CHAPTER 14
Back Pain: General Approach and Differential Diagnosis
• Back pain is an uncommon presenting issue in young children but increases in presentation during adolescence.
• Fifty percent of individuals will have one episode of back pain by age 20 years, and evidence suggests that back pain in children, especially idiopathic, correlates directly with continued back pain in adulthood.
• A retrospective review of children with back pain demonstrated that no specific diagnosis was made in 78% of cases. Even so, children and adolescents are more likely than adults to have a specific diagnosis assigned to their back pain.
• Causes range from relatively benign, with little concern for long-term consequences; to somewhat concerning, such as infections, with the potential for lasting repercussions; to malignancies, which have potential for immediate harm (Table 14-1).
• Patient age can help narrow the differential diagnosis (Table 14-2).
Table 14-1. Distinguishing Features of Common Causes of Back Pain in Children and Adolescents
| Causes of Back Pain | Distinguishing Signs/Symptoms | Evaluation/Treatment |
|---|---|---|
| Diskitis | Inflammatory condition in disk space commonly seen in children ≤ 4 y. Presents with back/abdominal pain. May refuse to walk. Likely infectious, although pathogen often difficult to identify. Most commonly identified pathogen is Staphylococcus aureus. | CBC, CRP level, ESR, and blood cultures. Radiographs are negative for 10–14 d, then show disk space narrowing and vertebral end plate changes. Bone scan helpful for diagnosis. MRI also good for diagnosis and for identifying abscess or neural compression (see Chapter 9, Miscellaneous Infections, Figure 9-1). Treated with 5–7 d IV antibiotics, then transition to oral antibiotics. |
| Osteomyelitis | All ages. Constant pain, night pain. May have fever and chills, generalized malaise, anorexia, and weight loss. | WBC, CRP, and ESR typically elevated. Blood cultures positive in 50%. Radiographs are negative for 10–14 d, then show periosteal thickening or elevation, and focal osteopenia. Bone scan or MRI helpful for diagnosis. Treated with 5–7 d IV antibiotics, then transition to oral antibiotics. |
| Benign tumors Osteoid osteoma | Small, benign lesion causing a dull, well-localized pain that is worse at night Pain often relieved by NSAIDs May lead to scoliosis | Involvement of the pedicle may lead to characteristic obliteration of the pedicle on AP radiograph known as the “winking owl” sign (Figure 14-1). Typically resolves over the course of several years; some may benefit from surgery. Requires referral to pediatric orthopaedic specialist. |
| Bone cyst (unicameral or aneurysmal) | Benign cystic lesions that usually affect posterior elements of the spine Usually chronic, dull pain, or may present with pathologic fracture PE often normal, but aneurysmal cysts may have neurologic symptoms secondary to cord or nerve root impingement | Usually identified on plain radiographs. MRI features are diagnostic. Require referral to pediatric orthopaedic specialist. |
| Eosinophilic granuloma | Benign tumor of anterior portion of spine. Can be isolated or part of Letterer-Siwe or Hand-Schüller-Christian disease. Rarely, presents with fever and leukocytosis. | Radiographs show flattened lesion of vertebra, “vertebra plana” (Figure 14-2). Biopsy necessary to confirm diagnosis. Skeletal survey helpful to look for other lesions. Requires referral to pediatric orthopaedic specialist. |
| Malignant tumors | Unrelenting, deep, and progressively more severe pain, especially at night. May have fever and chills, generalized malaise, anorexia, and weight loss. Most common in children < 4 y. Osteosarcoma and Ewing sarcoma most common primary bone tumors affecting spine. May also be caused by leukemia or metastatic disease. Metastatic disease in children frequently involves the spine. | Back pain caused by leukemia has no characteristic radiographic features but may demonstrate compression fractures. Bone scan is the best study to evaluate for skeletal metastases. Intraspinal tumors that present with neurologic signs and symptoms require urgent referral to a pediatric neurosurgeon. |
| Herniated intervertebral disk | Usually seen in adults, but can also occur in adolescents. Can occur at any level; lower lumbar most common. Usually sudden onset of severe “burning” or “shooting” back pain, typically worse with flexion, with or without radicular leg pain. True radicular pain will radiate to the foot in a dermatomal pattern. Exacerbated by straining, as with coughing or sneezing. May have positive straight-leg raise test, and weakness or sensory changes on examination. | MRI will confirm diagnosis. High rate of resolution with nonoperative care, including anti-inflammatory medications and physical therapy. Pediatric sports medicine physician can assist with management. Large disk herniations associated with bowel or bladder dysfunction and saddle anesthesia (cauda equina syndrome) require emergent MRI and surgical decompression. |
| Slipped vertebral ring apophysis | May present similar to herniated disk. Injury unique to growing children. Typically occurs with a flexion injury, such as with extreme straining during weight lifting. Pain is usually of intense, sudden onset. | Avulsed bony fragment may be small and difficult to visualize on radiographs; if seen, will be within the spinal canal. MRI helpful to diagnose and differentiate from disk herniation. Requires urgent referral to pediatric orthopaedic specialist. Often requires surgical treatment. |
| Spondylolysis and spondylolisthesis | Activity-related pain, worse with hyperextension Common in sports requiring repetitive back extension and axial loading (eg, gymnastics, American football [lineman position], volleyball, weight lifting, soccer) | Oblique radiographs may reveal classic Scotty dog (see Chapter 13, Spondylolysis and Spondylolisthesis, Figure 13-2) of spondylolysis. Lateral view can identify spondylolisthesis (Figure 13-3). MRI indicated when radiographs are normal but clinical suspicion for spondylolysis is high. (See Figure 13-4 for a positive MRI finding.) Related posts: Stay updated, free articles. Join our Telegram channel
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