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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
  • INFECTION
  • INFLAMMATION
  • MECHANICAL
  • ORTHOPEDIC
  • TRAUMA
  • MALIGNANCY
  • SYSTEMIC DISEASE
  • OTHER
etiology of back pain1
Etiology of back pain
  • INFECTION
    • Sacroiliac infections
    • Vertebral osteomyelitis
    • Diskitis
    • Pyelonephritis
    • Potts disease
    • Spinal epidural abscess
    • Psoas abscess
etiology of back pain2
Etiology of back pain
  • INFLAMMATION
    • Ankylosing spondylitis
    • Reiter’s syndrome
    • Inflammatory bowel disease
    • Spondyloarthropathy
    • SEA syndrome
etiology of back pain3
Etiology of back pain
  • MECHANICAL
    • Musculoskeletal (sprain/strain)
    • Herniated disc
  • ORTHOPEDIC/TRAUMA
    • Spondylolisthesis
    • Spondylolysis
    • Scheuermann’s disease
    • (Scoliosis)
    • Vertebral compression fracture
etiology of back pain4
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 pain5
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 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
  • 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
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
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
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
enthesitis
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
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
slide37
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 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

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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