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Volume 3 Number 2 |
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Review for the Generalist: Evaluation
of the adolescent with back pain Karen Onel1, MD T Lehman2, MD 1La 2Hospital for Special
Surgery, Contact:
Karen
Onel, MD La
Rabida Children's Hospital Email:
kbonel@peds.bsd.uchicago.edu Introduction In this age of increasingly large book bags and
backpacks, backache is becoming an increasingly common complaint among
adolescents. Fortunately serious back problems are uncommon. Nonetheless, most of these children will be
initially referred to orthopedists. However, the pediatrician can easily do
the initial evaluation in the office and determine whether orthopedic or
rheumatologic referral is appropriate. Common causes of back pain in
adolescence To properly assess these
adolescents to have an awareness of the many problems that can cause back
pain in a teenager (Table 1). The history is crucial (Table 2). Important
considerations are whether the pain is relieved by rest or exacerbated by
activities. It is important to ask whether the pain awakens the child from
sleep. Does the pain radiate or is it
confined to one location? Pain which
comes on suddenly following an injury or fall is most likely mechanical in
nature, while problems that are described primarily as stiffness that is
worse in the morning or after prolonged inactivity, may well be secondary to
an inflammatory disease. Table
1 Common causes of back pain in
childhood Spondylolysis/Spondylolisthesis Scoliosis Scheuermann’s
disease Vertebral
osteomyelitis Diskitis Tumors—benign
or malignant Disc
disease Spondyloarthropathies Hypermobility Pain
Augmentation Table
1 Initial historical assessment
In older children spondylolysis, a stress fracture
of the pars interarticularis of the lumbar spine, is the most common
structural abnormality that causes back pain. [1-2] This incidence is
especially high for athletic children and is associated with sports requiring
repetitive lumbar motion, including diving, gymnastics and rowing. [3]
Spondylolysis may be unilateral or bilateral, occurs most commonly at L5 and
is often associated with spina bifida occulta (Figure 1). It may be seen in
the radiographs of asymptomatic children. However, spondylolysis is of
concern because of possible progression to spondylolisthesis.
Spondylolisthesis is an anterior slippage of one vertebra over another. This
occurs most often at the junction of the lumbar and sacral spine (L5-S1
level). [3] Although mild degrees of spondylolisthesis may be asymptomatic,
more severe involvement characteristically leads to low back pain that may
radiate down the back of the thighs. These children often complain of dull
pain in the gluteal region which is made worse by standing for prolonged
periods or attempting to carry a heavy load.
In the early stages, spondylolisthesis is rarely associated with
stiffness. Most children with this condition can be followed conservatively,
but some require orthopedic intervention.
Figure
1 Representations of spondylolysis and spondylolisthesis in adolescents. Back pain in childhood is frequently attributed to
scoliosis, however, scoliosis is usually painless and only detected on
examination. Pain is a common part of this condition only when mechanical
damage has occurred – usually years after the onset of the disease—at which
point pain tends to be moderate at most. [4-5] Every physician should be comfortable
examining children for the presence of scoliosis. Children are routinely screened for
scoliosis at school, but the expertise and thoroughness of the examiners
varies widely. Any child whose spine
appears crooked should have a careful orthopedic evaluation. Once detected, scoliosis should be
carefully evaluated and followed. Many
children have only mild curvatures and require no treatment, but others have progressive
disease requiring bracing and, less frequently, surgery. Since the curvature
occurs with growth, it is rare for scoliosis to become evident before the age
of ten years. Children with back pain or abnormal curvature in the preteen
years often have serious infections, tumors, or metabolic abnormalities that
require immediate orthopedic evaluation. Kyphosis is
an excessive curvature of the thoracic spine in which the spine is bent
forward. Looking at the child from
behind, a curvature is not visible. If the child is viewed from the side when
they are bending over, the upper part of the back angles forward sharply
instead of the normal rounded shape.
This abnormal forward curvature may be the result of abnormalities in
the bone resulting from fractures, severe osteoporosis, or infections.
However, most often it occurs without explanation. Some
children have postural kyphosis. This
is usually a mild increase in the forward bend of the spine leading to the
appearance that they are always slumping over. Typically this is asymptomatic
and the children are brought to the physician with complaints of poor
posture. These children often have no abnormal findings on X-ray.
Importantly, children with postural kyphosis can lie face down with their
back perfectly flat. Children with
more significant abnormalities usually have changes in the bones. As a
result, they cannot lie perfectly flat on their stomachs. Children who cannot
lie flat on their stomachs need to be investigated by an orthopedist with
appropriate X-rays to evaluate the reason for kyphosis. For children without
significant abnormality, a program of exercises is often adequate. Scheuermann’s disease is one specific cause
of back pain and kyphosis in teenagers.
It is thought to result from abnormalities in vertebral development
leading to the development of wedge shaped vertebral bodies. The diagnosis is
easily made when the abnormal bone structure is seen on X-ray; diagnostic
criteria include the presence of three adjacent wedged vertebrae,
irregularity of the endplates, narrowing of the disc space and a kyphosis angle
of more than 45o (Figure 2). [6] Children with Scheuermann’s
disease often need to wear a brace to relieve their pain and prevent
worsening of their condition. Rarely,
severe or worsening cases require orthopedic surgery. Figure
2 Radiographic evidence of Scheuermann’s disease
Kyphosis may also be the result of damage to the
bones of the spine by infection, tumor, or poor bone formation. These conditions are all rare. Children with conditions that are known to damage
the spine (such as children who have previously undergone radiation therapy)
should be carefully monitored. Parents
of children with poor bone formation or children on medications such as
corticosteroids that predispose to osteoporosis and can damage the bones,
need to be reminded that their children should be watched carefully for spine
problems. Figure 3 demonstrates compression fractures due to osteoporosis
that developed in a child on long-term corticosteroids. If a child has been
diagnosed with an infection or a tumor in or around the spine the family
should be made aware of the need for continued careful monitoring of the
spine as the child grows. Figure
3. Compression fractures due to osteoporosis after long-term corticosteroids There are a variety of infections that may damage
the spine. These generally present
with rapidly progressing complaints of pain and may awaken the child at
night. In the Figure
4. Osteomyelitis of the spine due to tuberculosis (Pott’s disease)
Diskitis is a confusing cause of back pain in young
children. Most often it affects
children under the age of five. [7] These children may have initial symptoms
of a cold or flu-like illness. They
then develop severe back pain, may refuse to walk and stand, or develop a
limp. In some cases a bacterial
infection is identified and the infection is treated with antibiotics. In many cases no causative bacteria is
identified. This illness is usually
diagnosed on the basis of the typical clinical picture with appropriate
radiographic studies. These may include a combination of a back radiograph
demonstrating narrowing of intervertebral space with destruction of the end
plates (Figure 5), CT/MRI showing vertebral disk space involvement with
normal appearance of the nonadjacent vertebrae, or technetium-99m bone scan
with abnormal uptake in the affected area. Figure
5. Radiographic changes of diskitis: narrowing of disc space with end plate
destruction.
Tumors, both benign and malignant, may be a cause
of chronic low-grade back pain.
Leukemia and lymphoma may occasionally present as back pain during
childhood with osteopenia, lytic lesions and pathologic fractures. [9]
Osteoid osteomas most commonly present in the femur and tibia during the
second and third decades of life, but may involve the spine. Osteoid osteomas in the spine typically
come to attention because a child complains of chronic back pain that is
intermittent. The pain is often worse
at night and may be relieved by NSAIDs, but continues to recur. Large osteoid osteomas can be seen on
X-rays; smaller ones may require bone scan.
Osteoid osteomas may be confused with malignant tumors on MRI due to
significant soft tissue involvement and bone marrow edema and may be more
easily visualized by CT scan (Figure 6). [10] Figure
6: Representation of a osteoid osteoma of the spine.
Herniated discs are a common complaint among adults
and a frequent explanation for back pain which starts in adulthood. This condition is relatively rare in
children because they have more flexibility and are less likely to be doing
the work-related heavy lifting.
Although MRI of the spine is very accurate at identifying disc
problems, the finding of minor disc problems on the MRI is not a reliable
explanation for back pain. Family
history of disc disease, high body mass index and structural abnormalities,
such as scoliosis are important prognostic factors. [11] Low back pain and morning stiffness are
commonly due to spondyloarthropathies in teenagers. However, adolescents rarely come to the
doctor complaining of low back pain when they wake up in the morning. Since the onset is very gradual, most
accept this stiffness as normal. The
key to suspecting a spondyloarthropathy lies in carefully examining the
teenager and finding evidence of arthritis or tendon insertion pain
(enthesitis) elsewhere [12] A strong
family history of back pain also should suggest this diagnosis. Another key indicator is that children with
spondyloarthropathies almost never have the ability to bend over and touch
their toes. Radiographs of the back
and sacroiliac joints are usually negative though rarely abnormalities of the
SI joint may be noted (Figure 7). Figure
7. Radiographic sacroilitis typical of a spondyloarthropathy
Although
the history or morning stiffness and difficulty bending over may be ascribed
to mechanical problems, this is unlikely to be true in children and
adolescents. Asking the series of
questions in Table 1 will help the physician to suspect a rheumatic disease
rather than an injury. In addition
children with back pain secondary to a spondyloarthropathy often have heel
pain, sacroiliac joint pain, or knee pain.
Many children have benign musculoskeletal pain,
including back pain, due to hypermobility. These children have mostly
afternoon pain after exercising and back pain is often one of many
musculoskeletal complaints. [14] Teenagers with a pain augmentation syndrome
may have back pain complaints. They often fit a predictable profile. Their
back pain is severe, incapacitating, often associated with sleeping problems
and fatigue, and occurs with other severe muscle and joint pains. School
absences are common. The adolescent usually is in a stressful life situation.
[15] Physical Exam A careful examination, including full
neurologic examination, should be performed on any child complaining of back
pain. Point tenderness is suggestive of infection or bony injury. Careful inspection may reveal unexpected
masses suggestive of tumors. Scoliosis often results in one shoulder
appearing higher than the other or the hips appearing uneven. A positive scoliosis screen is typically
described in the literature as occurring when the ribs on one side appear
higher than the other when the child bends over. Since the primary curvature is usually in
the thoracic spine with a secondary compensatory curvature occurring in the
lumbar spine, it is often easier to detect scoliosis by running one’s hand
over the lumbar spine and feeling the unevenness in height between the muscle
bundles on the two sides.
Spondylolysis/spondylolisthesis will usually be manifested by pain
with lumbar hyperextension. Forward
bending is generally painless but extension to an upright position may
produce pain. Straight leg raising test should be positive in the setting of
lumbar disc disease. Adolescents with
a spondyloarthropathy (ankylosing spondylitis, psoriasis) may have reduced
lumbosacral spine mobility and limited anterior forward flexion as
demonstrated by an abnormal modified Schober test. [13] Children with
hypermobility must demonstrate significant hypermobility at least 4/9
Beighton points (Figure 8) and the pain augmentation teen will have exam only
multiple musculoskeletal trigger points. Figure
8. A hypermobile child with excessive back flexibility Laboratory testing Laboratory
testing is useful in the evaluation of children with back pain when it is
necessary to exclude an infection or other serious problem. Children with osteomyelitis or discitis
often have elevated erythrocyte sedimentation rates. However children with spondyloarthropathies
may have entirely normal laboratory testing falsely reassuring the physician
that the child could not possibly have arthritis. Because the most severe spondyloarthropathy
is ankylosing spondylitis many physicians expect children with this condition
to be male and HLA B27 positive. HLA B
27 positive males are over represented among children with
spondyloarthropathies, but girls with the appropriate findings and HLA B27
negative individuals are common. Plain radiographs may be useful for large
lesions, such as scoliosis. Further imaging studies, such as bone scan, CT
scan and MRI are all useful for more subtle defects and should be used when
necessary. Adolescents with
hypermobility or pain augmentation syndromes may need a back radiograph and a
complete blood count and sedimentation rate to exclude the more serious back
problems. Summary As backache becomes an increasingly common
complaint among adolescents, it becomes more important for the general
pediatrician to be well versed in the causes of pain as well as their
evaluation and treatment. Through proper questioning, the cause of most
children’s pain can be identified and treated in the most effective way.
Proper evaluation may help determine whether orthopedic, rheumatologic, sport
medicine, physical therapy, or other consultations are needed. References 1. Faingold R, Saigal G, Azouz
EM, Morales A, 2. Bezer M, Erol B,
Kocaoglu B, Aydin N, Guven O. Low back pain among children and
adolescents. Acta orthop Traumatol
Turc. 2004;38:136-44. 3. Lim M, Yoon S, Green DW.
Symptomatic spondylolysis: diagnosis and treatment. Curr Opin Pediatr.
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sagittal and frontal spinal curvatures, athletic activity, and dorsal and low
back pain in schoolchildren and adolescents. J
Spinal Disord Tech. 2004;17:33-40. 5. Weinstein SL, Dolan LA,
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Ubags LH. Clinical outcome and radiographic results after operative treatment
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Rheumatol Int. 2004;24:9-13. 9. Kobayashi D, Satsuma S,
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