Clinical Guideline

BACK PAIN MANAGEMENT IN CHILDREN

SETTING Bristol Royal Hospital for Children (BRHC) and primary care

FOR STAFF Paediatricians, emergency department staff, surgeons, emergency nurse practitioners,
general practitioners

PATIENTS All children age under 16 years presenting with back pain

_____________________________________________________________________________

GUIDANCE
Back pain is an uncommon presenting complaint in young children becoming more common after early
adolescence. Although most cases of back pain in children are thought to arise from the muscles due to
self-limiting trauma or non-specific musculoskeletal pain, underlying pathology always needs to be
excluded – especially in younger children where serious pathology is more likely. This guideline has been
developed to guide clinicians in the assessment and management of children presenting with back pain.

HISTORY
Detailed history including but not limited to:

 Back pain site/onset/character/location/radiation/exacerbating factors/relieving factors;

 Bladder or bowel dysfunction or incontinence;

 Lower limb symptoms e.g. paraesthesia, reduced sensation, weakness;

 Fever;

 Weight loss;

 Night time symptoms;

 Morning back stiffness;

 Buttock pain;

 Activities/repetitive back action sport participation e.g. cricket, gymnastics;

 Trauma of significant mechanism;

 Underlying medical condition associated with possible increased musculoskeletal back pathology –
psoriasis (or family history of), inflammatory bowel disease (or family history of), Trisomy 21,
malignancy, hypermobility etc.;

 Systemic symptoms appropriate to site e.g. dysuria.

EXAMINATION
Full examination including but not limited to:

 Temperature, blood pressure and urine dip;

Version 1.0 From: May 2018 – To: May 2021 Author(s) Dr Alison Kelly, Consultant Rheumatologist; Dr Will Page 1 of 5
Christian, Consultant in Paediatric Emergency Medicine.
  Systemic examination of other systems;

 Full musculoskeletal examination;

 Observe gait and movement;

 Back examination (with back fully exposed);

 Observe any clinically obvious scoliosis on forward bend;

 Site of any vertebral bony tenderness or paravertebral soft tissue tenderness;

 Neurological examination – include straight leg raise.

MANAGEMENT
Consider appropriate investigations according to the detailed history and examination for all children e.g.
urine MC+S. Following the Paediatric Back Pain Management algorithm if appropriate (p.4). Manage pain
according to the BRHC pain management guidelines for children. Any child with back pain of uncertain
aetiology should be considered for senior clinical review (middle grade/consultant).

RED FLAGS OF SERIOUS PATHOLOGY

Note the presence of any “red flags” on history and examination (see next page) as these may indicate the
presence of serious pathology such as infection, inflammation or malignancy. They should prompt senior
(middle grade or consultant) review of the patient and further investigation (bloods and/or radiology) to
exclude a serious underlying cause. Children with neurological symptoms affecting their lower limbs,
bladder or bowel require urgent (same-day) spinal neuroimaging and neurosurgical referral.

MUSCULOSKELETAL CAUSES
Most back pain in older children, as in adults, is thought to arise from within the muscles. The majority of
paediatric non-specific musculoskeletal back pain has no identifiable cause. Specific musculoskeletal
causes of back pain may include spondylolysis, spondylolisthesis, scoliosis, juvenile ankylosing
spondylitis, and intervertebral disc herniation.

IMAGING
With the exception of spinal trauma, MRI spine is usually the most appropriate first line radiological
investigation for children with back pain, rather than plain radiograph which has a low yield and associated
radiation dose. If the MRI is non-urgent then this should usually be requested by the paediatrician
following the child up in clinic.

DISCHARGE AND FOLLOW-UP

Discharge advice should include safety netting advice that ensures patients and their families with new,
unresolved or worsening symptoms know when and how to access further help. This should include a
description of the “red flag features” (see “RED FLAGS – HISTORY” below) that would mandate
immediate return for medical assessment, e.g. symptoms affecting a young person’s lower limbs, bladder
or bowel.

All young people presenting with back pain will require appropriate follow up to ensure resolution of their
symptoms. The most appropriate route (either GP or hospital follow up) will depend upon senior review
and the features identified in the history and examination at the time of the presentation.

Version 1.0 From: May 2018 – To: May 2021 Author(s) Dr Alison Kelly, Consultant Rheumatologist; Dr Will Page 2 of 5
Christian, Consultant in Paediatric Emergency Medicine.
 PAEDIATRIC RED-FLAGS FOR BACK PAIN
RED FLAGS – HISTORY POTENTIAL SIGNIFICANCE

 Fever and / or systemically unwell  Spinal or paraspinal infection (e.g.,

osteomyelitis, epidural abscess)

 Young age (particularly < 6 years)  Malignancy

 Infectious/inflammatory conditions (e.g.,
osteomyelitis, discitis)

 Pain that has any of the following  Spinal tumour

qualities:  Infection
o Severe  Nerve root compression
o Constant
o Present at night
o Progressive / worsening with
time
o Interfering with activities of daily
living
o Representation of child to health
professional

 Weight loss  Malignant tumours (e.g., leukaemia,

lymphoma, Ewing sarcoma)

 History of previous or current  Spinal Metastases

malignancy

 History of exposure to TB  Tuberculosis of the spine (Pott’s disease)

 Neurological features:  Nerve root compression

o changes in gait  Epidural abscess
o incontinence or retention of  Transverse myelitis
bladder / bowel  Trauma
o numbness/sensory changes
o pain that radiates down the legs
o weakness on rising from squat

 New onset scoliosis  Malignancy

 Infectious/inflammatory conditions (e.g.,
osteomyelitis, discitis)

 History of repetitive lumbar  Spondylolysis, spondylolisthesis

hyperextension during sports (e.g.
cricket / gymnastics)

 RED FLAGS – EXAMINATION (see above for potential significance)

 Fever
 Gait disturbance / limping
 Any abnormal neurological features e.g.:
o Reduced straight leg raise in either leg
o Lack of sensation in the legs / buttocks
o Altered power or reflexes
 Reduced spinal flexion
 Vertebral (rather than paraspinal muscular) tenderness on palpation

Version 1.0 From: May 2018 – To: May 2021 Author(s) Dr Alison Kelly, Consultant Rheumatologist; Dr Will Page 3 of 5
Christian, Consultant in Paediatric Emergency Medicine.
 Paediatric Back Pain Management Algorithm

Child
presents
with back
pain

Definite/Convincing
history of trauma as
cause?

YES NO

High Risk 1 or more red

mechanism of flags present
injury1 with 1 or on history or
more red flags examination

YES NO
YES NO

Children with no red flags, a

Fever or
short duration of symptoms, a
Systemically
normal neurologic examination,
Ensure spinal Unwell?
Vertebral and an otherwise benign
precautions bony appearance may be appropriate
Senior (middle tenderness? for conservative management
grade or YES NO without radiologic testing.
consultant) Consider senior clinical review.
review
Senior (middle 1 or more neurological Back pain advice
Arrange features present or
urgent grade or Arrange follow up to ensure
YES: NO: consultant) history of previous or resolution
neuroimaging current malignancy or
(C- consider Consider review Discharge with safety netting2
spinal senior any other clinical
spine/CT/MRI) Consider: concerns
radiograph clinical
review Bloods: FBC,
Culture, CRP,
Back pain PV, Blood film, YES
advice NO
Normal Abnormal U&E, Senior (middle
Arrange creatinine grade or
follow up Urine for dip + consultant)
to ensure MC&S review Age < 6 years
Consider senior resolution Consider:
clinical review Senior Neuroimaging
Discharge (CT/MRI) Urgent MRI
Back pain (Middle with safety spine YES
advice grade or netting2 Admit under NO
consultant) appropriate Bloods: FBC, Senior (middle
Arrange follow Consider senior clinical
review team Culture, CRP, grade or
up to ensure review
PV, Blood film, consultant)
resolution. U&E, review Back Pain Advice
Discharge with creatinine If no concerns Arrange follow-up to
safety netting2 Urine for dip + on review then: ensure resolution
MC&S Back Pain Discharge with safety
Admit under Advice netting2
appropriate Arrange follow-
team. up to ensure
resolution.
Discharge with
safety netting 2

1
Examples of high risk mechanisms include fall from a height of greater than 3 metres, axial load to the head or base of the spine
(e.g. falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection
from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents) – NICE Spinal
Injury Guideline NG41, 2016.
2
See under “Discharge and Follow-Up” for details of safety netting and follow-up.

Version 1.0 From: May 2018 – To: May 2021 Author(s) Dr Alison Kelly, Consultant Rheumatologist; Dr Will Page 4 of 5
Christian, Consultant in Paediatric Emergency Medicine.
_____________________________________________________________________________

RELATED NICE guideline NG41: Spinal Injury: Assessment and Initial Management;
DOCUMENTS https://www.nice.org.uk/guidance/ng41

AUTHORISING BRHC General Paediatric Governance Group; BRHC Paediatric Emergency

BODY Governance Group.

SAFETY No specific/unusual safety concerns identified

QUERIES Contact Rheumatology Team (secretary x 20146/20149) or BRHC Paediatric

Emergency Team (secretary x 28187) Governance Leads.

Version 1.0 From: May 2018 – To: May 2021 Author(s) Dr Alison Kelly, Consultant Rheumatologist; Dr Will Page 5 of 5
Christian, Consultant in Paediatric Emergency Medicine.