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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

Back Pain in Children and Adolescents

Christine Hom, M.D

Division of Pediatric Rheumatology

New York Medical College

Back pain
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 pain1
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
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
    Etiology of back pain





    • TRAUMA



    • OTHER

    Etiology of back pain1
    Etiology of back pain


      • Sacroiliac infections

      • Vertebral osteomyelitis

      • Diskitis

      • Pyelonephritis

      • Potts disease

      • Spinal epidural abscess

      • Psoas abscess

    Etiology of back pain2
    Etiology of back pain


      • Ankylosing spondylitis

      • Reiter’s syndrome

      • Inflammatory bowel disease

      • Spondyloarthropathy

      • SEA syndrome

    Etiology of back pain3
    Etiology of back pain


      • Musculoskeletal (sprain/strain)

      • Herniated disc


      • Spondylolisthesis

      • Spondylolysis

      • Scheuermann’s disease

      • (Scoliosis)

      • Vertebral compression fracture

    Etiology of back pain4
    Etiology of back pain


      • Spinal cord tumors (lipoma, teratoma)

      • Bone tumors

        • Osteoid osteoma

        • Ewing’s sarcoma

        • Vertebral osteosarcoma

      • Neuroblastoma

      • Leukemia

      • Eosinophilic granuloma

      • Aneurysmal bone cyst

    Etiology of back pain5
    Etiology of back pain


      • Secondary hyperparathyroidism

        (Stones, bones, groans, moans)

      • Sickle-cell anemia - back pain is common

      • Osteoporosis

      • Corticosteroid use

      • Aseptic necrosis

      • Nephrolithiasis

    Etiology of back pain6
    Etiology of back pain

    • OTHER

      • Fibromyalgia

      • Reflex sympathetic dystrophy

      • Conversion disorder

      • Pain amplification syndrome

      • Psychogenic

    Evaluation of back pain
    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 pain1
    Evaluation of back pain


      • Increasing pain

      • Pain wakes child from sleep

      • Function: usual activities impaired

      • Weight loss

      • Fever

      • Bowel or bladder dysfunction

      • Young age, < 4 yo


    • 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
    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
    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 disease1
    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


    • 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
    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
    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 spondylitis1
    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 spondylitis2
    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
    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 spondylitis3
    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

    Back pain in children and adolescents

    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


    weight bearing exercise

    calcium, Vitamin D suppl.


    Pain amplification syndromes
    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 syndromes1
    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 syndromes2
    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 syndromes3
    Pain amplification syndromes


    • 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