Back Pain in Children

Mr Purnajyoti Banerjee
 Epdemiology
• Less common than in adults
• Usually has an identifiable cause
• Prevalence increases with age (11% at 11
years to 50% by 15 years)
• In 80 to 90 % cases pain resolves within 6
weeks
 Differential diagnosis
Common causes Less Common causes Uncommon/rare causes

Muscular Infection (discitis/ Disc prolapse

strain/apophysities osteomyelitis)

Overuse Scheuermann kyphosis Ankylosing spondylitis

Spondylolysis Trauma with fracture Juvenile rheumatoid

arthritis

Spondylolisthesis Bone tumours

Trauma with bone Spinal cord tumour

oedema/microfracture

Psychogenic back pain

 Pathoanatomy
• Serious pathology more common if <10 years
• Mechanical back pain is commonest cause
amongst all age group
• Spinal deformities can cause structural back
pain/ pain due to muscle spasm
• Intra abdominal pathologies can present with
back pain (pyelonephritis, appendicitis)
• Heavy school back packs are also potential
cause
 Evaluation
• Location
• Associated known deformity
• Onset
• Duration
• Any relation to activities
• Night pain with/without sleep disturbances
• Neurology
• Constitutional symptoms
 Evaluation
• Night pain associated with tumours/infection
• Visceral pain is not relieved by pain or
aggravated with activities!!
• Examine the whole spine irrespective of
symptoms
• Neurologic examination including P/R
examination is must in patients with neuro
deficits
 Red Flag Signs/Symptoms
• Positive finger test!! Well localised
pain/tenderness
• Pain worsens with time
• Pain at rest and not associated with activities
• Bowel/bladder incontinance
• Acute trauma with neurology
 Investigations
• Plain radiographs- best for assessing bony
alignment, destruction and instability
• CT –bone related abnormalities (
spondylolysis, thoracic fractures)
• MRI – recommended in any patient with
neurology to assess cord, roots
• Bone scan- helps to locate fractures, infection,
tumour
• Lab studies- FBC, CRP, ESR, smear
 Classification –Anterior pathology
• Pain due to deformity
• Discitis
• Neoplasia
• Spondylolysis / spondylolisthesis
• Disc herniation
• Vertebral apophyseal end plate fractures
• ABC
Classification- Posterior pathology
• Posterior pathology
-Osteoid osteoma
-Osteoblastoma

• Systemic causes
- Histiocytosis X ( vertebra plana)
-Leukemia (commonest malignancy)
 Approach-Spinal Trauma
• Bones and ligaments of paediatric spines can
tolerate more stretch than the spinal cord
• Children can sustain cord/ root injury despite
completely normal radiographs
• MRI is mandatory for children with neurology
after acute trauma irrespective of radiological
findings
Bad disc Good news!!!
 Approach-Spinal Infection
• Infection can affect the disc( discitis), vertebral
body ( osteomyelitis) or vertebra-disc-vertebra
unit (spondylodiscitis)
• Elevated CPR/ESR are most sensitive indicators
• MRI to detect level and assess response to
treatment
• Staphylococcus aureus most common organism
• Mostly treated non operatively with IV/oral
antibiotics
Good Disc bad news!!!
 Approach-Spinal Tumours
• Present with fever, night sweats, weight loss

• Radiographs, FBC with smear and ESR

• MRI?CT helps in localising and type of lesion

• Bone scan can be used (high radiation)

• Biopsy may be needed to confirm diagnosis

 Management
Non Operative
• Benign tumours- osteiod osteomas can be
treated with NSAIDs alone
• Histiocytosis X resolves spontaneously
 Surgical management
• Lumbar disc herniation-non responsive to
conservative Rx for more than 3 months/
Neurology
• Osteiod osteoma/ABC- excision preferred over
radioablation if unresponsive to NSAIDs
• Osteoblastoma- marginal excisions non
responsive to conservative Rx
• Malignant tumours –combination of
resection/chemotherapy and radiotherapy
 Summary
• Most common causes of back pain is muscle
strain/overuse
• Red flag signs should always besought during
initial consultation
• MRI must be obtained in children with back
pain and neurodeficit
• Trauma , infection and tumours should be
actively ruled out in any children with acute
back pain