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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
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
    • 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
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