • Less common cause of back pain today • Dull local pain present over involved vertebrae • There may be a localized swelling • Destruction of vertebrae may cause pressure on spinal nerves • Stiff gait • Back held rigid

20. II. Back pain Infections • Tuberculosis • Less common cause of back pain today • Dull local pain present over involved vertebrae • There may be a localized swelling • Destruction of vertebrae may cause pressure on spinal nerves • Stiff gait • Back held rigid

21. II. Back pain Infections • Spinal epidural abscess • Generally exquisite pain and tenderness on palpation over the site of abscess • Rapidly developing signs of spinal cord dysfunction such as paraparesis, loss of bladder and bowel control and sensory changes

22. II. Back pain Infections • Brucellosis • Small abscesses may develop in vertebrae • Generally associated with widespread lymphadenopathy • Acute transverse myelopathy • Rare disorder • Preceded by upper respiratory infection • Back pain may be an early sign • Progressive weakness develops in 2 or 2 days

23. II. Back pain Neoplastic disorders – Benign tumors • Osteoid osteoma • Gradual onset • Worse at night • Often relieved by aspirin • Palpation discloses localized tenderness • Radiographs reveal a small translucent area with surrounding dense bone

24. II. Back pain Neoplastic disorders – Benign tumors • Benign osteoblastoma • Symptoms similar to those of osteoid osteoma, but larger lesion and less adjacent bone density seen on radiograph films • Eosinophilic granuloma • Usually only one vertebra involved with collapse • Intervertebral disc spaces maintained • Condition may be asymptomatic • May be backache and postural change

25. II. Back pain Neoplastic disorders – Benign tumors • Aneurysmal bone cyst • Cystic expansile lesion in a vertebra may cause neurologic symptoms • Neuroenteric cysts • Signs of cord dysfunction present

26. II. Back pain Neoplastic disorders – Malignant tumors • Spinal cord tumors • Symptoms may be subacute or chronic • Most common: gliomas, neurofibromas, teratomas, lipomas • Developmental defects may be associated with cutaneous changes • Signs of cord compression with changes in gait, bladder and bowel dysfunction, localized tenderness and scoliosis • Deformity of foot such as cavus or cavovarus – frequent presenting complaint

27. II. Back pain Neoplastic disorders – Malignant tumors • Ewing sarcoma • Osteogenic sarcoma Neoplastic disorders – Metastatic tumors • Neuroblastoma • Wilms’ tumor • Leukemia and lymphoma • Pain not localized and may be fleeting • Rarely, spinal cord compression may occur producing typical signs of spinal cord tumors

28. II. Back pain Bone abnormalities • Scheuermann disease (vertebral osteochondrosis) • Produces a round-back deformity • Several vertebrae may be wedged anteriorly • Pathophysiologic mechanism thought to be prolapse of nucleus pulposis into the vertebrae body, possibly due to osteoporosis • Pain – common, usually located over the apex of kyphosis

29. II. Back pain Bone abnormalities • Spondylolisthesis • Pain caused by anterior displacement of vertebrae • Usually L5 slides forward on S1 • Sciatica, increased lumbar lordosis and tight hamstrings – often present

30. II. Back pain Bone abnormalities • Spondylolisthesis • Pain caused by anterior displacement of vertebrae • Usually L5 slides forward on S1 • Sciatica, increased lumbar lordosis and tight hamstrings – often present

31. II. Back pain Bone abnormalities • Spondylolysis • Defect in pars interarticularis without vertebral slipping • Probably result of a stress fracture • Low-back pain – common, sometimes with radiation down the leg • Pain increased by activity

32. II. Back pain Bone abnormalities • Occult fractures • Trauma, sometimes minor, may result in fractures of pars interarticularis or the transverse or spinous processes • May not be seen on plain radiographs

33. II. Back pain Bone abnormalities • Osteoporosis • Fractures most likely to occur in osteoporotic bones present in disorders such as Cushing synd., OI, homocystinuria, Turner synd., malabsorption and immobilization • Idiopathic juvenile osteoporosis: • Onset between 8 and 14 years of age • Self-limited

34. II. Back pain Bone abnormalities • Scoliosis • Almost always a painless disorder • When back pain present, underlying problem should be sought such as infection, diskitis or tumor

35. II. Back pain Psychogenic pain • Back pain may be associated with reaction to stressful situations • Should always be considered if patient’s affect is inconsistent with symptoms or if findings are unexplainable • Careful history must be obtained • Psychogenic causes as cause of back pain seem to be on the rise

36. II. Back pain Miscellaneous causes • Sickle cell disease • Painful crises may be associated with back pain • Juvenile rheumatoid arthritis • Occasionally, cervical pain may be a presenting complaint

37. II. Back pain Miscellaneous causes • Ankylosing spondylitis • Usually boys • Arthritis in hips or knees and loss of mobility of the back may be found • Chronic hemolytic anemias • Signs of cord compression may result from extramedullary hematopoiesis in extradural space

38. II. Back pain Miscellaneous causes • Calcification of intervertebral discs • Localized back pain • Loss of mobility due to muscle spasm • Cause unknown • Fluffy calcification in the disc space on radiograph films may not appear for 1 to 2 weeks following onset of pain

39. II. Back pain Miscellaneous causes • Spinal dysraphism • Lesions such as fibrous bands, lipomas, etc., may cause a tethered cord => back pain in addition to neurologic findings in lower extremities and bladder problems • Clues to underlying problem should be sought by close examination of the skin over spine for cutaneous abnormalities

40. II. Back pain Miscellaneous causes • Diastematomyelia • Developmental defect causes a cleft in the cord by bone, cartilage or fibrous septum • Cutaneous abnormalities over affected area may be apparent • Low-back pain aggravated by cough or sneeze • Bladder dysfunction or slowly progressive weakness of legs – earlier signs than back pain

41. II. Back pain Miscellaneous causes • Arteriovenous malformation of cord • Symptoms usually slow to develop • Low-back pain – common, with progressive gait and bladder or bowel dysfunction • May be a cutaneous angioma over the cord lesion

42. II. Back pain Miscellaneous causes • Limb girdle dystrophy • Not a single disease entity but a group of dystrophies and myopathies • Usually with autosomal recessive inheritance pattern • First symptoms usually appear during 2nd decade • Early sign: difficulty in climbing stairs or rising from the floor - low-back pain may be the source of either complaint • Pseudohypertrophy sometimes present • Deep tendon reflexes difficult to elicit

43. II. Back pain Miscellaneous causes • Paroxysmal cold hemoglobinuria • Most commonly seen after viral infections • After cold exposure, child experiences back or abdominal pain, followed by chills, fever and hemoglobinuria • Multiple epiphyseal dysplasia • Most prominent symptom: painful joints – usually hips, knees and ankles – with decreased mobility • Frequent back pain • Gait may be waddling

44. II. Scoliosis • Defined as a lateral curvature of the spine from its normal straight position • Rotational deformity of spine present as well • Many children have an inconsequential curvature of less than 10° to 15 ° • True scoliosis worrisome because of the possibility of progression during growth to a degree that might affect cardiopulmonary function • Described by the direction of convexity of the curve • Right thoracic and left lumbar scoliosis = most common pattern in idiopathic scoliosis

45. II. Scoliosis • Prevalence of scoliosis with curves >10° in adolescents estimated to be 2% to 3% • Idiopathic scoliosis comprises 60% to 80%of cases • Most children with idiopathic scoliosis require no therapy • Close follow-up recommended in order to detect undue progression of curvature • Scoliosis in an adolescent is not necessarily idiopathic • May be a sign of an occult neuromuscular disorder or other pathologic conditions

46. II. Scoliosis • Of importance in determining possible causes: • age at which scoliosis is noted • rapidity of development • Painful scoliosis should never be considered idiopathic in adolescent • Adolescent with left thoracic kyphosis should be evaluated for underlying pathology • Delayed developmental milestones may suggest neuromuscular cause

47. Idiopathic Congenital vertebral defect Leg length discrepancy Neurofibromatosis Neuromuscular disorder II. Scoliosis – Most common causes

48. II. Scoliosis – Nonstructural causes • Primary postural scoliosis • Condition most commonly seen in children between 10 and 15 years of age • Shoulders may be rounded • One hip may seem more prominent than the other • Apparent curvature disappears on forward flexion or on lying down

49. II. Scoliosis – Nonstructural causes • Secondary postural scoliosis • Curvature = a result of other conditions, such as leg discrepancy • Curve disappears on forward flexion • Hysterical scoliosis • Unusual type • Scoliosis not present on forward flexion

50. II. Scoliosis – Structural causes • Idiopathic scoliosis • Probably genetic cause in 90% of cases • Infantile scoliosis • Noted in the first 3 years of life • Rare in US • More common in boys than in girls • Curvature lessens with age in most cases