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Back Pain in Children

• Dr. Donald W. Kucharzyk
• The Orthopaedic, Pediatric Spine Institute
• Crown Point, Indiana

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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

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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

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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

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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

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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

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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 childs participation in
  sports or voluntarily gives up an activity is
  worrisome

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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, Scheuermanns, and overuse

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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,
  Scheuermanns, or inflammatory
• Radicular suggests neurocompression

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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

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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

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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

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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

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Back Pain in Children

• Detailed neurologic examination should be
  performed motor, sensory and reflexs
• 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

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Back Pain in Children

• Radiographic Evaluation
• AP and lateral radiographs
• 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

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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

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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

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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

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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

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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

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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

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Back Pain in Children

• Differential Diagnosis
• Mechanical
• Developmental
• Inflammatory
• Neoplastic

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Back Pain in Children

• Mechanical Disorders
• Postural problems
• Muscular problems
• Overuse syndromes
• Herniated Nucleus Pulposis

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Back Pain in Children

• Developmental Disorders
• Spodylolysis
• Spondylolisthesis
• Scheuermanns Disease

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Back Pain in Children

• Inflammatory Disorders
• Discitis
• Disc Space Calcification
• Osteomyelitis
• Rheumatologic Conditions
• JRA
• Ankylosing spondylitis

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Back Pain in Children

• Neoplastic Disorders
• Vertebral column
• Spinal cord/canal
• Muscle
• Metastatic tumors

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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

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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
  Scheuermanns

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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

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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 OHata et al
• Major presenting complaint hamstring tightness
  and buttock discomfort with decrease flexibility
  lumbar spine

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Back Pain in Children

• Scheuermanns Disease
• Second most common cause
• Pain that starts later in the day or after
  strenuous activity
• Poor posture
• Symptoms are aggravating but not limiting

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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

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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

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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

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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

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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

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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

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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

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Back Pain in Children

• THANK YOU