back pain in children daniel j. sucato, m.d., m.s. b. stephens richards, m.d. texas scottish rite...

Back Pain in Children

Daniel J. Sucato, M.D., M.S.Daniel J. Sucato, M.D., M.S.B. Stephens Richards, M.D.B. Stephens Richards, M.D.Texas Scottish Rite Hospital for ChildrenTexas Scottish Rite Hospital for Children

GeneralGeneral

• Different from adults - whose cause is often Different from adults - whose cause is often not apparent.not apparent.

• In young children, back pain of lasting In young children, back pain of lasting duration is distinctly abnormal. Such duration is distinctly abnormal. Such complaints are very significant and require complaints are very significant and require thorough evaluation.thorough evaluation.

Prevalence of childhood back painPrevalence of childhood back pain

• Increases with age:Increases with age:– 1% in 7 year olds1% in 7 year olds– 6% in 10 year olds6% in 10 year olds– 18% in 14 year olds18% in 14 year olds

– 11.6% in 11 year olds11.6% in 11 year olds– 50.4% in 15 year olds50.4% in 15 year olds

Taimela et al Spine 22, 1997Burton et al Spine 21, 1996

HistoryHistory

Important aspects in evaluating back pain:Important aspects in evaluating back pain:

• Onset (insidious or traumatic)Onset (insidious or traumatic)

• DurationDuration

• IntensityIntensity

• ChronicityChronicity

HistoryHistory

• Type Type (repetitious pain after activity? night pain?)(repetitious pain after activity? night pain?)

• Location Location (localized or radiating)(localized or radiating)

• What aggravates or relieves pain What aggravates or relieves pain (anti-(anti-inflammatories)inflammatories)

• Neurological changes Neurological changes (gait, (gait, incontinence)incontinence)

• Fever, weight lossFever, weight loss

Physical ExamPhysical Exam

Properly dressed down to gown and underwear.Properly dressed down to gown and underwear.


Check for:Check for:• Posture Posture (Kyphosis – roundback)(Kyphosis – roundback)

• ScoliosisScoliosis (usually not painful and may (usually not painful and may be secondary to underlying pathology)be secondary to underlying pathology)

• Pelvic obliquityPelvic obliquity• Stiff movements Stiff movements (a child may not bend over)(a child may not bend over)



• ScoliosisScoliosis (usually not painful and (usually not painful and may be secondary to underlying may be secondary to underlying

pathology)pathology)




• ScoliosisScoliosis (usually not painful and may (usually not painful and may be secondary to underlying pathology)be secondary to underlying pathology)



• Direct pain to palpation or Direct pain to palpation or percussion.percussion.

• Loss of normal back contours Loss of normal back contours (flat (flat back in lumbar region back in lumbar region may may suggest spondylolisthesis)suggest spondylolisthesis)


• Pain with flexion (herniated Pain with flexion (herniated disc? – uncommon)disc? – uncommon)

• Pain with hyperextension Pain with hyperextension (spondylolysis – common (spondylolysis – common cause cause of childhood back of childhood back pain)pain)


• Neurological exam Neurological exam (reflexes, strength, (reflexes, strength,

size, etc.)size, etc.)

Aids in DiagnosisAids in Diagnosis

• AP and Lateral x-rays of region AP and Lateral x-rays of region of of symptomatic spinesymptomatic spine

• Oblique x-rays Oblique x-rays (spondylolysis)(spondylolysis)

• Bone scan (stress fractures, Bone scan (stress fractures, diskitis, diskitis, tumors)tumors)

Aids in DiagnosisAids in Diagnosis

• MRI (cord abnormalities, tumors)MRI (cord abnormalities, tumors)

• CT scanCT scan

• LabsLabs

– CBC, CRP, ESR, UA, CBC, CRP, ESR, UA, occasional rheumatological occasional rheumatological

studiesstudies

Causes of childhood back pain Causes of childhood back pain ….….

Musculoskeletal StrainMusculoskeletal Strain

• The most common cause of back pain in children The most common cause of back pain in children and adolescents.and adolescents.

• TreatmentTreatment– RestRest– Anti-inflammatoriesAnti-inflammatories– Low back exercise programLow back exercise program

Do Backpacks = Back pain ?Do Backpacks = Back pain ?

21 pounds

Backpacks………………..Backpacks………………..

• Books weighing more than 15-20% body Books weighing more than 15-20% body weight is associated with back pain.weight is associated with back pain.

• No evidence that spinal deformity can result No evidence that spinal deformity can result from backpack use.from backpack use.

• 89% of backpack injuries do 89% of backpack injuries do notnot involve the involve the back back (head/face, hand, wrist/elbow, shoulder, foot/ankle)(head/face, hand, wrist/elbow, shoulder, foot/ankle)

Mackenzie et al Clin Orthop 409:78, 2003Wiersema et al Pediatrics 111:163, 2003Siambanes et al J Ped Orthop 24:211, 2004

Other “common” causes to be aware Other “common” causes to be aware of……of……

SpondylolysisSpondylolysis

• Defect in posterior aspect Defect in posterior aspect (pars (pars interarticularis) of interarticularis) of a a lower lumbar vertebralower lumbar vertebra

• Frequent “diagnosable” Frequent “diagnosable” cause of childhoodcause of childhood back painback pain

• Present in 5% of the North Present in 5% of the North American American populationpopulation


• Gymnasts, dancers, football players, weight Gymnasts, dancers, football players, weight lifterslifters


• Acquired during growth (not congenital) Acquired during growth (not congenital) usually between age 5-10.usually between age 5-10.

• If symptomatic, the pain is chronic - If symptomatic, the pain is chronic - worsening with activity and improving with worsening with activity and improving with rest.rest.

• Pain increases with hyperextensionPain increases with hyperextension


• X-rayX-ray– Oblique views are best to show Oblique views are best to show

defectdefect– Begins as a stress (fatigue) Begins as a stress (fatigue)

fracturefracture– Bone scan may demonstrate Bone scan may demonstrate

stress fracture if not apparent stress fracture if not apparent on plain x-rayson plain x-rays


• RXRX– If not symptomatic,If not symptomatic, observe onlyobserve only– If symptoms are mild,If symptoms are mild, limit the limit the

offending activitiesoffending activities– If symptoms are moderate, may If symptoms are moderate, may

bracebrace– If symptoms are severe and resistant to If symptoms are severe and resistant to

conservative treatment, surgery is beneficialconservative treatment, surgery is beneficial

Treatment Treatment OperativeOperative

• Screw in pedicle with wire around spinous Screw in pedicle with wire around spinous processprocess

FusionFusion

SpondylolisthesisSpondylolisthesis

• Forward slippage of the 5Forward slippage of the 5 thth lumbar on the lumbar on the sacrum.sacrum.

• Spondylolysis (above) is Spondylolysis (above) is always present.always present.

• Physical exam demonstrates Physical exam demonstrates flat back and tight flat back and tight

hamstrings.hamstrings.

SpondylolisthesisSpondylolisthesis

• RXRX– If “slip” is mild and asymptomatic, only If “slip” is mild and asymptomatic, only

observe.observe.– If “slip” is progressive or severe, surgical If “slip” is progressive or severe, surgical

fusion is necessary.fusion is necessary.

Scheuermann’s Kyphosis - RoundbackScheuermann’s Kyphosis - Roundback

• Occurs most commonly Occurs most commonly in adolescent males.in adolescent males.

• May cause midthoracic May cause midthoracic or low thoracic back or low thoracic back pain of aching nature.pain of aching nature.

Scheuermann’s Kyphosis -RoundbackScheuermann’s Kyphosis -Roundback

• Lateral x-ray demonstrates Lateral x-ray demonstrates kyphosis kyphosis exceeding 45 exceeding 45 degrees and wedging degrees and wedging of of the involved vertebral the involved vertebral

bodies.bodies.

Scheuermann’s Kyphosis - RoundbackScheuermann’s Kyphosis - Roundback

• TreatmentTreatment– In a growing child, bracing might arrest In a growing child, bracing might arrest

progression and relieve symptoms.progression and relieve symptoms.

Scheuermann’s Kyphosis -RoundbackScheuermann’s Kyphosis -Roundback

• SurgerySurgery

Disc Space Infections Disc Space Infections

• More common in children than adolescents.More common in children than adolescents.

• Isolated disc infection usually caused by Isolated disc infection usually caused by staph aureus.staph aureus.

Disc Space InfectionsDisc Space Infections

• Irritable child refuses to walk or stand, but Irritable child refuses to walk or stand, but does not appear acutely ill.does not appear acutely ill.

• Back pain, spasm, tenderness Back pain, spasm, tenderness (usually lumbar) loss of (usually lumbar) loss of lordosis, lordosis, limited spine motion.limited spine motion.


• LabsLabs– Elevated ESR and CRP, normal WBC, +/- Elevated ESR and CRP, normal WBC, +/-

positive blood culturespositive blood cultures


• Needle aspiration is not necessaryNeedle aspiration is not necessary..


• RxRx– Rest - Bedrest with/without cast or corset.Rest - Bedrest with/without cast or corset.– Antibiotics – penicillinase resistant anti-staph.Antibiotics – penicillinase resistant anti-staph.

• Studies demonstrate improvement Studies demonstrate improvement with/without the use ofwith/without the use ofantibiotics.antibiotics.

SummarySummary

• Musculoskeletal strainMusculoskeletal strain

• SpondylolisthesisSpondylolisthesis

• Scheuermann’s kyphosisScheuermann’s kyphosis

• Disc space infectionsDisc space infections

• Other less common causes….Other less common causes….(tumor, trauma, infection, visceral)(tumor, trauma, infection, visceral)

Thank youThank you

back pain in children daniel j. sucato, m.d., m.s. b. stephens richards, m.d. texas scottish rite...

Documents

physical exam pain

physical exam slide

direct pain

pain increases

night pain

spondylolisthesis slide

pain of lasting duration

overstiff movements