evaluation of back pain

SYMPOSIUM: CONNECTIVE TISSUE AND BONES

Evaluation of back painRebecca Mills

Colin Nnadi

Nick Wilkinson

AbstractBack pain in childhood has been shown to be far more common than previ-

ously thought, with the estimated lifetime prevalence as high as 70e80% by

the age of 20. For most of these children, the pain is not severe enough to

limit their daily activities and they do not present to the clinician. However

in those that do it is important to have a clear strategy for the consult to

ensure that those likely to have serious underlying pathology are appropri-

ately investigated and are referred to specialists promptly. Likewise it is help-

ful to be able to identify those with non-specific musculoskeletal back pain

who are likely to respond well to conservative management with rest, anal-

gesia and physiotherapy as necessary. This article provides an overview of

the important and common causes of back pain in children, and highlights

key features in the history and examination that should raise suspicion of

an underlying disorder and prompt further investigation.

Keywords adolescent; back pain; child; diagnosis; diagnostic imaging;

medical history taking; spinal diseases

Introduction

Population studies suggest back pain is common in children and

adolescents with the estimated lifetime prevalence reaching as high

as 70e80% by age 20. Back pain in this age group is largely self-

limiting, and rarely sufficient to warrant non-attendance at school

or sports activities. Few of these children present to the medical

profession, however in those that do, the likelihood of finding

underlying pathology is thought to be considerably greater than it

would be for the adult population. Thus each and every consulta-

tion requires a thorough history and examination focussing

particularly on those features suggestive of the more worrying

causes (tumours, infection, disc herniation etc) whilst retaining the

ability to positively identify those with a more benign musculo-

skeletal cause. It is also important to remember that pain from else

where in the body, particularly the abdomen and other joints, may

manifest initially as back pain.

This review is to aid the non-specialist clinician organize their

approach to a child or adolescent complaining of back pain. This

Rebecca Mills BA BMBCh Nuffield Orthopaedic Centre, Headington,

Oxford, UK. Conflict of interest: none declared.

Colin Nnadi MBBS FRCS (Trauma & Orth) is a Consultant Orthopaedic Surgeon

at the Nuffield Orthopaedic Centre, Headington, Oxford, UK.

Conflict of interest: none declared.

Nick Wilkinson MB ChB MRCP MRCPCH DM is Consultant Paediatrician and

Paediatric Rheumatologist at the Nuffield Orthopaedic Centre,

Headington, Oxford, UK. Conflict of interest: none declared.

PAEDIATRICS AND CHILD HEALTH 21:12 534

includes the request of appropriate investigations and when to

make a timely referral. It is intended to not only illustrate key

features that encourage a prompt specialist referral when serious

acute pathology is considered, but also identify those features that

can be managed locally through, for instance, a physiotherapy-led

home exercise plan. This article is split into two sections, firstly an

approach to the evaluation of a child with back pain, and then

a summary of the key diagnoses to be considered.

Clinical evaluation

History

Any child presenting with prolonged and intractable pain with

neurological symptoms, including bowel and bladder dysfunc-

tion, or in the presence of systemic features should be a cause for

concern. In other cases it is advisable to assess back pain in the

context of the age of the child (see Table 1). Back pain in a child

under eight is uncommon, especially in the absence of trauma and

more likely to be associated with spinal pathology. In a particu-

larly young child, the parents may not observe spinal discomfort

but rather report non-specific symptoms such as irritability,

refusal to weight bear or crawl. It is only when a full musculo-

skeletal examination is performed that the tenderness or deformity

of the spine is identified. This may indicate discitis or, if system-

ically unwell with lethargy and weight loss, other infections or

neoplasia such as neuroblastoma or leukaemia.

Equally worrying in an infant and older child is the possibility

of non-accidental injury and a detailed enquiry about the

mechanism of proposed injury may identify a lack of congruence

with subsequent examination findings or collateral histories.

In older children and adolescents, back pain in the presence of

systemic or neurological features will also cause significant

concern. A spiking fever with bony tenderness and nocturnal

wakening may suggest infection, whereas weight loss and bruising

with back pain could indicate malignancy. Pain that consistently

wakes a child at night should never be ignored and a primary bone

tumour should be considered.

Structural spinal abnormality is more common in the older

child and adolescent. Localization of the painmay bemore diffuse,

but there is often a precipitating event. Stress fractures of the pars

inter-articularis may be attributable to repetitive straining activi-

ties such as hyperextension manoeuvres in tennis, fast bowling in

cricket and gymnastics. Pain may be unilateral or bilateral and is

typically mild to moderate with sharp episodes on rotation or

extension of the spine.

Inflammatory conditions cause prolonged early morning stiff-

ness with the pain and stiffness improving with physical activity.

The pain is often episodic with cycles of disease flare and remis-

sion. Broader musculoskeletal enquiry may identify pain of

enthesopathy, such as at the insertion of Achilles, or joint swelling

and there may be a family history of psoriasis, inflammatory

bowel disease or ankylosing spondylitis.

A systems enquiry may indicate a gastrointestinal or renal cause

for pain, while a history of chronic disease, prolonged steroid use,

wheelchair dependence, reduced sun exposure and amenorrhoea in

an adolescent may identify risk factors for reduced bone minerali-

zation and fracture. In many areas of the UK, it is becoming

increasingly common to consider tuberculosis and enquiry about

travel and infectious contacts is important.

Crown Copyright � 2011 Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.paed.2011.07.012

Practice points

Key features in history:

C Intractable pain

C Neurological symptoms

C Systemic features

C Age

Causes of back pain in children by age of likelypresentation

Causes of back pain <8 years >8 years

Infection

Discitis U U

Vertebral osteomyelitis U U

Tuberculosis U U

Inflammatory

Juvenile idiopathic arthritis (JIA) (neck) U U

Juvenile spondyloarthropathy

(lumbosacral)

U

Developmental

Spondylolisthesis U

Spondylolysis U

Scoliosis U U

Neurological

Cord tethering U

Disc herniation U

Intradural lesion U U

Tumour

Malignant

Primary bone tumour U U

Secondary e.g. astrocytoma,

neuroblastoma,

U U

Leukaemia U U

Benign

Osteoid osteoma U

Osteoblastoma U U

Eosinophilic granuloma U

Aneurysmal bone cyst U

Metabolic

Osteoporosis U

Congenital

KlippeleFeil syndrome U U

Spinal dysraphism

Trauma (including non-accidental injury) U U

Chronic idiopathic pain U

Adverse biomechanics or

non-specific pain

U U

Table 1


The history is not complete without considering the impact of

pain on function and every day activity and, conversely, reduced

or sedentary activity may be the cause of the back pain. Back

pain is common in the adolescent population but infrequently

associated with significant pathology. Gauging the level of

disability will help guide management in terms of level of

medicinal and physiotherapy support. Furthermore dispropor-

tionately high levels of reported pain and disability, including

frequent or prolonged school absence, when compared to

examination findings may indicate chronic idiopathic pain or

juvenile fibromyalgia. In such instances sympathetic assessment

of disability will help to guide referral for full multidisciplinary


approach including clinical psychology once other conditions

have been ruled out by investigation.

Examination

The history and initial inspection of the young person will often

indicate whether a thorough systems examination is required.

However, routine examination especially of the younger child

should include measurement of weight and height, plotted

against a growth chart, and survey of the skin. This may identify

bruising, hairy patches overlying the spine or other congenital

lesions such as caf�e au lait marks and axillary freckling sugges-

tive of neurofibromatosis.

Examination of the spine requires full exposure of the back. It

may become difficult in a distressed young child to identify key

features of bruising or even a gibbous defect in a toddler without

doing so. Focal bony tenderness identified through simple

palpation or percussive compression should be assessed further

through radiological investigation. Other features to be assessed

include spinal alignment, paravertebral muscle spasm, mobility

and a stork test which requires the patient to stand on one leg

and balance while extending and rotating the spine.

Neurological assessment should include gait, level of activity,

balance and co-ordination. Motor power and sensation should

include functional assessment. Deep tendon reflexes and long

tract signs such as the Babinski sign or sustained ankle clonus

should be looked for. Clues to a neuromuscular disorder may be

found when examining proximal muscle power (eg gower sign)

and looking for cavus foot deformities.

A full screening assessment of the musculoskeletal system is

achieved by undertaking the pGALS (paediatric gait, arms, legs,

spine (see URL address below)). This will quickly identify

a limp, limb anomaly and any peripheral joint restriction from

arthritis or excess movement as in hypermobility disorders.

Assessment of the Beighton score will also help with the latter

diagnosis. Any abnormality detected by pGALS should be fol-

lowed up with a regional joint and muscle exam. Arthritic joints

are not always hot or clearly swollen, but may be detected by

subtle loss of range of or stiff movement. The Schober’s Test

measures thoraco-lumbar spinal movement, which is reduced

in juvenile spondyloarthropathy (see Figure 1).

Amore detailed assessment of biomechanics is required in those

with a non-specific history and examination in order to guide both

referrals to physiotherapy and promote self care. Growth spurts or

a physically deconditioned state may result in biomechanical

imbalances including hamstring, calf or hip adductor and flexor

tightness. Reduced muscle power can be directly assessed or

through observation of hopping or single leg dips.



5cm below

Iliac crest line/ dimples of Venus/ lumbosacral junction

10cm above

Figure 1 Modified Schober’s test: skin markings are made 10 cm above and

5 cmbelow the lumbosacral junction in themidlinewith the patient standing.

The patient is then asked to flex fully forward and the distance between the

two marks measured. The length should increase by at least 6 cm, an

increase of any less than this suggests limited lumbar mobility and is asso-

ciated with the spondyloarthropathies.

Practice points

Examination components:

C General

C Musculoskeletal

C Neurological

C Special tests


Imaging

The key decision is whether to image the spine and will depend on

the presence of intractable pain, focal tenderness, deformity,

neurological and systemic features, and suspicion of developmental

disorders or spondyloarthritis. Inmost cases anMRI scanwill be the

modality of choice, although is less accessible to those who are

young or claustrophobic, when a general anaesthetic may be

required.

Plain X-rays consisting of standing antero-posterior and lateral

views are useful in assessing sagittal and coronal plane deformities.

These help with grading of the severity of the condition as seen in

spondylolisthesis or scoliosis. Flexion and extension views are

controversial but can be used to assess instability in the cervical or

lumbar spine. Other useful diagnostic tools include CT as an alter-

native to MRI and bone scans to look for lesions elsewhere in the

skeleton.

Blood tests

These include a full blood count with inflammatory markers

(erythrocyte sedimentation rate and C-reactive protein). Auto-

antibodies such as anti-nuclear antibody or rheumatoid factor are

not diagnostic and rarely helpful in the assessment of back pain.

Genetic analysis may be considered where skeletal dysplasias or

syndromic conditions are suspected.

Other tests

Figure 2 Lateral radiograph showing narrowing of the intervertebral disc

space associated with discitis.

Muscle biopsy or nerve conduction studies may be helpful when

neurological pathology has been identified.

Key diagnoses

The differential diagnosis of back pain in the child includes

congenital, infective, inflammatory, developmental, trauma,


neurological, neoplastic (benign andmalignant), psychological and

non-specific causes.

Congenital

Congenital causes are rare. In a cephalo-caudal distribution, causes

includeKlippeleFeil syndrome in the neck,which canbe associated

with instability or degenerative changes adjacent to the vertebral

anomalies. Spinal dysraphismassociatedwith a tethered cord in the

thoraco-lumbar area can also lead to back pain. Neurological

anomalies are often associatedwith skin dimpling, pigmentation or

hairy patches. They are also characterized bymusclewasting in the

lower limbs or cavus foot deformities. MRI is used to investigate

cord anomalies and CT to assess the bony anatomy.

Infection

Discitis usually occurs in the younger child and commonly affects

the lumbar spine. The child will often complain of back pain and

be reluctant to bend the spine. Refusal to walk in a previously

mobile child, as well as abdominal pain, is not uncommon. These

children may look systemically well. Blood tests are often normal,

although the inflammatory markers may be raised. Plain radio-

graphs in the early phases are often unhelpful, however disc space

narrowing may be seen after 2e4 weeks (see Figure 2). MRI is the

imaging modality of choice and will show increased signal uptake

on the T2 weighted images. Blood cultures and biopsy do not

always yield positive results, with the latter investigation often

only being used after conservative treatment has failed. Most of

these children will be treated empirically with antibiotics, rest and

bracing. The commonest organism isolated is Staphylococcus

aureus. Atypical organisms are seen in the older child.

Inflammation

Juvenile idiopathic arthritis (JIA) affects 1 in 1000 children and

adolescents and may present as neck, back, or buttock pain alone.

Typically the history includes morning stiffness easing with

activity and, if severe, spondyloarthritis may be associated with




reduced lumbar movement. A full musculoskeletal assessment

may identify peripheral joint involvement as in polyarticular JIA

and recurrent fever and rash may indicate systemic onset JIA. In

both cases presentation may be with torticollis. In an older child or

adolescent lumbosacral back pain associated with enthesopathy,

pain at the insertion of tendons into bone, may indicate spondy-

loarthropathy attributable to juvenile ankylosing spondylitis or

psoriasis. Bone oedema, and sometimes synovitis, on MRI of the

spine, sacroiliac joints and pelvis will confirm the diagnosis.

Tissue typing for HLA-B27 and blood test inflammatory markers

do not confirm or refute spondyloarthritis, but may be helpful.

Developmental

Back pain in this group can be due to the presence of spondylolis-

thesis or spondylolysis. It normally occurs in the older child or

adolescent and affects about 7% of the population. Spondylolis-

thesis is classified according to causative factors with the dysplastic

(type 1) and isthmic (type 2) types occurring more often in this age

group. Spondylolisthesis describes the forward slippage of one

vertebra on another and is also graded according to severity of

slippage. A grade 1 is mild and a grade 5, known as a spondy-

loptosis, is the most severe with complete forward slippage of the

vertebra. Spondylolysis is described as a stress or fatigue fracture of

the pars inter-articularis, which occurs during repetitive loading in

this area in young athletes such as gymnasts, rowers or cricketers.

Symptoms are usually localized to the lower back but can also

involve the buttocks and posterior thighs. The hamstrings may be

tight and thismay lead to gait abnormalities. Neurological deficit is

rare. On examination, there is often a hyperlordotic profile with

midline tenderness and a step between the spinous processes in

patients with spondylolisthesis. Those with spondylolysis may

have restricted movement and pain on deep palpation.

Plain radiography is usually sufficient for diagnosis, using

a standing lateral film to identify spondylolisthesis or an oblique

view (demonstrating the classic ‘scotty dog’ sign) in spondylolysis.

MRI is becoming more frequently used to diagnose the latter due to

concerns regarding radiation exposure. Treatment is mostly

symptomatic with activity modification, rest, analgesia and

strengthening exercises. Surgery is rarely indicated. Patients should

be followed up until skeletalmaturity due to the risk of progression,

particularly in females.

Scoliosis

L5 verterbral body

Idiopathic scoliosis does not normally cause back pain. The pres-

ence of pain should lead to a low threshold for further investigation

as it may represent an underlying cause such as a tumour, syrinx,

tethering or infection. Most thoracic curves are right sided, thus

a left sided curve with pain may be indicative of underlying

pathology and this should be excluded with an MRI scan.

Spinal cordOsteoblastoma
Trauma invading right
pedicle & facet joint

Figure 3 Unenhanced CT showing a 18 mm osteoblastoma invading the

right L5 pedicle and demonstrating the mixed lytic and sclerotic features

of the lesion.

Spinal pathology is usually obvious with major trauma, but in

some cases occult fractures can occur after relatively innocuous

injuries. These can involve fractures to the spinous processes,

transverse processes, the pars, and facet joints. MRI or CT may

be needed for diagnosis. Treatment is symptomatic. Major

trauma can cause fractures to the cervical and thoraco-lumbar

spine. Conservative treatment with bracing will suffice in most

cases, but surgery may occasionally be required.


Tumour

Benign and malignant tumours can present with back pain. Other

features include spinal deformity, neurological signs in the lower

limbs, loss of sphincter control and systemic features. They are

commonly located in the thoracic and lumbar regions. Most will

be benign, and of those that are malignant, the majority will be

primary tumours.

Benign tumours include osteoid osteomas, osteoblastomas and

eosinophilic granulomas. Osteoid osteomas are small and sclerotic.

They are found in the posterior elements of the spine and cause

pain, which characteristically responds to non-steroidal anti-

inflammatory drugs. Osteoblastomas are larger andmay cause cord

compressionwith sequelae (see Figure 3). Eosinophilic granulomas

classically cause a vertebra plana deformity, which can be confused

with a fracture.

Malignant tumours of the spine are uncommon in children. They

may be osseus, extradural, intradural or a combination of all three.

Theymay be secondary deposits or haematological in origin such as

the leukaemias. Examples of primary tumours include astrocy-

tomas and neuroblastomas. These tumours are investigated with

MRI and CT and tissue biopsies are obtained. Treatment is usually

surgical.

Scheuermann’s disease

Scheuermann’s disease commonly occurs in adolescents. It causes

a hyper-kyphosis in the thoracic or thoraco-lumbar spine and is

associated with activity-related pain, which is worst over the apex

of the deformity. Pain can also be present in the lumbar spine if

there is a compensatory hyperlordosis. Some of these patients may

have an associated pars defect in the lumbar spine. Diagnosis is

based on the presence of anterior wedging of greater than 5� in at

least three adjacent vertebral bodies on lateral plain films (see

Figure 4). Indications for treatment include progressive pain and

worsening deformity. Normal thoracic kyphosis is 20e40�.Kyphosis over 60� with intractable pain requires treatment.



Figure 4 Lateral radiograph demonstrating Scheuermann’s kyphosis.


Skeletally immature patients respondwell to exercises and bracing.

Severe deformity (greater than 75�) with failure of conservative

therapy requires surgery.

Non-specific musculoskeletal back pain

Musculoskeletal back pain can be attributed to a number of factors

such as poor posture and lack of exercise.Weak abdominalmuscles

and tight hamstrings are often noted on examination, both of which

are key targets for physiotherapy. Musculoskeletal back pain may

also have a significant psychosocial component and thus it is worth

identifying any likely stresses in the home or school environment

during the history.


Other causes

Disc herniation in children, unlike in adults, presents with back

pain as the predominant symptom and positive nerve tension

signs on examination. Conservative therapy is tried initially.

Idiopathic juvenile osteoporosis is uncommon. It usually presents

a few years before adolescencewith symptoms similar to that of an

inflammatory arthritis. Laboratory markers are often normal, and

the disease follows a self-limiting course. Other causes of back

pain include sickle cell crises, abdominal pathology such as

cholecystitis and pancreatitis, urological causes such as stones and

pelvi-ureteric junction obstruction and gynaecological causes

including pelvic inflammatory disease and ovarian cysts.

Conclusion

Evaluation of back pain in children and adolescents requires

a knowledge of the common causes and is helped by considering

age and the presence of systemic or neurological features, which

may guide the urgency of referral for specialist opinion. A

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