“Back Pain in Children”

1. “Back Pain in Children” Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana

2. “Back Pain in Children” • The problem with back pain in children is that little has been written • Very little has been published concerning the incidence or causes of back pain in children • Recently, we have now realized that children do have back pain

3. “Back Pain in Children” • Experience indicates that the complaint of back pain in children warrants careful evaluation • This evaluation will lead one to an diagnosis of organic pathology • Most importantly, a carefully planned strategy of evaluation so no significant problems are missed must be formulated

4. “Back Pain in Children” • It is ill-advised to make the diagnosis of stress or psychological problems until all possible organic causes have been excluded • Likewise, the diagnosis of “growing pains” of the spine should not be rendered until a detailed workup is completed and no other causes noted

5. “Back Pain in Children” “Medical History” • Detailed history should be obtained with both the child and parent present • Look at onset of symptoms, location, frequency, duration, and intensity • Identify traumatic from those with a slow insidious onset

6. “Back Pain in Children” • Inquire about sports and other specific activities • ‘Spondylolysis’ is frequently seen in those patients engaged in football, dance, or gymnastics • This may also help one identify “overuse” syndromes

7. “Back Pain in Children” • Children who participate at a very high level and practice for many hours, support the diagnosis of stress fracture or overuse • Symptoms that are interfering with normal activity or limits the child’s participation in sports or voluntarily gives up an activity is worrisome

8. “Back Pain in Children” • Night pain is important • Can be associated with tumors, infection, and inflammatory conditions • This mandates a complete and meticulous workup • Symptoms that improve with bed rest leads one to the diagnosis of spondylolysis, spondylolisthesis, Scheuermann’s, and overuse

9. “Back Pain in Children” • Nature of the pain is important suchn as localized, diffuse, or radiating • Localized seen with spondylolysis and tumors • Diffuse seen with overuse problems, Scheuermann’s, or inflammatory • Radicular suggests neurocompression

10. “Back Pain in Children” • Question family and child about changes in neurologic function • Changes in balance and coordination must be evaluated • Falls or recent stumbling are important to the diagnosis

11. “Back Pain in Children” • Question the child and family about weight loss, fever, lethargy, skin rashes, joint pains, and swelling • Lymphomas, Leukemia, infections and rheumatologic conditions can present with a primary complaint of back pain

12. “Back Pain in Children” “Physical Examination” • General screening examination • Spinal exam looks at posture, alignment, and skin patterns • Midline skin defects, café-au-lait spots and cysts should be noted and can indicate underlying problems • These can communicate with underlying neural structures

13. “Back Pain in Children” • Forward bending test is a critical part of the examination • Look for thoracic or lumbar asymmetry, limited or asymmetric movement of the spine • Listing or dysrhythmia or a rigid lumbar lordosis on forward bending will lead one to the cause for the back pain

14. “Back Pain in Children” • Detailed neurologic examination should be performed: motor, sensory and reflex’s • Look for clonus or a Babinski sign • Abnormal abdominal reflex is a subtle sign of spinal cord pathology • Asymmetry or absence of the reflex has been associated with syringomyelia or spinal cord tumors

15. “Back Pain in Children” “Radiographic Evaluation” • AP and lateral radiograph’s • Oblique radiographs are not necessary initially unless a suspicion exits • Bone scan, CT scan and MRI are utilized as the specific differential is worked through

16. “Back Pain in Children” “Bone Scan” • Useful in finding tumors, discitis, and stress fractures • Pinhole images are useful for tumor nidus such as osteoid osteoma or for a pars stress fracture • Three-phase is used if vascularity is of a concern

17. “Back Pain in Children” • SPECT scan is utilized and is better for stress fractures of the spine and are more precise • Help locate stress fractures if a plain bone scan is negative and there is a high suspicion on plain radiographs as well as differentiate unilateral from bilateral pars defects

18. “Back Pain in Children” “CT Scan” • Used as an adjunct to evaluate lesions seen on plain radiograph or bone scan • Not a screening study • Used for evaluating tumors, fractures, disc herniations, and spondylolytic lesions for healing or age for bracing decision making

19. “Back Pain in Children” “MRI” • Useful for evaluating the spinal cord, neural elements, tumors, and syringomyelia • Not though a shot gun screening examination to replace all others • Used best when the clinical signs and symptoms deem it appropriate

20. “Back Pain in Children” • Best for the evaluation of spinal cord tumors, syringomyelia, bone tumors, discitis, and disc herniations • Not helpful in the evaluation of stress fractures though recent studies point to an increase sensitivity

21. “Back Pain in Children” “Laboratory Evaluation” • Used if suspicion exists for infection, rhematologic disease, lymphoma, or leukemia • Useful tests include CBC, ESR, urinalysis, and lytes • HLA B27, RF, RA, ANA if rheumatologic condition is suspected

22. “Back Pain in Children” “Differential Diagnosis” • Mechanical • Developmental • Inflammatory • Neoplastic

23. “Back Pain in Children” “Mechanical Disorders” • Postural problems • Muscular problems • Overuse syndromes • Herniated Nucleus Pulposis

24. “Back Pain in Children” “Developmental Disorders” • Spodylolysis • Spondylolisthesis • Scheuermann’s Disease

25. “Back Pain in Children” “Inflammatory Disorders” • Discitis • Disc Space Calcification • Osteomyelitis • Rheumatologic Conditions • JRA • Ankylosing spondylitis

26. “Back Pain in Children” “Neoplastic Disorders” • Vertebral column • Spinal cord/canal • Muscle • Metastatic tumors

27. “Back Pain in Children” • Incidence is variable in the population • Fairbanks et al found an incidence of 26% • Grantham et al reported an incidence of 11.5% • Balague et al a 14% incidence of back pain that required medical attention

28. “Back Pain in Children” • Spondylolysis and spondylolisthesis are the most common causes of back pain in children • 11% of children with back pain had a tumor identified: King et al • Age gives a clue to the diagnosis too • Under 10: discitis and tumor • Over 10: spondylolysis, spondylolisthesis and Scheuermann’s

29. “Back Pain in Children” “Spondylolysis/Spondylolisthesis” • Nonspecific back pain • Aggravated with activity • Improved with rest • Higher Incidence female and gymnast • Ferguson et al: competitive football linemen

30. “Back Pain in Children” • Teitz et al reported incidence of 15 to 20% in dancers • Recent study shows a high hereditary incidence of pars defect Wiltse et al and O’Hata et al • Major presenting complaint: hamstring tightness and buttock discomfort with decrease flexibility lumbar spine

31. “Back Pain in Children” “Scheuermann’s Disease” • Second most common cause • Pain that starts later in the day or after strenuous activity • Poor posture • Symptoms are aggravating but not limiting

32. “Back Pain in Children” • Obvious kyphosis on forward bend • Radiographs show typical findings of wedging of three or more consecutive vertebral bodies and end-plate irregularities • If symptoms and history do not match the radiographic findings, consider bone scan

33. “Back Pain in Children” “Discitis” • Seen patients from one to twelve years of age • Long duration of symptoms • May or may not be febrile • Generally ill appearance • Back pain, refusal to walk, abdominal pains can be seen as initial presentation

34. “Back Pain in Children” • Radiographs can confirm the diagnosis • Bone scan helpful early in the course of the disease process • ESR and WBC elevated • MRI helpful to localize the lesion and the extent bone and soft tissue involvement • Treatment variable: brace, antibiotics, rest

35. “Back Pain in Children” “Tumors” • Occur in the bone, along the spinal cord, and in the soft tissue • Present with nonspecific complaints of back pain • Night pain or pain unrelated to any activity • Changes in coordination and bowel/bladder changes frequently seen

36. “Back Pain in Children” • Clinically show back listing or atypical scoliosis • Left sided scoliosis is common with tumors • Clonus, Babinski sign, or asymmetry of abdominal reflex can be seen • MRI with and without gadolinium is the best test for the evaluation of the spinal cord and soft tissue

37. “Back Pain in Children” • Back pain is a fascinating area of pediatric orthopaedics • Incidence of back pain in children is fairly high • Vast majority never seek medical advice • Those who do, the incidence of a definable cause of symptoms is quite high

38. “Back Pain in Children” • Careful, detailed medical and radiographic evaluation must be performed • Imaging studies should be used when indicated • But even with all this, after a diligent workup, one can expect to identify the cause in over 50% of the patients only

39. “Back Pain in Children” THANK YOU