Licensed to M ©2007 UpToDate®
Peter A Nigrovic, MD
Andrew P Wilking, MD
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on January*10,*2007. The next version of UpToDate (15.3) will be released in October 2007.
INTRODUCTION*—*Back pain is an uncommon presenting complaint in children. Although benign musculoskeletal disease or trauma accounts for most cases, congenital or acquired conditions such as infection, noninfectious inflammatory disease, and neoplasm must be excluded (show table 1).
The differential diagnosis of back pain in children and adolescents is reviewed here. The epidemiology and evaluation of back pain in children is discussed separately. (See "Evaluation of the child with back pain").
Nonspecific musculoskeletal pain*—*In most larger published series, even from referral centers, most children with back pain receive no definitive diagnosis [1-3]. These children typically are thought to have "muscle strain" or a similar benign source of discomfort. Such muscle strain may be caused by a backpack overloaded with heavy school books. The American Academy of Pediatrics has developed a guide to the safe use of backpacks and one of its recommendations is that a backpack should never weigh more than 10 to 20 percent of the child's body weight . An especially soft mattress may cause morning back pain and stiffness . Most such children do well, although a fraction of them will have prolonged and occasionally disabling pain similar to chronic back pain in adults. A small number of females complain that their disproportionately large breasts are a cause of back pain. Depression, anxiety, and psychosocial distress are regularly found at elevated levels in children complaining of nonspecific back pain [2,6,7].
Spondylolysis and spondylolisthesis*—*Spondylolysis is a unilateral or bilateral defect (separation) in the vertebral pars interarticularis, usually in the lower lumbar vertebrae, particularly L5. Spondylolisthesis occurs when bilateral defects permit anterior slippage of the vertebral body (show figure 1).
Spondylolysis may be congenital (malformations of the facet joints) but more typically is acquired as the bone "fatigues" from recurrent microtrauma during excessive lumbar hyperextension. Thus, it is a common problem in gymnasts, dancers, divers, weight lifters, and football linemen [8-10]; soccer players and other sports participants also are at risk , while some patients with spondylolysis have no identified risk factors . Spondylolysis was present in almost one-half of adolescent athletes who were evaluated for acute low back pain in a sports medicine clinic .
Spondylolysis also occurs in the general population. A carefully-done natural history study of 500 children found a prevalence of 4.4 percent by age six years and 6 percent by adulthood . Caucasians are at higher risk than are blacks, and boys are at higher risk than are girls, although girls progress to spondylolisthesis more often. Additional risk factors include a family history of spondylolysis [15,16] and occult spina bifida at S1 .
In one series of 185 patients with 346 defects who were seen in a sports medicine clinic, 90 percent of defects occurred at L5, 80 percent were bilateral, and 4 percent of patients had defects at more than one level . Approximately 20 percent had begun to slip at first evaluation. Further progression after initial presentation seldom occurs, especially after the adolescent growth spurt .
Spondylolysis manifests as aching low back pain that is exacerbated by lumbar hyperextension but may be asymptomatic. The typical age of presentation is early adolescence. If unilateral, the pain may be localized to the side of lysis. On examination, the patient often has a positive ipsilateral one-legged hyperextension test (show figure 2) . Standing on one leg, the patient leans backward. Pain ipsilateral to the weight-bearing leg constitutes a positive test. Hamstring tightness is observed commonly, manifest by limited passive straight leg raising (SLR), and limited forward bending. In spondylolisthesis, a prominent spinous process may be palpated if significant slippage is present. If the slip is severe enough, the sacrum becomes relatively more vertical, impairing hip extension and compelling the patient to walk with a knee-flexed, hip-flexed gait (Phalen-Dickson sign) . Neurologic impairment from spondylolisthesis rarely occurs because the vertebra slips anteriorly away from the spinal cord and nerve roots.
Imaging begins with lumbosacral plain films, including oblique views, which reveal the spondylolysis as a crack (or collar) on the neck of the "Scotty dog" (show figure 1). Early or incipient fractures may escape detection on plain films, but they can be detected by bone scan . Bone scan also can distinguish whether a fracture is new or old, which has implications for potential healing [20,21]. Early detection is important because progression to spondylolisthesis correlates with poorer long-term prognosis for healing and pain relief [17,22].
Treatment of spondylolysis and spondylolisthesis is controversial and should be managed by an orthopedic specialist. Therapeutic modalities include rest and lumbar bracing to prevent hyperextension. Surgical fusion is indicated for intractable pain or slippage of greater than 50 percent in a child who is still growing and, therefore, at risk of progression, whether or not symptoms are present .
Scoliosis*—*Scoliosis is defined as an abnormal lateral curvature of the spine and can be idiopathic or result from congenital spinal anomalies, muscular spasm or paralysis, infection, tumor, or other causes.
Systematic surveys have documented that musculoskeletal back pain occurs more commonly among patients with scoliosis than among matched controls [23,24]. Among more than 2000 patients evaluated for idiopathic adolescent scoliosis at one center, 23 percent had back pain at presentation . No correlation was found with degree of curvature. Only 9 percent of 560 patients with pain had a cause other than scoliosis, of which spondylolysis and Scheuermann kyphosis were the most common. The authors concluded that evaluation beyond plain radiographs rarely was necessary . However, scoliosis that presents atypically (for instance, before age 10 years, with neurologic signs, or with rapid progression) should be evaluated aggressively to rule out an underlying cause such as tumor or syringomyelia (a cystic degeneration of the spinal cord) [26,27]. A thoracic curve convex to the left is associated with an underlying cause slightly more often than is a rightward curve, but the difference is too small to have important implications for the evaluation of the child with scoliosis .
Scheuermann kyphosis (juvenile kyphosis)*—*Scheuermann kyphosis is defined as anterior wedging of 5 degrees or greater in at least three adjacent vertebral bodies, as measured on lateral spine radiographs . Degeneration of the vertebral end plates may be seen radiographically as well (show radiograph 1).
Onset typically occurs in early adolescence, with localization to the thoracic or thoracolumbar spine. Some degree of Scheuermann-like change is quite common: one survey of 500 17- and 18-year-old New Zealanders found an incidence of 56 percent in males and 30 percent in females, although changes were severe in only 7 percent and 1.8 percent, respectively, closer to other estimates of disease prevalence, ranging from 4 to 8 percent [29,30]. Tall males were found to be at higher risk for developing severe disease.
Scheuermann kyphosis presents as a rigid thoracic kyphosis with a relatively sharp angulation when the child bends over, best viewed from the side of the patient. The diagnosis can be missed if the thoracic curvature is ascribed to poor posture. However, clinical examination is neither sensitive nor specific . The etiology of Scheuermann kyphosis remains undefined. An association with sports or heavy lifting remains controversial, although a period of prolonged bed rest has been found more commonly in patients than controls, suggesting that the wedging reflects compression fractures associated with transient osteoporosis .
Pain related to Scheuermann kyphosis typically is subacute in onset without a clear episode of precipitating trauma. It is worse after activity and at the end of the day and improves with rest. Pain tends to improve with skeletal maturity, although long-term follow-up has shown an elevated prevalence of back pain in adulthood . Because Scheuermann kyphosis is associated with spondylolysis, oblique radiographs should be considered to rule out this condition if clinically indicated .
Conservative management with strengthening and stretching exercises, analgesics, and avoidance of precipitants is all that usually is necessary for treatment, although bracing or other orthopedic interventions are required if pain is persistent or the kyphosis exceeds 60 degrees [29,33].
Degenerative disc disease*—*Herniation of the nucleus pulposus is a far less common cause of back pain in children than in adults, making up no more than a few percent of all disc operations in most series . Risk factors include acute trauma  and Scheuermann kyphosis. A family history of disc herniation was noted in 32 percent of 63 children (younger than 21 years) who underwent surgery for disc disease, compared to 7 percent of controls (RR 5, 95% CI 1.7-14.6) . Presentation before the age of 10 rarely occurs, though cases have been reported in early childhood. Degenerative changes of the discs are seen on pathology, as is the case in adults .
Even in the absence of abject prolapse, degenerative disc changes (with or without disc calcification) are associated with pain in some adolescents, although in others they may be no more than an incidental finding [38,39].
The presentation of degenerative disc disease in children is similar to that in adults. L4-L5 and L5-S1 are most frequently involved, and lumbar pain, sciatica, limitation of spinal flexibility, and a positive SLR test commonly are present (show table 2) [34,35,40,41]. (See "Approach to the diagnosis and evaluation of low back pain in adults" and see "Evaluation of the child with back pain" section on Straight leg raising).
Initial treatment is conservative, although surgical therapy generally is successful if indicated for neurologic deficits or intractable pain .
Disc space calcification*—*Intervertebral disc space calcification is an idiopathic, presumed postinflammatory, and generally transient condition that typically affects preadolescent children from infancy onward . In contrast to degenerative disc changes, which usually are lumbar, calcification typically involves cervical and/or thoracic discs. This condition can be an incidental finding or can present with torticollis or back pain, particularly because herniation occurs in one-quarter of cases . The course usually is benign, and spontaneous resolution of calcification commonly occurs .
Other*—*Other mechanical causes of back pain include congenital absence of a lumbar pedicle , idiopathic juvenile osteoporosis , aneurysmal bone cyst of the spine, vertebral apophyseal fracture from rapid hyperflexion in dancers or gymnasts [47,48], and sacroiliac joint stress reaction related to sports training .
INFECTIOUS*—*Infectious causes of back pain in children and adolescents include discitis, vertebral osteomyelitis (including tuberculous), epidural abscess, and sacroiliac joint infection. Nonspinal infections that can present with back pain include paraspinous muscle abscess, pyelonephritis, pneumonia, pelvic inflammatory disease, endocarditis, and myalgia caused by viral illness.
Discitis*—*Inflammation of the intervertebral disc is a relatively rare disease of childhood, with an incidence of one to two per 32,500 pediatric hospitalizations and clinic visits at one academic medical center .
Discitis usually presents with the gradual onset of irritability and back pain or refusal to walk, without systemic toxicity and only occasionally accompanied by fever . Children typically have had symptoms for three or more weeks by the time the diagnosis is made [51,52]. In some patients, abdominal pain may be the only complaint. The usual age of presentation is infancy to three years, though cases may occur through adolescence . The lower lumbar discs are affected most commonly, but any disc (and occasionally more than one) may be involved. Neurologic findings (eg, decreased muscle strength or reflexes) may be present . Fever is present in approximately one-quarter of patients, blood cultures typically are sterile, and the white blood cell count usually is normal, although the erythrocyte sedimentation rate is elevated in more than 90 percent of patients [50,55].
The etiology of discitis is controversial. A significant proportion (as many as 60 percent)  of biopsied discs grow bacteria, usually Staphylococcus aureus. However, children often recover without antibiotic therapy. In fact, given the mild and nonspecific manner in which these patients can present, many cases probably go undiagnosed. The current consensus, backed by scant supportive evidence, is that discitis in children is a low-grade infection. Host defense systems usually are capable of overcoming the infection without assistance because the disc is richly vascularized up to seven years of age [50,56]. Occasionally, however, host defenses are overwhelmed, and complications such as abscess formation may result .
Plain radiographs usually are normal at the start of the illness, but by two to three weeks later they illustrate narrowing of the intervertebral space . Occasionally, the diagnosis is made incidentally on radiographs performed to exclude intraabdominal pathology .
Diagnosis of discitis is best made by magnetic resonance imaging (MRI), which can define the inflammation and exclude alternative diagnoses such as vertebral osteomyelitis and tumor. MRI frequently documents involvement of both adjacent vertebral end plates as well, suggesting that significant overlap between discitis and vertebral osteomyelitis may be present . Bone scan also can localize the inflammation, but lack of specificity and imperfect sensitivity limit the utility of this modality . (See "Evaluation and diagnosis of hematogenous osteomyelitis in children").
Treatment for discitis is not standardized. Aspiration of the affected disc for culture usually is not performed. Limited retrospective data suggest that initial treatment with intravenous antibiotics until the child shows clinical improvement, followed by oral antibiotics, is associated with a somewhat more rapid response and fewer relapses than is treatment with oral antibiotics or analgesia alone . Empiric antibiotic therapy should be directed against S. aureus. Immobilization, either through bedrest, or occasionally, casting, may assist with pain control . The long-term outcome usually is good, although anomalies of the disc space and adjacent vertebrae (often asymptomatic) are common findings on long-term follow-up (occurring in 50 of 55 patients in two series) [58,59].
INFLAMMATORY ARTHRITIS*—*A limited number of systemic inflammatory conditions can affect the spine and manifest as back pain: ankylosing spondylitis, psoriatic arthritis, the arthritis of inflammatory bowel disease, and Reiter syndrome. (See "Spondyloarthropathy in children", see "Ulcerative colitis in children and adolescents", and see "Clinical manifestations and diagnosis of Crohn's disease in children and adolescents").
The hallmark of inflammatory disease is morning stiffness. After a night's rest, the patient awakes with axial discomfort and limited mobility that improves with a hot shower or bath and usual activity, only to return after a period of prolonged inactivity ("gelling"). Severe or nocturnal pain is most unusual. Because inflammatory spondylitis often is HLA-B27-related, a family history sometimes is informative, although testing for HLA-B27 itself rarely is useful because HLA-B27 is a relatively common finding in the normal population and absent in many patients with spondylitis [60,61].
On examination, sacroiliac joint tenderness may be found, and pain may be elicited by maneuvers that stress the SI joints. These maneuvers include application of direct pressure to anterior iliac spines and the so-called "figure of four" maneuver (also referred to as the Patrick or FABER test). It consists of flexion of the hip and knee, with abduction and external rotation at the hip, so that the ankle of one leg is on top of the opposite knee (a figure four configuration) . Pain with this maneuver in the absence of pain with passive hip joint motion suggests discomfort arising from the sacroiliac joint. However, the sensitivity and specificity of the physical examination are limited .
Sacroiliac joint changes may be observed on plain radiographs, although MRI is more sensitive for detection of early disease .
NEOPLASTIC*—*The most common neoplasm that presents with back pain in children is osteoid osteoma, a benign bone tumor characterized by nocturnal pain and prompt relief with NSAIDs, although these features are not invariable. Ten to 20 percent of osteoid osteomas localize to the spine, where they can cause scoliosis either by bony deformity or muscle spasm [65,66]. The diagnosis is made using plain film, bone scan, or MRI.
Other tumors that can present in the spine include leukemia, lymphoma, Ewing sarcoma, neuroblastoma, osteoblastoma, osteosarcoma, neurofibromas, and Langerhans cell histiocytosis (eosinophilic granuloma) [33,67]. (See appropriate topic reviews). A small series found that constant pain, nocturnal pain, and duration of pain less than three months were associated with tumors, although these characteristics were not specific .
MISCELLANEOUS*—*Additional causes of back pain in children and adolescents include sickle cell pain crisis, syringomyelia, cholecystitis, pancreatitis, chronic recurrent multifocal osteomyelitis, pyelonephritis, and chronic pain syndromes.
Chronic pain syndromes*—*Chronic pain syndromes comprise 10 to 15 percent of referrals to pediatric rheumatology practices [68-70]. The bulk of these patients are adolescents; nonorganic pain is considered a very rare occurrence before the age of seven to nine years . Complaints limited to the back are uncommon.
Hallmarks of functional illness include discordance between reported symptoms and physical findings, frequent school absences, and withdrawal from social activities with peers. Pain prolonged over the course of years is a common occurrence. The parent often is inappropriately invested in the child's complaints, answering questions on his or her behalf . Associations have been noted between nonorganic pain and low parental education, psychosocial stresses, pending litigation, and a parental history of chronic pain [2,72,73]. As always, however, a chronic pain syndrome remains a diagnosis of exclusion.
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