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Back Pain in Children and Adolescents. Christine Hom, M.D Division of Pediatric Rheumatology New York Medical College. Back Pain. Back pain in children - abnormal until proven otherwise! 75% of children with back pain have an identifiable etiology

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Back Pain in Children and Adolescents

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Back Pain in Children and Adolescents

Christine Hom, M.D

Division of Pediatric Rheumatology

New York Medical College


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


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


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


  • Etiology of back pain

    • INFECTION

    • INFLAMMATION

    • MECHANICAL

    • ORTHOPEDIC

    • TRAUMA

    • MALIGNANCY

    • SYSTEMIC DISEASE

    • OTHER


    Etiology of back pain

    • INFECTION

      • Sacroiliac infections

      • Vertebral osteomyelitis

      • Diskitis

      • Pyelonephritis

      • Potts disease

      • Spinal epidural abscess

      • Psoas abscess


    Etiology of back pain

    • INFLAMMATION

      • Ankylosing spondylitis

      • Reiter’s syndrome

      • Inflammatory bowel disease

      • Spondyloarthropathy

      • SEA syndrome


    Etiology of back pain

    • MECHANICAL

      • Musculoskeletal (sprain/strain)

      • Herniated disc

    • ORTHOPEDIC/TRAUMA

      • Spondylolisthesis

      • Spondylolysis

      • Scheuermann’s disease

      • (Scoliosis)

      • Vertebral compression fracture


    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


    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


    Etiology of back pain

    • OTHER

      • Fibromyalgia

      • Reflex sympathetic dystrophy

      • Conversion disorder

      • Pain amplification syndrome

      • Psychogenic


    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


    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


    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)


    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


    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


    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


    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


    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


    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


    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)


    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


    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


    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)


    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


    JRA or JAS?


    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


    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


    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


    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


    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


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