Back pain in children is much more likely to have a serious underlying disorder compared with adult back pain and deserves careful attention.¹ Unfortunately the diagnosis of serious disease causing back pain in children is often made late or missed completely.^2,3 However, although persistent back pain in children and adolescents is more often due to a specific or serious cause,⁴ back pain in children and adolescents is still often benign.⁵

Epidemiology

• Nonspecific back pain in children is increasingly prevalent.⁶
• However, back pain is much less common than in adults with fewer than 30% of children and adolescents reporting back pain, and very few presenting to doctors with their pain.⁷

Aetiology

Older children

• Overuse and back strain or musculoligamentous injury
• Disc problems: disc herniation, Scheuermann's disease
• Vertebral fractures
• Spondylolysis
• Spondylolisthesis

Younger children and older children

• Infection; usually in under 10 year-olds:
  • Discitis
  • Osteomyelitis
  • Pyelonephritis
  • Retroperitoneal infection
• Bone tumours: primary osseous neoplasms are rare. The most common are Ewing's sarcoma, aneurysmal bone cyst, benign osteoblastoma,⁸ osteoid osteoma and primary lymphoma
• Tumours of spinal cord, e.g. ependymoma
• Congenital disorders of the spine, e.g. scoliosis
• Systemic disease, e.g. sickle cell disease

Presentation

• Good clinical assessment will diagnose most causes of pain.
• The younger the child and the longer the history, the more likely it is that a serious underlying condition is responsible for the symptoms.
• An algorithmic approach to paediatric back pain has been tested.⁷

History

It is essential to take a careful history. This should incorporate:

• Characteristics of pain, including duration, severity, radiation of pain, disturbance of sleep and activities, and associated and exacerbating factors.
• Accompanying symptoms, e.g. fever, weight loss, neurological symptoms (weakness, numbness, gait disturbance, bowel and bladder dysfunction.
• Past medical history, e.g. previous episodes of neck or back pain, arthritis, trauma.
• Family history, e.g. arthritis, scoliosis.
• Psychological history, e.g. depression aggravating back pain or back pain causing depression. See separate article Depression in Children and Adolescents.
• Social history, e.g. carrying school bags, school activities, sports activities (especially contact sports, gymnastics,⁹ diving, bowling in cricket).

Examination

See also the separate article Examination of the Spine. Physical findings are likely to be found, particularly in persistent back pain (unlike in adults).¹⁰ Examination should include:

• Localisation and evaluation of pain
• Tenderness (site of maximal tenderness)
• Inspection (to detect deformity, wasting, kyphosis and scoliosis)
• Gait
• Flexibility
• Neurological examination (including power, tone, reflexes, sensation)

Clinical indicators of serious pathology⁴

• Age under four years
• Symptoms persisting for more than four weeks
• Interference with function
• Systemic features (fever, weight loss)
• Worsening pain
• Neurological features
• Recent onset of scoliosis
• Stiffness

Investigations

Persistent back pain in children can usually be diagnosed by history, examination and relatively simple tests (blood tests, plain radiography, bone scans).^5,11 In the absence of indications for urgent referral (see below), initial assessment can be performed in general practice.

• Blood investigations might include full blood count, ESR and CRP, rheumatoid factor and other rheumatological autoantibody tests (may be indicated if arthritis is suspected), urea and electrolytes, liver function tests, amylase.
• Imaging: plain X-rays, including posterior-anterior (PA) and lateral, CT scanning, MRI scan.
• Radionucleotide imaging studies: including planar bone scanning and single-photon emission computed tomography scanning (SPECT). Indications for SPECT include young at-risk athletes with persistent symptoms, to uncover stress fractures.¹²

Differential diagnosis

It is important to pursue a diagnosis. It is more usual to make a diagnosis of a specific cause in children and nonspecific back pain is a diagnosis of exclusion. When considering the aetiology and diagnosis of back pain consider:

• Scheuermann's disease.¹³
• Vertebral fractures.
• Lumbar spondylolysis (a unilateral or bilateral stress fracture of the narrow bridge between upper and lower pars interarticularis):
  • This causes low back pain quite commonly in adolescent athletes.
  • Consider especially age 11-17 years.
  • Occurs in sports with repetitive flexion and extension. Sports include: gymnastics, diving, weight lifting, rowing, tennis, cricket and football.
  • On examination patients may have a waddling gait associated with hamstring tightness and a lordotic posture.
  • Most memorable test for spondylolysis is the stork test (standing on one leg and bringing back into lumbar extension elicits pain on the side ipsilateral to pars interarticularis lesion).
  • SPECT scanning is the most sensitive imaging test to detect spondylolysis.
• In some cases, spondylolysis persists to become spondylolisthesis (25% of cases). This occurs particularly in adolescent athletes.
  • It is often asymptomatic, but symptoms typically occur at the time of the growth spurt.
  • It usually causes focal pain aggravated by certain activities (particularly spinal extension and, to a lesser degree, rotation).
  • Rest improves pain. Pain is sharp, mild-to-moderate in intensity and can radiate to the buttock.
  • The classic Phalen-Dickson sign (knee-flexed, hip-flexed gait) may occur in spondylolysis, especially if there is associated spondylolisthesis.
• Infection:
  • Pyogenic vertebral osteomyelitis is the most common form of vertebral infection.
  • Children usually present with abrupt onset of malaise, fever and back pain with stiffness, restricted movement, guarded walking and spinal tenderness.
  • Leucocytosis, raised ESR and CRP are usual findings.
  • CT scanning detects earlier than plain radiographs, and MRI scanning is better still.
  • Radionucleotide scanning, especially technetium combined with gallium, demonstrates virtually all pyogenic vertebral infections.
• Ankylosing spondylitis:
• Tumours: bone tumours may present with pain and can be demonstrated on plain radiographs.
• Overuse, nonspecific back pain and musculoligamentous injury. This settles quickly with rest but caution is due particularly with respect to the diagnosis of spondylolysis.

Management

About half of adolescent patients will have self-limiting, short-lived pain caused by overuse or strain. Management should incorporate:

• Confirmation of diagnosis and exclusion of serious pathology.
• Simple analgesia.
• Preventative measures with:
  • Advice and education
  • Physiotherapy
  • Exercise

For those patients more likely to have a serious pathology, early assessment to establish a differential diagnosis, and hence urgency of referral is important. All will require referral, and subsequent management will vary according to the underlying diagnosis.

Referral

Urgent referral is indicated if:¹⁴

• Pain is persistent. Particularly if under 11 years old and for several weeks.
• Pain is worsening.
• Persistent fever.
• Neurological deficit.
• Pain is accompanied by stiffness.¹⁵

Complications

• A variety of complications can arise depending on the diagnosis. In general terms complications may be reduced or prevented by timely diagnosis.
• Complications include delayed diagnosis (with possible implications for management and prognosis) and psychosocial difficulties, such as exclusion from sport, and depression.¹⁶

Prognosis

This is determined by the underlying diagnosis.

Prevention

Posture and psychosocial factors are important in back pain.¹⁷ Back education programmes are effective at improving posture but whether there is an effect on back pain in later life requires further investigation.^6,18

• Back packs:¹⁹ if back packs are too heavy or the weight is carried unevenly (over one shoulder) they can cause back pain. Recommendations include:
  • Limit weight to avoid:
    • Leaning or bending forward.
    • Distorting natural curves of middle and lower back.
    • Causing rounding of shoulders.
  • Avoid habitually carrying over one shoulder.
  • Choose good back pack design:
    • Lightweight material.
    • Padded adjustable side straps (2 inches wide).
    • Padded back.
    • Hip strap to distribute weight from shoulders to pelvis.
    • Wheeled varieties (to pull rather than carry).
  • Educate child on correct loading and wearing:
    • Use both shoulder straps.
    • Pack heavy items low in the backpack.
    • Use compartments to prevent sudden shifting of weight distribution.
    • Correct adjustment of backpack.
    • Advice on lifting backpack (bend legs not back).
    • Avoid overloading (which causes leaning and postural changes likely to cause strain and pain).
• Beware of certain sports in younger children, e.g. rowing, diving, gymnastics,⁹ cricket bowling.
• Encourage sports which improve isometric muscle endurance, as high isometric muscle endurance is associated with less back pain.²⁰

Screening

Screening programmes for scoliosis are not indicated but back pain in children requires vigilance and opportunistic diagnosis.

Document references

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Acknowledgements