Research Review By Dr. Jeff Muir©

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Date Posted:

October 2014

Study Title:

Back pain in children & adolescents

Authors:

Altaf F, Heran MKS, Wilson LF

Author's Affiliations:

Royal National Orthopaedic Hospital, Spinal Surgical Unit, Brockley Hill, Stanmore, UK; British Columbia’s Children’s Hospital, Department of Radiology, University of British Columbia, Vancouver, Canada.

Publication Information:

Bone & Joint Journal 2014; 96-B: 717–23.

Background Information:

Low back pain in children and adolescents, while largely ignored previously, has become an area of increased interest of late. Back pain in adolescents is most prevalent between ages 13 and 15 and can vary between 7-58% (1), with an equal distribution between genders (2). General risk factors include: increasing age, increased height, family history, increased physical activity and competitive sport, psychological distress, smoking, manual work, and carrying a heavy backpack (3). Assessing and treating back pain in younger patients has inherent difficulties, from dealing with a distressed or uncooperative child/toddler, to their occasional inability to localize pain.

The etiology of back pain in children is significantly different from that of adults and, although serious pathologies are rare, there are several that require consideration. This paper reviewed the important causes of back pain in children and adolescents. EDITOR’S NOTE: the authors did not discuss uncomplicated, mechanical causes of back pain. Younger patients can, and do, develop spinal pain and dysfunction for reasons that respond very well to manual therapy, lifestyle modification and rehabilitation. The conditions reviewed below help complete our list of differential diagnoses.

Summary:

Spondylolysis and Spondylolisthesis:
Spondylolysis is a defect in the pars interarticularis (normally a stress or fatigue fracture) and it most commonly occurs between L4 and L5. Spondylolisthesis, on the other hand, refers to a bilateral pars defect accompanied by anterior movement of the affected vertebrae on the next caudal segment. Together, these two pathologies are the most common serious causes of back pain in children over age 10 (4, 5).

These injuries are more common in boys and those engaged in sports that involve repetitive extension, flexion and rotation (6, 7). Diagnosis is made through imaging, with plain films and CT scanning the most commonly utilized and most reliable. Treatment generally begins with rest and avoidance of aggravating activities and can also include non-steroidal anti-inflammatory medication, bracing and physiotherapy, which emphasizes hamstring stretching and core strengthening (NOTE: evidence pertaining to manual therapy in patients with these conditions is relatively sparse at this time). Surgery is reserved only for patients who do not respond to conservative management.

Lumbar Intervertebral Disc Prolapse:
Lumbar disc prolapse is exceedingly rare in children and adolescents, with < 10% of children with low back pain having a prolapsed disc. Disc injuries in children also present clinically in a very different manner than adults, with 30-60% of childhood disc injuries resulting from trauma or sport-related injury (8). The clinical presentation is predominantly tightness of the dorsolumbar fascia and the hamstrings, with minimal back pain and often no associated sciatica (which is, of course, common in adult patients). Thoracolumbar scoliosis often accompanies this injury. Childhood disc injuries often remain contained within the annulus and are not associated with neurological symptoms, due to the relative resiliency of the neurologic tissue in this age group. As such, motor, sensory and reflex deficiencies are often absent.

Adolescents do not respond as well to non-surgical treatment as their adult counterparts (Perhaps due to the often traumatic mechanisms of injury?) and respond well to surgical correction once the disc is actually prolapsed (9, 10).

Apophyseal Ring Fracture:
The junction between the vertebral endplate and intervertebral disc is relatively weak in adolescence. As a result, trauma can cause prolapse of the disc and fracture or fragmentation of the ring apophysis (11, 12). Symptoms tend to mimic those of adolescent disc injury and occur more often in males (ratio is 2:1) (13). Diagnosis is generally made through imaging (plain film, MRI, CT). Non-operative treatment is often sufficient for this type of injury (the author’s did not specify here, but we can assume that refers to relative rest, pain control and appropriate manual therapy or rehabilitation).

Scheuermann’s Disease/Kyphosis:
Scheuermann’s disease is the most common cause of hyperkyphosis in adolescents, occurring in between 1-8% of the adolescent population (14). The deformity occurs most frequently in the thoracic spine, but can also present in the thoracolumbar junction. Diagnosis is often delayed, as the kyphosis itself is often attributed to poor posture. Scheuermann’s disease presents as a dull, non-radiating pain around the apex of the deformity, with local tenderness. The increased kyphosis is often accompanied by increased cervical and lumbar lordosis, which can also contribute to symptoms (15). Diagnosis is confirmed via plain film radiography. The following findings are indicative of Scheuermann’s:
  • Kyphosis exceeding 45 degrees (normal range is 20-45 degrees)
  • Anterior wedging of at least 5 degrees of three adjacent segments
  • Irregularities of vertebral end plates +/- loss of disc height
  • Occasional protrusion of disc material into vertebral body (Schmorl’s nodes)
Treatment traditionally consists of anti-inflammatory medication and physiotherapy, including strengthening exercises. Bracing is an option for skeletally immature patients with severe or progressive curves, but the type of brace to utilize and overall efficacy remains controversial. Surgery is reserved for extreme cases where skeletally mature patients exhibit a curve of > 70 degrees with pain and concerns about appearance (16).

Scoliosis:
Idiopathic scoliosis affects 1-3% of children and adolescents (17) and is generally identified by Adam’s forward bending test and a Cobb angle of at least 10 degrees on standing plain films (18). Presentation involves asymmetry of the shoulders, a flank crease, prominence of the ribs, and back pain, although the latter is not present in all cases. A recent retrospective study of over 2000 patients found that only 23% of patients with idiopathic scoliosis had back pain on presentation and an additional 9% developed it during the study period (19). Painful scoliosis should be considered a red flag and MRI investigation should be pursued. Management is highly variable and depends largely on the severity of the curvature, the age and skeletal maturity of the patient and the degree of pain associated with the curvature. The myriad of treatment options available for scoliosis is beyond the scope of this review (see Related Reviews below).

Infectious Diseases:
Intervertebral discs are more vascularized in children than in adults which accounts for the higher rate of discitis in adolescence, versus overt vertebral osteomyelitis. Other common infectious causes of back pain in children include tuberculous osteomyelitis, epidural abscess and sacroiliac joint infections.

Discitis is a rare condition, with an estimated incidence of 1-2 cases in 30,000 (20). It has a characteristic biphasic distribution, affecting toddlers and older adolescents (21). Discitis presents as general irritability, a refusal to walk or to stand due to abdominal pain, hamstring spasm or back pain and it may be associated with a limp. Diagnosis can be challenging, as many children having difficulty localizing pain. White cell count and C-reactive protein are generally normal; erythrocyte sedimentation rate is mildly raised; blood cultures are usually negative (when positive, S. aureus is most common). MRI often confirms the diagnosis, however in rare cases, a biopsy is required (this is reserved for rare cases where patients do not respond to treatment as it requires conscious sedation or general anesthesia).

Inflammatory Diseases:
The spondyloarthropathies are a group of inflammatory rheumatic disorders characterized by axial and/or peripheral arthritis. The diseases in the group share a common genetic predisposition, namely the HLA-B27 gene. Of the common spondyloarthropathies, Ankylosing Spondylitis (AS) is the most common, occurring in 0.2-1.2% of the Caucasian population (22). Its initial symptoms can be noted in adolescence and early adulthood, such as dull pain over the lower back and buttocks and morning stiffness eased by exercise and worsened with inactivity. Of concern is the frequent lengthy delay between symptom onset and diagnosis (often up to eight years), an issue clinicians should keep in the front of their minds with characteristic patients with this symptom pattern. AS usually responds well to non-steroidal anti-inflammatories (NSAID), although in more progressive/severe cases, tumour necrosis factor inhibitors have shown good results (despite their adverse effect profile). Patients suspected of having AS, or other inflammatory disease, should be promptly referred to a rheumatologist.

Neoplasm:
Neoplastic disease of the spine, while rare in children, can occur in both the posterior column (osteoid osteoma, osteoblastoma, aneurysmal bone cyst) and anterior column (eosinophilic granuloma aka. histiocytosis X):
  • Osteoid Osteoma: 1% of all tumours and 11% of all primary benign tumours in patients between 10 and 25; primarily located in the pedicle and lamina; back pain is usually present at night and relieved by aspirin and/or NSAIDs; definitive treatment is surgical resection.
  • Osteoblastoma: 1% of all primary benign tumours, 40% are located in the spine; usually >2 cm in diameter; primarily located in the pedicle and lamina; NSAIDs are ineffective; tumours are often locally expansive and destructive; surgical treatment ranges from intralesional curettage to complete resection.
  • Aneurysmal Bone Cyst (ABC): bubbly, cystic appearance with a thin rim of surrounding bone, in the posterior column of the spine and visible on plain films; treatment includes selective arterial embolization followed by either complete curettage or en bloc marginal excision. Radiotherapy has a limited role (23).
  • Eosinophilic Granuloma (Histiocytosis X): a subgroup of syndromes related to abnormally functioning monocytes, macrophages and dendritic cells; present in 10-15% of children with histiocytosis (24); back pain localized to area of granuloma formation (usually anterior vertebral body); plain films can show collapsed vertebrae, due to the lytic nature of the tumour; treatment options are controversial, as some patients undergo spontaneous resolution; surgery is reserved for patients with neurological deficits or polyostotic involvement.
Child Abuse:
Spinal injuries associated with child abuse are rare, with spinal fractures constituting only 3% of abuse-related fractures. In cases where child abuse is suspected, plain films of the entire spine should be obtained as part of a skeletal survey. Fractures and dislocations of the vertebral bodies have moderate specificity for child abuse, but this increases to a high level of specificity if a history of trauma is absent or inconsistent with the injuries. Treatment follows the typical clinic recommendations, with serious fracture/dislocations often requiring surgery, while non-operative treatment is recommended for stable injuries.

Clinical Application & Conclusions:

Diagnosis and treatment of back pain in children can be challenging and requires a thorough history and examination. Appropriate imaging and diagnostic testing can rule out serious pathologies and facilitate referral for specialist intervention when required for neoplastic and rheumatological disorders.

Additional References:

  1. Smith DR, Leggat PA. Back pain in the young: a review of studies conducted among school children and university students. Curr Pediatr Rev 2007; 3: 69–77.
  2. Fairbank JC, Pynsent PB, Van Poortvlict JA, Phillips H. Influence of anthropometric factors and joint laxity in the incidence of adolescent back pain. Spine 1984; 9: 461–464.
  3. Sato T, Ito T, Hirano T et al. Low back pain in childhood and adolescence: assessment of sports activities. Eur Spine J 2011; 20: 94–99.
  4. Turner PG, Green JH, Galasko CS. Back pain in childhood. Spine 1989; 14: 812–814.
  5. King HA. Back pain in children. Pediatr Clin North Am 1984; 31: 1083–1095.
  6. Jackson DW, Wiltse LL, Cirincione RJ. Spondylolysis in the female gymnast. Clin Orthop Relat Res 1976; 117: 68–73.
  7. Teitz CC. Sports medicine concern in dance and gymnastics. Pediatr Clin North Am 1982; 29: 1399–1421.
  8. Gerbino PG, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 1995; 14: 571–590.
  9. Epstein JA, Epstein NE, Marc J et al. Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies. Spine 1984; 9: 427.
  10. DeLuca PF, Mason DE, Weiand R et al. Excision of herniated nucleus pulposus in children and adolescents. J Pediatr Orthop 1994; 14: 318–322.
  11. Ikata T, Morita T, Katoh S et al. Lesions of the lumbar posterior end plate in children and adolescents: an MRI study. J Bone Joint Surg (Br) 1995; 77: 951–955.
  12. Laredo JD, Bard M, Chretien J, Kahn MF. Lumbar posterior marginal intra-osseous cartilaginous node. Skeletal Radiol 1986; 15: 201–208.
  13. Epstein NE. Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions. Spine 1992; 17: 1489–1496.
  14. Lowe TG. Schuermann’s kyphosis. Neurosurg Clin N Am 2007; 18: 305–315.
  15. Tribus CG. Scheuermann’s kyphosis in adolescents and adults: diagnosis and management. J Am Acad Orthop Surg 1998; 6: 36–43.
  16. Arlet V, Schenzka D. Schuermann’s kyphosis: surgical management. Eur Spine J 2005; 14: 817–827.
  17. Weinstein SL, Dolan LA, Cheng JC et al. Adolescent idiopathic scoliosis. Lancet 2008; 371: 1527–1537.
  18. Fairbank MJ. Historical perspective: William Adams, the forward bending test, and the spine of Gideon Algernon. Spine 2004; 29: 1953–1955.
  19. Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg (Am) 1997; 79-A: 364–368.
  20. Cushing AH. Diskitis in children. Clin Infect Dis 1993; 17: 1–6.
  21. Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics 2000; 105: 1299–1304.
  22. Sieper J, Rudwaleit M, Khan MA, Braun J. Concepts and epidemiology of spondyloarthritis. Best Pract Res Clin Rheumatol 2006; 20: 401–417.
  23. Boriani S, De Lure F, Campanacci L, et al. Aneurysmal bone cyst of the mobile spine: report on 41 cases. Spine 2001; 26: 27–35.
  24. Gasbarrini A, Cappuccio M, Donthineni R et al. Management of benign tumors of the mobile spine. Orthop Clin North Am 2009; 40: 9–19.