Basics
Description
Any condition causing pain of the thoracic, lumbar, or sacral spine
Epidemiology
- 12-month period prevalence: 10-20% of children
- Lifetime prevalence: 12-50%
Risk Factors
- Poor conditioning or high athletic performance
- Joint hypermobility
- Role of backpack weight and style of wear undetermined
- Role of overweight or obesity yet to be determined
General Prevention
- Back muscle strengthening and hamstring stretching exercises may be helpful.
- Maximum backpack load: 10-15% body weight
- Weight loss and increased physical activity in overweight or obese children
Pathophysiology
- Dependent on underlying cause
- Hyperextension with rotational spinal loading in the case of pars defects (e.g., spondylolysis or spondylolisthesis)
- Autoimmune or autoinflammatory processes as with juvenile idiopathic arthritis (JIA) or juvenile ankylosing spondylitis
Etiology
- Unidentified in 50% of cases
- 30% of chronic cases (back pain >3 years) without clear etiology despite workup
Diagnosis
History
- History can be helpful with elucidating most likely cause.
- Musculoskeletal/trauma
- Direct trauma
- Worsening pain after activity
- Repetitive movements causing microtrauma
- Inflammatory
- Morning stiffness (variable pain)
- Pain/stiffness improves with movement.
- Family history of rheumatic disease
- Infectious
- Fever
- Recent exposure to infection or tuberculosis (TB)
- Malignancy
- Night sweats, fever, weight loss, malaise, pain waking at night
- Previous history of malignancy
- Neurologic
- Radiating pain or foot drop
- Loss of bowel or bladder function
- Endocrine/metabolic
- Long-term steroid use
- Vitamin D deficiency
- Psychosocial stressors (e.g., family coping mechanisms and response to pain and stress)
Physical Exam
- Finding: observation: sacral dimple, vascular anomalies, posture, spinal curvature, anterior superior iliac spine (ASIS) height, limb length discrepancy, foot arch, lower limb alignment, rib rotation
- Significance: occult problem; mechanical or musculoskeletal problem. Scoliosis is rarely painful. Increased fixed kyphosis of 40 degrees is indicative of Scheuermann disease.
- Finding: palpation: point or focal tenderness along spine; sacroiliac (SI) joint tenderness
- Significance: If bony, consider fracture, vertebral osteomyelitis; if paraspinal, consider muscle strain. If SI tenderness, consider spondylitis.
- Finding: range of motion: pain with spinal extension (causing strain of anterior elements of spine)
- Significance: Consider spondylolisthesis (forward vertebral displacement), spondylolysis (vertebral defect), fracture, vertebral osteomyelitis, or tumor.
- Finding: range of motion: forward spinal flexion limitation
- Significance: If painful, consider diskitis, vertebral osteomyelitis, vertebral body tumor, and herniated disc if pain radiates.
- Significance: If limited as noted by flattening of lumbosacral region with movement, consider spondylitis.
- Finding: range of motion: restriction of spine with pain (especially with neck extension) and other associated joint abnormalities (swelling or pain/tenderness with limitation)
- Significance: Consider JIA.
- Special Tests: pain with straight-leg raise: Consider tight hamstrings, psoas strain, or disc herniation.
- Special Tests: pain with FABER (flexion, abduction, external rotation with foot on opposite knee) testing or direct palpation of SI joint: SI joint irritation or inflammation
- Special Tests: Assess reflexes, sensation, Babinski, pain, and proprioception; deficits may indicate neuronal involvement.
- Abdominal or pelvic exam may be helpful.
Diagnostic Tests & Interpretation
- Tests: CBC with differential, sedimentation rate, C-reactive protein (CRP), and comprehensive metabolic panel with uric acid and LDH
- Significance: malignancy, infection, inflammatory
- Antinuclear antibody, rheumatoid factor, anticyclic citrullinated antibody, and HLA B27 only if obvious other associated joint abnormalities found
- Significance: inflammatory/autoimmune disorders
- Cultures, PPD, or other TB study
- 25-OH vitamin D, PTH, calcium, phosphorus, alkaline phosphorus
- Significance: vitamin D deficiency or osteoporosis
Imaging
- Plain x-rays
- AP and lateral; oblique and flexion/extension (if warranted) of the spine
- Assess for fracture, spinal curvature, osteomyelitis, and masses.
- Intra-articular pars defect commonly in L4/L5 indicates spondylolysis.
- Bilateral pars defect with vertebral body displacement indicates spondylolisthesis.
- Bone scan
- Occult/subtle bony lesions and spondylolysis and spondylolisthesis
- CT spine
- Useful to categorize lesions seen on bone scan such as spondylosis/spondylolisthesis
- MRI
- Tumor, infection, disk injuries, synovitis (including effusions or erosions), and neurologic findings
Differential Diagnosis
- Mechanical/trauma
- Overuse injury
- Disc herniation
- Direct trauma, contusion
- Musculoskeletal strain in children with closed growth plates
- Apophyseal ring fracture
- Structural
- Pars defects: children usually >10 years of age
- Spondylolysis/spondylolisthesis (anterior displacement/"slip" of vertebral body, evolution of bilateral spondylolysis)
- Scheuermann kyphosis: deformity of thoracic spine associated with vertebral body wedging
- Inflammatory
- JIA
- Juvenile ankylosing spondylitis
- Chronic recurrent multifocal osteomyelitis
- Neoplastic
- Ewing sarcoma
- Lymphoma, leukemia
- Infectious
- Osteomyelitis
- Epidural abscess
- Pyelonephritis
- Diskitis
- Endocrine/metabolic
- Osteoporosis
- Vitamin D deficiency
- Other
- Pain amplification syndrome (fibromyalgia, myofascial pain)
- Sickle cell crises, abdominal disease (pancreatitis, pyelonephritis)
- Age differentiation
- <10 years: diskitis, tumor, epidural
- >10 years: pars defects, inflammatory disorders
Alert
- Warning signs of potentially serious causes of back pain in children include the following:
- Young age: <7 years old
- Duration of pain: >4 weeks
- Acute trauma
- Night pain, fever, weight loss, or malaise
- Abdominal mass
- Early morning stiffness
- History of tumor
- Exposure to TB
- Limp
- Chronic interference with normal activity (e.g., school, sports, play)
- Postural changes causing scoliosis or kyphosis
- Other associated joint abnormalities (swelling OR pain/tenderness with joint limitation)
Treatment
Medication
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for overuse or strains in adolescents and for patients with arthritis
- Additional medication may be necessary depending on underlying condition such as antibiotics for infection, chemotherapy for malignancy, immunosuppression for inflammatory/autoimmune, or vitamin D and calcium supplementation for vitamin D deficiency or osteoporosis.
Additional Treatment
General Measures
- If no warning signs, conservative management with NSAIDs, physical therapy, and close follow-up are appropriate.
- Abnormal exam/history or focal symptoms warrant imaging.
- Spondylolysis/spondylolisthesis
- <50% slip: conservative medical treatment
- >50% slip/persistent back pain: surgical treatment
- Diskitis: antistaphylococcal coverage
- Bed rest/activity limitation: Adult data do not support this strategy.
Issues for Referral
- Sports medicine or orthopedics appropriate with Scheuermann disease, spondylolysis or spondylolisthesis
- Concern for malignancy or long-standing inflammatory process such as JIA or juvenile ankylosing spondylitis warrants referral to hematology/oncology or rheumatology, respectively.
- Endocrinology referral for suspected osteoporosis
Additional Therapies
- Physical therapy with focus on core strength and flexibility if cause is due to overuse or due to a sedentary lifestyle
- Removal from activity for overuse injuries with slow gradual return
- Structural problems such as spondylolysis, spondylolisthesis, and Scheuermann disease often respond to rest, ice, NSAIDs, and thoraco-lumbar-sacral orthosis bracing.
- A biopsychosocial approach is needed for patients with pain amplification syndromes in conjunction with physical and cognitive behavioral therapies and emphasis on functionality.
Complementary & Alternative Therapies
- Yoga and Pilates emphasizing core strength and flexibility may be useful in the adolescent.
- Cochrane systematic review determined massage may be useful in the setting of acute or subacute back pain in adults.
- Acupuncture may be useful for dealing with pain.
Surgery/Other Procedures
Indicated in patients with spondylolisthesis slip of >50%
Ongoing Care
Follow-up Recommendations
- Patients managed conservatively should be reevaluated within 2 weeks and then spaced further as their pain improves.
- If symptoms not improving with conservative measures, then consider workup as outlined and appropriate referral depending on results.
Patient Monitoring
No specific lab tests need to be routinely followed.
Patient Education
- Patients and families need to be aware that musculoskeletal and structural causes may take several weeks to heal.
- Pain in spondylolysis and spondylolisthesis does not always correlate with degree of involvement.
- Patients should be told to report changes in symptoms, especially any red flags.
Prognosis
- Dependent on the underlying cause
- With proper diagnosis and treatment, the majority do well, without significant sequelae.
- Not possible to predict future course of spondylolysis, spondylolisthesis, or Scheuermann kyphosis
Complications
- Contractures and loss of function
- Paralysis, other permanent neuromuscular injury
- Chronic back pain or development of pain amplification syndrome
Additional Reading
- Davis PC, Williams HJ. The investigation and management of back pain in children. Arch Dis Child Educ Pract Ed. 2008;93(3):73-83. [View Abstract]
- Furlan AD, Imamura M, Dryden T, et al. Massage for low-back pain: an updated systematic review within the framework of the Cochrane Back Review Group. Spine (Phila Pa 1976). 2009;34(16):1669-1684. [View Abstract]
- Houghton, K. Review for the generalist: evaluation of low back pain in children and adolescents. Ped Rheum. 2010;8:28. [View Abstract]
- Jackson C, McLaughlin K, Teti B. Back pain in children: a holistic and diagnostic approach. J Ped Health Care. 2011;25(5):284-293. [View Abstract]
Codes
ICD09
- 724.5 Backache, unspecified
- 724.1 Pain in thoracic spine
- 724.2 Lumbago
- 724.6 Disorders of sacrum
- 847.9 Sprain of unspecified site of back
- 720.0 Ankylosing spondylitis
ICD10
- M54.9 Dorsalgia, unspecified
- M54.6 Pain in thoracic spine
- M54.5 Low back pain
- M53.3 Sacrococcygeal disorders, not elsewhere classified
- M45.9 Ankylosing spondylitis of unspecified sites in spine
- S39.012A Strain of muscle, fascia and tendon of lower back, init
SNOMED
- 161891005 backache (finding)
- 279038004 thoracic back pain (finding)
- 279039007 low back pain (finding)
- 61486003 sacral back pain (finding)
- 9631008 Ankylosing spondylitis (disorder)
- 262965006 Strain of back muscle (disorder)
FAQ
- Q: Which children with back pain should have activity restriction?
- A: Children with spinal or bony abnormalities should avoid hyperextension and high-impact sports.
- Q: When can/should the child resume activities after an acute back injury?
- A: Children with a normal neurologic exam and diagnostic studies can resume activity or sports as tolerated.
- Q: Should a trial of steroids be used to rule out inflammatory back pain?
- A: Pain improvement with glucocorticoids may suggest an inflammatory condition but is not diagnostic. It is not recommended in children, as it can often complicate the clinical picture, as noninflammatory back pain will sometimes respond to treatment as well.