Back Pain in Children

Back pain in children, as compared to an adult is more likely to have a serious underlying disorder. Back pain in children is often due to organic causes, especially if it persists longer than two months. Up to 85% of children with back pain could have a detectable pathology.

Therefore, a careful history and a thorough physical examination are mandatory for every child who presents with back pain.

This is especially true if the child is 4 years old or younger, or if a child of any age has back pain accompanied by fever, weight loss, weakness or numbness, difficulty in walking, radiating pain, bowel/bladder issues or pain that does not let the child sleep.

While back pain in teens is often the result of aggressive sports or other activities, back pain in young children is more likely to be a symptom of something more serious.

Causes of Back Pain in Children

Following is the detailed list of the causes of back pain in children.

Congenital

• Bony segmentation defects
• Diastematomyelia, tethering of cord etc.

Developmental

• Painful scoliosis
• Kyphosis (Scheuermann disease)

Traumatic

• Muscle strain
• Spondylolysis and spondylolisthesis
• Herniated disc

Infections

• Discitis
• Vertebral osteomyelitis
• Tuberculosis

Systemic diseases

• Storage diseases
• Juvenile osteoporosis
• Rheumatoid arthritis
• Ankylosing spondylitis

Tumors

• Osteoid osteoma
• Osteoblastoma
• Aneurysmal bone cyst
• Eosinophilic granuloma

Malignant

• Osteogenic sarcoma
• Spinal cord tumor
• Metastatic

Overview of Important Causes of Back Pain in Children

Congenital Abnormalities

Back pain due to congenital abnormalities of the spine is uncommon. Occasionally, congenital defects in the cervical spine in association with Klippel-Feil syndrome (due to hypermobility) , diastematomyelia in the thoracic spine, and cord tethering in the lumbar spine may be associated with pain.

Developmental Idiopathic Scoliosis

Scoliosis associated with back pain is not a routine presentation and should arouse suspicion of an underlying problem.

Left thoracic curvatures are uncommon and are often associated with an underlying abnormality, eg.  occult syrinx, spinal cord tumor, a neuromuscular disorder. Such a patient should have extensive neurological and radiological evaluation, prior to treatment.

Scheuermann Disease

Children who have Scheuermann disease present with pain, which is usually located over the apex of the kyphosis and in the lumbar spine, due to a compensatory increase in lumbar lordosis. Pain usually subsides with the cessation of growth. The diagnosis of Scheuermann disease is based on the physical findings of round back, thoracic in adolescents kyphosis.

Muscle Strain

Muscle strain is usually the result of overuse in sports or other activities. Improper conditioning and too-rapid advances in terms of the level of play are common causes of muscle strain. Recurrence is prevented by restriction of activities until the symptoms have resolved, followed by the use of proper training techniques. Younger children are less likely to stress their spines like older children and adults. Therefore, these children do not have medically significant back pain and their discomfort tends to be short-lived. But if the problem persists, it demands further work-up.

Older children and teenagers are more active and participate in a sports activity that requires to push their limits. Teenagers may engage in risky activities owing to adventurism, peer pressure or commercial pursuing.

Therefore, compression fractures, disc injuries, and other spinal injuries are common causes of back pain in these children.

Frequently, these children return to the same injurious behavior and suffer overuse injuries. Tumors and infection of the spine may occur in teens, but it is more common for back pain in teens to be caused by sports injuries or overuse syndromes.

Spondylolysis and Spondylolisthesis

Spondylolysis refers to a defect of the joint between vertebral bones. It is commonly found in those who tend to hyperextend their backs (bend backward), such as gymnasts. This injury may actually represent a stress fracture.

Spondylolisthesis refers to a slipping of one vertebra upon another. This condition can progress through adolescence, and if it results in instability and back pain it may require spinal fusion surgery at a later point.

These are is most common in children and adolescents. The origin of spondylolysis is currently believed to be a stress or fatigue fracture of the pars interarticularis.

Back pain due to spondylolysis or spondylolisthesis commonly develops in late childhood or adolescence. These children usually present with activity related to low back pain, which is decreased by rest and by restriction of activities. Neurological symptoms or deficits are uncommon except in severe spondylolisthesis. Tight hamstrings are a common finding.

The diagnosis of spondylolysis or spondylolisthesis can usually be made on routine posteroanterior and lateral or oblique standing x-rays of the lumbar spine. The most common site of involvement is the area between the fifth lumbar and the first sacral segment.

Restriction of activities, rest, and strengthening exercises for the muscles of the back and abdomen are relatively successful in controlling symptoms in adolescents who have long-standing spondylolisthesis associated with a mild backache and tight hamstrings. It is important that all children with spondylolysis be followed by x-rays, usually at four to six-month intervals.

Disc Injuries and Vertebral Fractures

These are common in the older children and teens who push themselves through gymnastics or extreme sports (such as skateboarding, in-line skating etc). The injury which can result in a vertebral fracture and/or damage to the intervertebral discs.

A herniated disc can cause mechanical back pain with radiculopathy. A positive straight-leg-raising test is the most common physical finding.

A herniated disc can be diagnosed best with magnetic resonance imaging studies. Conservative management, including restriction of activities, bed rest, and administration of analgesic medication, should be tried initially. If there is no relief of the pain, or if there are persistent neurological symptoms, then operative intervention may be necessary.

Tumors

Back pain caused by a spinal tumor is a very rare occurrence. The thoracic and lumbar regions are the most common sites of involvement in the spine. Common x-ray findings included erosion of the neural arch, erosion of the vertebral body, tumor shadow, paraspinal calcifications, and widening of the spinal canal.

The majority of tumors of the spine in children are benign, in contrast with spinal tumors in adults, which are most often malignant.

Children who have a spinal tumor can present with back pain, with a painful non-structural scoliosis, and with or without neurological deficits. The most common benign osseous tumors of the spine are osteoblastoma, osteoid-osteoma, solitary bone cyst, and eosinophilic granuloma.

Malignant tumors in the spine of a child are uncommon. They can present as a primary osseous lesion, a neurogenic lesion arising from the spinal cord, or a metastatic lesion.

Infection

Infection of the spine (discitis) in children will usually present with back pain and systemic symptoms. An infection of the spine is of great consequence and requires prompt diagnosis. Diagnosis of an infection is usually made with the assistance of a good physical exam and laboratory data. Signs of inflammation may be present.  Radiographic studies are frequently normal. Treatment consists of antibiotics and if required, drainage of the abscess.

Backpacks and Back Pain

This is being discussed separately from other injuries because of its importance.  A heavy weight carried in backpacks can distort the natural curves in the middle and lower backs, cause muscle strain and irritation to the spine joints and the rib cage.

It can further lead to rounding of the shoulders and cause a person to lean forward, making it easier to fall

If a child carries backpacks over one shoulder, it strains muscle to compensate for the uneven weight. The spine leans to the opposite side, stressing the middle back, ribs, and lower back more on one side than the other.

This can contribute to headaches, shoulder pain, lower back pain, and/or neck and arm pain.

Thus, backpack is a frequent cause of back pain in children and adolescents

The back pain caused by backpacks is short-term muscle strain that gets relieved with the short period of rest or reduced activity; any type of back pain that persists is uncommon and should be evaluated by a medical professional

Clinical Presentation

The detailed history is taken for

• Onset, location, character, and radiation of pain
• Duration of the symptoms
• Precipitating factors, such as injuries
• General health and development of the child
• Constitutional symptoms
• Any neurological symptoms

A complete examination of the spine and musculoskeletal system is done. S Spinal alignment, mobility, muscle spasm, and areas of tenderness are noted.

Neurological evaluation assessment of gait,  balance, coordination, muscle strength, sensory and motor evaluation, and reflexes. The slightest discrepancy should be viewed with suspicion.

Imaging

X-rays

X-rays of the involved area of the spine are done to look for any visible lesion. Stress / bending films may be done if instability is suspected e.g. listhesis

Bone scan

These are carried out in suspected tumors, and to elicit an ‘active’ lysis

CT scan

CT defines a bony pathology better and can catch the lesions earlier than x-rays.

MRI

MRI is able to tell better about nerve root and cord status

Lab Studies

Extensive initial laboratory testing as a routine procedure is usually unnecessary.

In suspected systemic lesions, a complete blood count, ESR, rheumatoid factor, antinuclear antibodies, HLA B27 can be done depending upon the need suggested by clinical work up.

Treatment

An acute back pain should be managed by rest and analgesics. Muscle strain and other minor ailments of the spine usually respond to rest and other measures.

If he back pain does not improve on the rest and initial medication, the patient should be investigated for a probable cause.

The treatment then would depend on the cause and patient profile.