Perhaps start by asking if the pain is getting better or worse. If it is getting better, is that because of rest? Does it hurt if they return to their sport? If so there is still a problem unless they want to stop the sport. Just because pain has been constant for years, does not mean there is not an underlying cause. Spondys (meaning spondylolysis and spondylolisthesis) can cause someone years of constant pain and remain undiagnosed after years of various health care evaluations. Progressively worse pain despite no activities must be taken seriously.

Be very suspicious of an underlying problem in young children who have stopped playing normally or patients who have any constitutional symptoms. Having the patient draw a pain diagram before seeing them can be helpful (Fig. 23-1). One complaint that is almost always benign is a young child who complains of pain primarily when sitting in a car seat. One treatment is to let them pick out their own new seat.

Many studies report a strong association between psychosocial factors (stress, anxiety, depression, loneliness) and back pain,²,³ and that psychosocial factors may be even more important than mechanical factors such as carrying a backpack.⁴ One can ask about a mental history gently, such as, “Do you see any other doctors, or therapists, or take any other medications?” Families are often welcome to this discussion, as they often suspect a link. Also inquire about other somatic complaints, such as headaches, stomachaches, and sore throats, which are associated with low-back pain.⁵ In a child with multiple complaints, a physical, treatable cause of back pain is less likely to be found. These children and adolescents
may benefit from a comprehensive pain service with psychological support. If there are family members eager to talk about their on-going medical problems, a certain amount of pain and somatic complaints may be the family norm.

Observe the patient’s movements and emotional state. Are they appropriate? histrionic? smiling or flat? Do they look like they are in pain when getting on and off the table?

Ask them to point to where their pain is with one finger. If they point to one specific location of pain (a positive finger test; Fig. 23-2), take that seriously; it is your job to prove there is nothing wrong there. Consider ordering imaging studies, including an MRI and CT, to prove that area is free of pathology. If they have pain over a widely distributed area, you may be much less rigorous in pursuit of discreet pathology.

Have the patient bend forward as if to touch their toes. This compresses the vertebrae and discs, and if it causes localized pain, this is notable. If bending forward causes modest discomfort over a wide distribution, welcome them to adulthood—this is common and usually not worrisome. Then ask them to bend
backward. If this causes localized pain, assume there is a posterior element fracture, usually a spondy and less commonly a facet fracture (Fig. 23-3).

Sacroiliac (SI) joint tenderness is fairly specific and sensitive for SI joint problems such as infection. Localized tenderness over a spinous process is consistent with a fracture or ligament injury, such as a clay shoveler’s fracture (avulsion of C7 usually or a Chance fracture).

If there are no red flags on history or physical, imagining may not be needed. If imaging with low-radiation doses is available, that may influence the decision. Discuss the pros and cons with the family. If any red flags are present, imaging is necessary. Radiographs are usually first, perhaps due to availability. If there are neurologic signs or symptoms, or a tumor is suspected, it may be reasonable to get an MRI. The default MRI is of the cervical, thoracic, and lumbar spine unless the pain is well localized.

When a patient has well-localized pain with back extension, you are looking for a posterior element fracture (Fig. 23-5). MRIs and X-rays (Fig. 23-6) will frequently miss posterior element fractures,⁶ so have a low threshold to order a limited CT scan of the few vertebrae in question. If you are at a center where technique is tightly controlled, a localized CT scan of one or two vertebrae can require as little radiation as AP and lateral radiographs of the lumbar spine.⁷ Sagittal and 3D reconstructions are particularly helpful in looking for spondys and facet fractures. Oblique radiographs are not recommended; they add radiation with no additional information.⁸ Similarly, while flexion-extension radiographs may be common in the world of adult low-back pain, there is no benefit of this additional radiation in children and adolescents.

Bone scans should be ordered only rarely, as they expose the entire body to significant radiation and usually do not add information that cannot be obtained from other studies.

First, set expectations that most of us have back pain at some point. Elimination of all back pain is not a reasonable goal. In terms of medications, ibuprofen seems to work best,⁹ with very little risk or side effects in the short term. The patient will likely have to get through the present episode of pain and then work on prevention. There is some evidence to suggest exercise helps.¹⁰ Back extension exercises anecdotally seem to work well in the motivated (Fig. 23-7).