Back Pain in Children and Adolescents

1. Back Pain in Children and Adolescents Christine Hom, M.D Division of Pediatric Rheumatology New York Medical College

2. Back Pain • Back pain in children - abnormal until proven otherwise! • 75% of children with back pain have an identifiable etiology • Adolescents more likely to have musculoskeletal pain or lower back pain syndromes

3. Back Pain • In children with back pain of >2 months’ duration: • 33% had a post-traumatic etiology: occult fracture or spondylolysis • 33% had kyphosis or scoliosis • 18% had a tumor or infection

4. Back pain in adolescents • In a school based study of 446 adolescents aged 13-17y: • 26% of adolescents report some back pain, especially related to sports • Male:Female ratio 1:1 • 50% of tennis and soccer players • up to 85% of male gymnasts • Maneuvers requiring posterior extension of the leg often provoke lower back pain

6. Etiology of back pain • INFECTION • INFLAMMATION • MECHANICAL • ORTHOPEDIC • TRAUMA • MALIGNANCY • SYSTEMIC DISEASE • OTHER

7. Etiology of back pain • INFECTION • Sacroiliac infections • Vertebral osteomyelitis • Diskitis • Pyelonephritis • Potts disease • Spinal epidural abscess • Psoas abscess

8. Etiology of back pain • INFLAMMATION • Ankylosing spondylitis • Reiter’s syndrome • Inflammatory bowel disease • Spondyloarthropathy • SEA syndrome

9. Etiology of back pain • MECHANICAL • Musculoskeletal (sprain/strain) • Herniated disc • ORTHOPEDIC/TRAUMA • Spondylolisthesis • Spondylolysis • Scheuermann’s disease • (Scoliosis) • Vertebral compression fracture

10. Etiology of back pain • MALIGNANCY • Spinal cord tumors (lipoma, teratoma) • Bone tumors • Osteoid osteoma • Ewing’s sarcoma • Vertebral osteosarcoma • Neuroblastoma • Leukemia • Eosinophilic granuloma • Aneurysmal bone cyst

11. Etiology of back pain • SYSTEMIC DISEASE • Secondary hyperparathyroidism (Stones, bones, groans, moans) • Sickle-cell anemia - back pain is common • Osteoporosis • Corticosteroid use • Aseptic necrosis • Nephrolithiasis

12. Etiology of back pain • OTHER • Fibromyalgia • Reflex sympathetic dystrophy • Conversion disorder • Pain amplification syndrome • Psychogenic

13. Evaluation of back pain • HISTORY and physical • point tenderness • CBC, ESR, SMA-20, urinalysis • Lyme titer • HLA-B27 • Plain films, including oblique views • Bone scan • CT/MRI

14. Evaluation of back pain • WARNING SIGNS • Increasing pain • Pain wakes child from sleep • Function: usual activities impaired • Weight loss • Fever • Bowel or bladder dysfunction • Young age, < 4 yo

15. Diskitis • Typical patient is 3-5 years old • Systemic findings: fever, irritability, abdominal pain, anorexia • Rigid posture; refuses to flex lumbar spine • Elevated ESR • Plain films reveal irregular vertebral endplates • CT/MRI reveal decreased signal in disk and increased in adjacent vertebrae • Usually hematogenous bacterial infection with S. aureus (88% no organism on aspirate)

16. Vertebral Osteomyelitis • Older children • Only accounts for 2-4% of osteomyelitis • Children appear more toxic: fever, irritability, refusal to walk • Elevated ESR, sedimentation rate • Radiographs show destruction of vertebral body • Organism usually recovered (S. aureus) on aspirate

18. Spondylolysis/spondylolisthesis • Defect of the pars interarticularis • Usually at L5 • Scottie-dog appearance on plain film • obtain oblique and lateral films • Complaints of low back pain, worse with palpation • Slippage of L5 on S1 is spondylolisthesis •  in athletes with hyperextension of spine

22. Scheuermann’s disease • Juvenile kyphosis • Painful in 50% of cases • Usually affects boys 13-17 years of age • 75% of cases affect the thoracic spine • Fixed dorsal kyphosis • Compensatory lumbar lordosis

23. Scheuermann’s disease • Lateral X-ray reveals Schmorl’s nodes and vertebral wedging with irregular vertebral endplates • The disease is self-limited with a benign course • Treatment: Nonsteroidal analgesics • severe cases may require bracing with an external Milwaukee brace for comfort

25. Enthesitis • Local tenderness to palpation at insertions of • tendon • ligament • capsule • On physical exam: • Patella at 10 o’clock, 2 o’clock, 6 o’clock • Tibial tuberosity • Insertion of the Achilles tendon • Plantar fascia insertion onto calcaneus • Metatarsal heads • Greater trochanter of the femur • Anterior superior iliac spine

26. Juvenile ankylosing spondylitis • Chronic arthritis of peripheral and axial skeleton • Enthesitis • Seronegative (rheumatoid factor negative) • Extraarticular manifestations: acute iritis, rarely low grade fever, urethritis or diarrhea • ALL have sacroiliac arthritis • Genetic basis: 2-10% of HLA-B27 positive patients will develop JAS

30. Juvenile ankylosing spondylitis:New York AS criteria •  expansion of lumbar spine • Pain at lumbar spine • Chest expansion 2.5 cm or less • AND • radiographic demonstration of sacroiliac arthritis (may be unilateral)

32. Juvenile ankylosing spondylitis • Iritis • Acute • Painful • Photophobia • Red eye • Anterior nongranulomatous uveitis • Few sequelae, but synechiae may develop • Episodic course most commonly seen in HLA-B27+ patients. If ANA positive, may develop chronic uveitis similar to JRA

33. Juvenile ankylosing spondylitis • HLA-B27 • Class I major histocompatibility antigen • varied presence in ethnic populations: • 50% of Canadian Haida Indians are HLA-B27+ • only 2% of Japanese general population • Incidence of JAS varies with HLA-B27 presence in a given population • 10% risk of AS in children of HLA-B27+ patient with AS • 20% risk of AS if they are also HLA-B27+ and male

34. Treatment of Juvenile AS • NSAIDs • tolmetin sodium (Tolectin) • indomethacin • Sulfasalazine • Intraarticular steroid injections • Local steroid injections at entheses • Physical therapy • New treatments include infliximab (monoclonal anti-TNF) and etanercept (sTNFR)

35. Juvenile ankylosing spondylitis • Children often develop peripheral arthritis years before axial involvement • Look for SEA syndrome: seronegative enthesitis and arthropathy • Complaints of pain in buttocks, groin, thighs, heels often predate frank sacroiliac disease

36. JRA or JAS?

37. DEXA Scan of Lumbar spine Look at Z-scores Percentage of bone mass relative to age matched controls Does not tell risk of fracture Risk of vertebral collapse more likely in pediatric population, rather than hip fracture Treatment: weight bearing exercise calcium, Vitamin D suppl. bisphosphonates

38. Pain amplification syndromes • Pain out of proportion to clinical findings • Pain does not follow anatomical boundaries • With autonomic findings • Chronic regional pain syndrome • Reflex sympathetic dystrophy • Causalgia/Sudeck’s atrophy • With painful tender points • Fibromyalgia • Hypervigilant • psychogenic/psychosomatic

39. Pain amplification syndromes • 80% are female • Median age 12 years • Mean duration of pain 1.6 years • Constant pain • Multiple locations • Lower extremity more often than upper • Role model for chronic pain • Personality: mature, excellent student, eager to please, many extracurricular activities

40. Pain amplification syndromes • Mother is the spokesperson and gives the history including subjective complaints • Incongruent affect: la belle indifference • Marked disability despite a paucity of physical findings • Other findings of headache, abdominal pain, sleep disturbance and fatigue • Allodynia - pain disproportionate to stimulus

41. Pain amplification syndromes Treatment • Physical therapy: • Aerobic exercise daily • Desensitization with toweling • Range of motion exercises • Cognitive behavioral therapy • Progressive muscle relaxation • Guided imagery • Self-hypnosis • Pharmacotherapy • Low dose amitriptyline or SSRI