• Pain or discomfort in the region from the upper thoracic vertebra (T1) and shoulder girdle to the sacrum and surrounding musculature
• Patients may have a specific sense of localization (eg, to a muscle group or vertebral body), or sense the pain as diffuse or deep and difficult to localize.

• Prevalence
  • Back pain is uncommon in pediatrics.
• Age
  • Most studies have shown that back pain increases with age.
    • < 10% of preteens report back pain.
    • Nearly 50% of 18- to 20-year-olds have ≥ 1 episode of lower back pain.
  • A 6-year study in a tertiary orthopedic setting found:
    • Back pain constituted < 2% of referrals in children age 15 years or younger, but roughly half of these children had serious underlying diseases.
  • From early adolescence onward:
    • Back pain becomes more common.
    • Back pain is more likely to be related to injury or repetitive stress.

• Back pain has many potential mechanisms.
• In the context of febrile illness, strongly consider an infectious, inflammatory, or neoplastic process.
• Back pain may also be secondary (eg, to vasoocclusive changes from sickle cell disease, or a progressive anatomic or structural issue).
• Consider musculoskeletal and trauma-related causes, and that in older children pain may be functional.

History should ascertain:

• Description of pain: OLDCAR
  
  • Onset/precipitating event (eg, trauma)
  • Location (eg, midline, paraspinal)
  • Duration
  • Characteristics, nature, or quality (continuous or not, severity, whether present when awakening from sleep)
  • Associated factors which improve or worsen (eg, activity)
  • Radiating pattern of pain
• Related neurologic findings
• Changes in urination or defecation
• Whether fever is present
  • Exposures to infectious agents (eg, tuberculosis)
  • Signs of systemic illness
    • Weight loss
    • Bone pain in other locations
    • Bruising
    • Organomegaly
    • Adenopathy
• Specific activities, especially those that require spinal extension (gymnastics, football); history of training
• Changes in activities, such as walking, play, sports activities
• Growth patterns/recent growth spurt
• Consider an evaluation of family and social factors if functional pain is in the differential diagnosis.

• Special considerations
  • Confirm pain history with others (parents, coaches, school personnel).
  • Children may minimize pain because of fear of procedures.
  • Children and adolescents usually do not use pain symptoms for secondary gain.

Physical examination considerations

• Vital signs
  • Temperature (febrile or not)
  • Pain may elevate the heart rate and blood pressure.
• Spinal examination
  • Palpate for step-offs.
  • See whether there is midline or paraspinal tenderness.
  • Straight leg-raising test
    • A positive result is highly suggestive of nerve root compression.
    • Using cervical flexion to accentuate the patient’s symptoms may add to the test’s sensitivity.
    • Any reproduction of the patient’s usual symptoms during testing before 60 degrees of hip flexion, or marked asymmetry, should be considered a positive result.
    • Pain after 60 degrees or limited to the posterior thigh is more likely caused by hamstring tightness.
  • May evaluate for scoliosis
  • In case of trauma, check ABCs, C-spine, ribs, pelvic stability and implement C-spine and other precautions as needed
• Neurologic evaluation: Evaluate the following at or below the suspected level of the lesion:
  • Motor function (including symmetry, strength, gait, coordination)
  • Sensation
  • Reflexes
  • Rectal sphincter tone
• Evaluate the skin for evidence of bruising or trauma.
• Check for the presence of organomegaly or lymphadenopathy.

Physical considerations particular to adolescents

• Look for excessive lordotic curvature, especially in children who perform repetitive spinal extension (eg, gymnasts, football linemen).
• Look for evidence of connective tissue disorders.
  • Hyperextensibility
  • Marfanoid body habitus
    • Joint hyperextensibility
    • Pectus excavatum
    • Pes planus
    • Dislocated lenses
    • Hernia
    • Arachnodactyly
    • Scoliosis
• Stork test: can pain be reproduced reliably by hyperextension of back while standing on one leg?
• Waddell test: presence of ≥ 3 of the following 5 criteria may help determine whether significant psychologic stress is associated with chronic low back pain.
  • Inappropriate tenderness that is superficial or widespread
  • Pain on pressing the top of the head or on passive rotation of shoulders and pelvis
  • Distraction signs, such as inconsistent performance between straight-leg raising in the seated and supine positions
  • Strength and sensory loss patterns that do not fit a directional distribution
  • Overreaction during the physical examination

All children

• Be aware of the relatively higher risk of serious underlying disease in younger children, even those without specific physical findings.
• Back pain before adolescence is uncommon.
• The combination of fever and back pain strongly suggests an infectious, inflammatory, or neoplastic process in all age groups.
• Fever in the setting of conditions below should prompt aggressive diagnostic evaluation for cancer.
  • Weight loss
  • Bone pain in other locations
  • Bruising
  • Organomegaly
  • Adenopathy
• Neurologic symptoms along with back pain may indicate lumbar disk herniation or other nerve compression.
• Idiopathic scoliosis usually does not cause back pain; thus, scoliosis with pain should raise concern for spinal tumor.

Infants (through 3rd or 4th year of life)

• Infants are not always capable of localizing or complaining about pain in the back.

• Differential diagnosis includes:
  • Diskitis
    • Unexplained fever or toxicity and
    • Refusal to walk or stand
  • Leukemia
  • Lymphoma
  • Vasoocclusive crisis
  • Vertebral osteomyelitis/epidural abscess, in a child with sickle cell disease
  • Trauma (especially intentional injury)
  • Pyelonephritis

Children

• Pyelonephritis
  • Consider with fever; costovertebral angle tenderness; dysuria; polyuria; urinary urgency; or cloudy, dark, or pink/red-tinged urine.
• Diskitis
  • Unusual, if not rare, condition
  • Most common in children < 10 years
  • Typical discomfort in an upright posture
  • Refusal to walk or pain when bending forward
  • Even in the absence of fever, a child (especially preschool age) who refuses to walk should be evaluated for diskitis.
• Tethered cord
  • Back pain when walking may be the only sign at presentation.
  • Sacral dimple of unclear depth, hairy patch, or discoloration
  • Bowel or bladder issues
  • Lower extremity weakness
• Vertebral osteomyelitis
  • Usually affects school-age children and teenagers
  • Causes severe back pain and systemic symptoms
• Ankylosing spondylitis
  
  • Consider with a family history of rheumatoid disease.
• Vasoocclusive crisis
  • Consider in patients with sickle cell disease.
• Leukemia, lymphoma
• Primary vertebral tumors
  • Ewing sarcoma
  • Aneurysmal bone cyst
  • Benign osteoblastoma
  • Osteoid osteoma
• Spinal tuberculosis (Pott disease)
  • Rare in US children; mainly occurs in children where tuberculosis is endemic
  • Consider if back pain is accompanied by low-grade fever.
• Muscular or ligamentous strain in this age group should be considered only after a thorough diagnostic evaluation.

Adolescents

Acute pain (< 3 weeks)

• Lumbar disk disease
• Muscle or ligament strain
• Sciatica/piriformis syndrome
• Vertebral osteomyelitis
• Epidural abscess
• Spinal tuberculosis
• Pyelonephritis
  • Consider with fever; costovertebral angle tenderness; dysuria; polyuria; urinary urgency; or cloudy, dark, or pink/red-tinged urine.

Chronic pain (≥ 3 weeks)

• Spondylolysis
  • One of the most common identifiable causes of low-back pain in this age group
  • Athletes participating in gymnastics, dance, cheerleading, football, and diving are at highest risk.
• Spondylolisthesis (anterior movement of vertebral body on top of another, usually L5 on S1)
  • A result of bilateral spondylolysis
  • One of the most common identifiable causes of low-back pain in this age group
• Scheuermann kyphosis (thoracolumbar spinal deformity with localized vertebral body changes)
• Facet or vertebral dysfunction
• Sacroiliac dysfunction
• Lumbar disk disease
  • Especially in athletes or others with cumulative trauma
• Spinal stenosis
• Spondyloarthropathy
• Tumor or cancer
  • Osteoid osteoma and osteoblastoma
    • Consider in cases of nocturnal back pain, even if relieved by nonprescription analgesics.
• Muscular or ligamentous strain
  • Typical presentation
    • Lower back pain ≤ 3 weeks’ duration
    • With or without recollection of an acute injury
  • Pain is exacerbated by lifting, stooping, and exercising.
  • May be caused by repetitive strain coupled with genetic predisposition and environmental factors, such as:
    • Studying or reading while sitting at a desk
    • Carrying an excessively heavy backpack (10–20% of body weight)
• Functional (nonorganic) pain
• Ankylosing spondylitis

• Complete blood count
• Uric acid
• Lactate dehydrogenase level
• Erythrocyte sedimentation rate
• Urinalysis and culture (if considering nephrolithiasis, urine calcium and creatinine)

• Imaging is guided by clinical suspicion; options include:

• Radiographs of the spine (anteroposterior [AP], lateral, oblique views)
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Nuclear medicine imaging (bone scans)

• Single-photon emission computed tomography (SPECT)

• By suspected diagnoses:

• Muscle or ligament strain
  • Studies not routinely indicated
• Compression fracture (eg, after trauma such as motor vehicle accident, or athletic injury)
  
  • Spinal radiography (AP, lateral)
• Diskitis
  • Spinal radiography
  • MRI as indicated
• Osteoid osteoma or osteoblastoma
  • Spinal radiography
    
    • Primary vertebral tumors almost always will be visible.
  • CT is the definitive study.
  • If radiography is inadequate, consider bone scan, CT, or MRI.
• Scheuermann disease
  • Spinal radiography (lateral)
    • Diagnosis is confirmed by anterior wedging of ≥ 3 contiguous vertebrae, by ≥ 5 degrees.
  • Consider oblique views, as associated with spondylolysis
• Spondylolysis
  • Spinal radiography (AP, lateral, oblique)
    • "Scotty dog with a collar" can be seen on the oblique view.
    • Normal radiography may not rule out the diagnosis.
  • Consider SPECT if the diagnosis is highly suggested.
  • A positive radiograph and negative SPECT indicates that spondylolysis not metabolically active (may not be the cause of back pain).
  • Back pain on extension with normal radiographs and positive SPECT usually indicates facet or vertebral dysfunction
• Spondylolisthesis
  • Spinal radiography (lateral)
    • Used to diagnose anterior slippage and to stage treatment
    • Rarely, may reveal congenital absence of a lumbosacral articular process

• In the case of vertebral osteomyelitis/epidural abscess, consider aspiration and culture.

• Consider whether pain is acute (< 3 weeks) or chronic.
  • Acute pain, especially with a history of musculoskeletal injury, may be managed conservatively.
• Chronic pain demands further investigation.
• Back pain that results from an underlying disorder will probably require treatment of the primary condition, in addition to treatment of pain.
• Psychosocial or nonorganic causes should be considered if:
  • Thorough diagnostic evaluation of chronic back pain is unrevealing and
  • Usual management involving exercise and stretching is not beneficial.
• As children and adolescents usually do not use pain symptoms for secondary gain, do not assume that pain is feigned; rather, assume that it represents a very real physical symptom rooted in psychologic or emotional distress.
  • This distress can be addressed openly by the clinician.
  • After diagnosis, remember to reconsider organic causes, especially if symptoms continue to evolve.

Diskitis

• Treatment depends on cause.
• Most experts recommend:
  • If bacterial cause, parenteral followed by oral antibiotics
  • Rest and pain management

Vertebral osteomyelitis/epidural abscess

• Prompt orthopedic surgery consultation
• Antibiotics (ensure staphylococcal coverage)
• Rest and pain management

Ankylosing spondylitis

• Best coordinated by a pediatric rheumatologist
• Antiinflammatories
• Physical and occupational therapy

Vasoocclusive crisis

• Careful evaluation and reassessment for acute chest syndrome and other related complications
• Hydration, red blood cell transfusion as indicated
• Pain management
• Physical therapy as indicated

Cancer, including leukemia, lymphoma, Ewing sarcoma

• Manage with a pediatric oncologist.

Osteoid osteoma

• Nonsteroidal antiinflammatory agents (NSAIDs)
• Refer to pediatric orthopedic surgery for possible excision

Musculoskeletal back pain

• For acute pain, think PRICEMMMS (protection, rest, ice, compression, elevation, medication, motion, modalities, strength)
• For chronic pain, heat may be helpful.
• Discourage bed rest, as this may delay recovery.
• Teach proper posture.
• Pain-free activity may be resumed gradually.
• Backpack weights should not exceed 15–20% of the person’s body weight.
• Exercises may be helpful.
  • Stretch after warming the muscles by gentle exercise
    • Improve flexibility of lower back and hamstrings
  • Strengthen core musculature (abdomen, hips, and back)
    • Abdominal muscle strengthening reduces pelvic tilt and decreases the tendency toward lordosis.
    • Strengthening spinal extensor muscles (eg, by raising the torso and head off the floor/exercise ball while lying prone) is recommended, as decreased strength and endurance of these muscles is associated with lower back pain.
  • May use an exercise ball or Pilates instruction
• Full sit-ups with fixed feet and bent knees should be discouraged.
  • Uses hip flexors rather than abdominal muscles
  • Increases intervertebral disk pressure
• Continuous frequency ultrasonography and massage may be helpful.

Spondylolysis

• Treatment is controversial and may be best managed with a pediatric sports medicine specialist or orthopedic surgeon.
• Provide symptomatic relief.
• Thoracolumbar bracing to prevent extension has been shown to be helpful; bracing should be used up to 6 months or until the patient is pain-free with extension.
• Some experts advocate restricting extension activities without a brace.
• Consider the Williams program: physical therapy that promotes abdominal strengthening and hamstring stretching.
• Bone stimulators have been used as adjunctive therapy.

Scheuermann disease

• Treatment is usually conservative.
  • Physical therapy: strengthening and stretching exercises
  • Avoid painful activities.
  • Analgesic medication if needed
• Thoracolumbar bracing and surgery may be indicated if kyphosis exceeds 60 degrees.
• Refer patients in whom conservative management fails, those with intractable pain, or those in whom kyphosis progresses to orthopedic surgery (pediatric or spinal).

• Prompt and urgent evaluation and referral are needed when back pain is accompanied by:
  • Radicular pain down the leg
  • Numbness or tingling
  • Bowel or bladder problems
  • Erectile dysfunction
  • Loss of sphincter tone on rectal examination
  • High clinical suspicion of vertebral osteomyelitis/epidural abscess
• Consider referral for:
  • Ankylosing spondylitis
    • Refer to pediatric rheumatology.
  • Leukemia, lymphoma, and Ewing sarcoma
    • Refer to pediatric oncology.
  • Osteoid osteoma
    • Refer to pediatric orthopedic surgery.
  • Spondylolysis
    • Refer to a pediatric sports medicine specialist or orthopedic surgery.
  • Scheuermann disease
    • Refer to orthopedic surgery (pediatric or spinal) if patients in whom conservative management fails, those with intractable pain, or those in whom kyphosis progresses or when diagnosis and evaluation are outside of scope of expertise

• Admit patients with back pain with associated fever or neurologic findings or when prompt and thorough diagnostic assessment cannot be completed as an outpatient.

• Prognosis depends on the underlying etiology of back pain.

• Muscular low back pain prevention measures

• Proper posture
• Backpack should not exceed 15–20% of body weight.

• Stretch to improve flexibility of lower back and hamstrings

• Exercise to strengthen core musculature (abdomen, hips, and back)

• Care of the Young Athlete, 2nd Editon (book), American Academy of Pediatrics and American Academy of Orthopaedic Surgeons
• Essentials of Musculoskeletal Care, 3rd edition (book), American Academy of Pediatrics and American Academy of Orthopaedic Surgeons
• Sports Shorts: Lower Back Pain in Athletes (fact sheet), American Academy of Pediatrics

• American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793-797.  [PMID:11533354]