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Traditionally, back pain in children has been considered as being due to a potentially serious condition until proved otherwise. This concern arose because some cases of serious disease were missed in the past. However, it is now known that benign back pain in children and adolescents is more common than was once thought. The emphasis now is on establishing diagnostic protocols that are accurate, inexpensive and, most importantly, less invasive than those which were thought necessary in the past. This does not detract from the fact that back pain in children remains a significant clinical challenge.
It is known that despite extensive investigation, the proportion of children who are afforded a diagnosis at the end of the day is small. The majority of cases have a benign and self-limiting cause, yet serious pathology must still be excluded.
- Nonspecific back pain in children is common but reported prevalence varies. Depending on the population studied and the definition used, prevalence is between 9-66%.
- It increases with age, is more common during times of rapid growth and is more common in girls than in boys.
- Back pain is more common in athletes, reportedly occurring in 20-30% of adolescent athletes. It is more common in relation to certain sports, such as gymnastics, dancing, American football, diving, wrestling, rowing and rugby.
It is important to pursue a diagnosis. It is more usual to make a diagnosis of a specific cause in children and nonspecific back pain is a diagnosis of exclusion. When considering the aetiology and differential diagnosis of back pain, consider:
- Overuse and back strain or musculoligamentous injury.
- Disc herniation.
- Scheuermann's disease (a juvenile osteochondrosis which causes kyphosis.)
- Vertebral fractures.
- Spondylolysis - unilateral fracture of the pars interarticularis, often due to hyperextension of the spine. This is a common cause of back pain in adolescent athletes.
- Spondylolisthesis - bilateral fracture of the pars interarticularis with anterior displacement of the vertebral body or sacrum. Symptoms typically occur at the time of the growth spurt. It usually causes focal pain aggravated by certain activities (particularly spinal extension and, to a lesser degree, rotation). Rest improves pain. Pain is sharp, mild-to-moderate in intensity and can radiate to the buttock.
- Inflammation: juvenile arthritis, ankylosing spondylitis.
- Infection - usually in those aged under 10 years:
- Bone tumours - primary osseous neoplasms are rare. The most common are Ewing's sarcoma, aneurysmal bone cyst, osteoblastoma (considered benign but can be locally aggressive), osteoid osteoma and primary lymphoma.
- Tumours of the spinal cord - eg, ependymoma.
- Referred pain: appendicitis, pelvic inflammatory disease, abdominal or pelvic tumours.
- Congenital disorders of the spine - eg, scoliosis.
- Systemic disease - eg, sickle cell disease.
- Good clinical assessment will diagnose most causes of pain.
- The younger the child and the longer the history, the more likely it is that a serious underlying condition is responsible for the symptoms.
It is essential to take a careful history. This should incorporate:
- Characteristics of pain, including duration, severity, radiation of pain, disturbance of sleep and activities and associated and exacerbating factors.
- Accompanying symptoms - eg, fever, weight loss, neurological symptoms (weakness, numbness, gait disturbance, bowel and bladder dysfunction).
- Past medical history - eg, previous episodes of neck or back pain, arthritis, trauma.
- Family history - eg, arthritis, scoliosis.
- Psychological history - eg, depression aggravating back pain or back pain causing depression. See the separate Depression in Children and Adolescents article.
- Social history - eg, carrying school bags, school activities, sports activities (especially contact sports, gymnastics, diving, bowling in cricket).
See also the separate Examination of the Spine article. Examination should include:
- Localisation and evaluation of pain.
- Tenderness (site of maximal tenderness).
- Inspection (to detect deformity, wasting, kyphosis and scoliosis).
- Gait. The classic Phalen-Dickson sign (knee-flexed, hip-flexed gait) may occur in spondylolysis, especially if there is associated spondylolisthesis.
- Flexibility: flexion, extension, lateral flexion and lateral rotation.
- To perform the modified Schober test for lumbosacral spinal mobility, mark points 10 cm above and 5 cm below the lumbosacral junction (dimples of Venus) with the patient standing. Repeat the measurements with the patient in full forward flexion with their legs straight. An increase between the two points of less than 6 cm suggests reduced lumbar spinal mobility - eg, due to spondyloarthropathies.
- Ask the patient to stand on one leg. The Trendelenburg sign is positive if the other hip drops (due to weak hip muscles). If there is spondylolysis, bringing the back into lumbar extension elicits pain on the side ipsilateral to the pars interarticularis lesion.
- Neurological examination (including power, tone, reflexes, sensation).
- Abdominal and hip examination for referred pain.
- One study reported that painless hyperextension combined with negative imaging closely correlated with a diagnosis of mechanical back pain.
Clinical indicators of serious pathology
- Age under 4 years.
- Symptoms persisting for more than four weeks.
- Interference with function.
- Systemic features (fever, weight loss).
- Worsening pain.
- Neurological features.
- Recent onset of scoliosis.
Persistent back pain in children can usually be diagnosed by history, examination and relatively simple tests (blood tests, plain radiography, bone scans)[1, 9]. In the absence of indications for urgent referral (see 'Referral', below), initial assessment can be performed in general practice. Investigations may include:
- Blood investigations might include FBC, ESR and CRP, rheumatoid factor and other rheumatological autoantibody tests (may be indicated if arthritis is suspected), U&Es, LFTs, amylase.
- Imaging: usually initially X-rays, which pick up fractures, spondylolysis, spondylolisthesis, Scheuermann's disease, and some bony lesions. There is no universal imaging screening protocol, so when to use X-rays can be a difficult decision. Imaging options include plain X-rays, including posterior-anterior (PA) and lateral, CT scanning, MRI scanning and single-photon emission computed tomography scanning (SPECT).
Many adolescent patients will have self-limiting, short-lived pain caused by overuse or strain. Management should incorporate:
- Confirmation of diagnosis and exclusion of serious pathology.
- Simple analgesia - eg, paracetamol or ibuprofen.
- Preventative measures with:
- Advice and education
For those patients more likely to have a serious pathology, early assessment to establish a differential diagnosis and hence urgency of referral is important. All will require referral and subsequent management will vary according to the underlying diagnosis.
- Worsening pain.
- Constant pain.
- Persistent fever.
- Systemic symptoms: night sweats, weight loss.
- Neurological deficit.
- Pain accompanied by stiffness.
- A variety of complications can arise depending on the diagnosis. In general terms complications may be reduced or prevented by timely diagnosis.
- Complications include delayed diagnosis (with possible implications for management and prognosis) and psychosocial difficulties, such as exclusion from sport, and depression.
This is determined by the underlying diagnosis.
Posture and psychosocial factors are important in back painBack education programmes are effective in reducing risk factors for long-term back pain but whether this benefit is sustained in later life requires further investigation.
- Backpacks can cause back pain if they are too heavy or the weight is carried unevenly (over one shoulder). The following should be advised:
- Load the minimum weight possible.
- Carry a school backpack on two shoulders.
- Correct the belief that school backpack weight does not affect the back.
- Use of a locker at school.
- Apart from swimming, the evidence supporting the benefits of sport in preventing back pain in children is sparse. Both intense activity and inactivity are associated with back pain.
Further reading and references
Jakes AD, Phillips R, Scales M; Teenagers with back pain. BMJ. 2015 Apr 2350:h1275.
Calvo-Munoz I, Gomez-Conesa A, Sanchez-Meca J; Physical therapy treatments for low back pain in children and adolescents: a meta-analysis. BMC Musculoskelet Disord. 2013 Feb 214:55. doi: 10.1186/1471-2474-14-55.
Altaf F, Gibson A, Dannawi Z, et al; Adolescent idiopathic scoliosis. BMJ. 2013 Apr 30346:f2508. doi: 10.1136/bmj.f2508.
Auerbach JD, Ahn J, Zgonis MH, et al; Streamlining the evaluation of low back pain in children. Clin Orthop Relat Res. 2008 Aug466(8):1971-7. Epub 2008 Jun 16.
Rodriguez DP, Poussaint TY; Imaging of back pain in children. AJNR Am J Neuroradiol. 2010 May31(5):787-802. doi: 10.3174/ajnr.A1832. Epub 2009 Nov 19.
Houghton KM; Review for the generalist: evaluation of low back pain in children and adolescents. Pediatr Rheumatol Online J. 2010 Nov 228:28. doi: 10.1186/1546-0096-8-28.
Calvo-Munoz I, Gomez-Conesa A, Sanchez-Meca J; Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013 Jan 2613:14. doi: 10.1186/1471-2431-13-14.
Patel DR, Kinsella E; Evaluation and management of lower back pain in young athletes. Transl Pediatr. 2017 Jul6(3):225-235. doi: 10.21037/tp.2017.06.01.
Taxter AJ, Chauvin NA, Weiss PF; Diagnosis and treatment of low back pain in the pediatric population. Phys Sportsmed. 2014 Feb42(1):94-104. doi: 10.3810/psm.2014.02.2052.
Palazzo C, Sailhan F, Revel M; Scheuermann's disease: an update. Joint Bone Spine. 2014 May81(3):209-14. doi: 10.1016/j.jbspin.2013.11.012. Epub 2014 Jan 24.
Bernstein RM, Cozen H; Evaluation of back pain in children and adolescents. Am Fam Physician. 2007 Dec 176(11):1669-76.
Bhatia NN, Chow G, Timon SJ, et al; Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop. 2008 Mar28(2):230-3.
Shillington M et al; Beware the Child with Back Pain!, J.Orthopaedics 20074(2)e34.
Curtis C, d'Hemecourt P; Diagnosis and management of back pain in adolescents. Adolesc Med State Art Rev. 2007 May18(1):140-64, x.
Prins Y, Crous L, Louw QA; A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents. Physiother Theory Pract. 2008 Jul-Aug24(4):221-42.
Habybabady RH, Ansari-Moghaddam A, Mirzaei R, et al; Efficacy and impact of back care education on knowledge and behaviour of elementary schoolchildren. J Pak Med Assoc. 2012 Jun62(6):580-4.
Vidal J, Borras PA, Ponseti FJ, et al; Effects of a postural education program on school backpack habits related to low back pain in children. Eur Spine J. 2013 Apr22(4):782-7. doi: 10.1007/s00586-012-2558-7. Epub 2012 Nov 10.
Skoffer B, Foldspang A; Physical activity and low-back pain in schoolchildren. Eur Spine J. 2008 Mar17(3):373-9. doi: 10.1007/s00586-007-0583-8. Epub 2008 Jan 8.
Plaszewski M, Nowobilski R, Kowalski P, et al; Screening for scoliosis: different countries' perspectives and evidence-based health care. Int J Rehabil Res. 2012 Mar35(1):13-9. doi: 10.1097/MRR.0b013e32834df622.
UK NSC recommendation on adolescent idiopathic scoliosis (AIS); UK National Screening Committee, July 2016