back pain in children
Unlike adults, children will present differently when experiencing a major or minor spinal condition, and many will not have back pain as their initial symptom. A child with back pain is more likely to have a more serious underlying condition and should be promptly evaluated by a spine specialist.
Children who have just finished their first growth spurt and are experiencing back pain should be evaluated. There are many other symptoms in children that should alert a parent or doctor that further evaluation is warranted. This includes:
•Reduced physical activity or trouble walking
•Weightloss
•Fever or night sweats
•Legache
•Urinary or bowel problems
•Difficulty to sleep
Cause of back pain in children
Childhood and adolescent obesity is currently on the rise in the United States and, along with reduced physical activity, muscle strain or sprains, has become a growing cause of low back pain in children. Increased physical activity and exercise along with weight loss and diet control will help reduce the incidence of this cause in children.
Other more serious causes include fractures, cancer, and infections. Herniated discs are less common in children, and early identification and treatment of more serious causes is important. Always see a doctor if your child’s back pain lasts for more than a few days or gradually worsens.
The history:
Along with the physical examination, the history provides the physician with a wealth of information and becomes the focal point by which the source of the problem is identified. Providing your child’s doctor with as much information about your child’s medical history, complaints, changes in activity patterns, and the presence of other symptoms or unusual behavior is important and should not be taken lightly, and will help guide the medical plan for testing diagnosis.
General medical questions:
•What is your child’s general health, including any illnesses or medical problems?
•What is your family history of illness?
• Any recent accidents, falls, or other trauma?
• Are there problems with your urination or bowel movements?
Questions related to sports or activities:
•Has your child stopped playing or has his or her activity level decreased?
•What are your primary and secondary sports or recreational activities?
•How often do they play, compete or train?
•What surface do they play, compete or train on?
Spine Related Questions:
• Where specifically is the pain or numbness?
•Does it extend to legacy?
•How long have they been experiencing these symptoms?
•How it began?
• Is the pain worse at night?
• Was the onset of symptoms slow or did it come on suddenly?
Physical exam:
The physical exam is a very important part of the process and should not be overlooked. This will include a very detailed musculoskeletal exam of the spine and extremities looking for neurological problems, weakness from muscle imbalance, or atrophy.
Your child will be asked to change into an open-back gown, followed by a simple initial assessment of their ability to walk, stand, stoop, and sit. Her posture will be examined followed by a hands-on musculoskeletal evaluation of the spine and extremities. This includes a sensory evaluation, motor tests of strength, examination of reflexes or other signs of spinal cord compression, and a vascular test.
This part of the evaluation is intended to be comprehensive and will help provide clarity to the surgeon, thereby narrowing down his or her possible list of conditions or causes. From here, the spine surgeon will be able to focus their diagnostic tests to further narrow down the possible causes.
Diagnostic Studies:
1. Plain radiographs: Standard reference radiographs may include a series of scoliosis or regional radiographs of the cervical, thoracic, or lumbar spine at various angles.
2.Bone Scans – This is a very sensitive test but it is not specific to any specific diagnosis. This allows the surgeon to focus his diagnostic options. If the test is negative, we will often request an MRI. If the test shows a “hot” spot, we will often order a CT scan and focus on the area of greatest activity. They can detect infections, tumors and fractures with a special camera.
3. Magnetic Resonance Imaging (MRI): Creates a magnetic field and creates an image of the body without radiation. It is very good at looking at soft tissue, as opposed to bone. Examples would include the spinal cord, nerve roots, and disc space.
4. Computed Tomography (CT): This is a specialized X-ray machine that allows the surgeon to see bone details with much better resolution than three-dimensional MRI.
Lab tests:
Laboratory tests may include a complete blood cell count and other tests that look for signs of local or system-wide inflammation.
Treatment for back pain:
Treatment is tailored to the cause. Once more serious conditions have been excluded, conservative management, if possible, will become the main approach to treatment and includes weight loss, exercise, physical therapy, nonsteroidal anti-inflammatory drugs, and, if necessary, the limited use of narcotics
Common causes of low back pain in children:
rounded back
Scheuermann’s kyphosis is a rounded back deformity of the thoracic spine (the mid-back at chest level) and can be a major source of pain in the adolescent population that coincides with the patient’s second growth spurt. The vertebrae become stuck, causing rounding of the back or a stooped posture. Scheuermann’s kyphosis is more common in boys than girls and usually occurs between the ages of 14 and 17.
Treatment for this condition consists of bracing, serial casting for stiff curves in youth, exercise, physical therapy, anti-inflammatory medications, and, rarely, surgery.
Stress fracture of the spine
A stress fracture is commonly located within the portion of the vertebra called the pars inter-articularis. This condition is also known as spondylolysis. This is a known cause of back pain in children and adolescents, but it is often asymptomatic and can remain so for many years after the initial fracture.
These spondylolysis stress fractures can occur during the child’s growth spurts or are related to sports activity related to repeated hyperextension activity. Those most at risk are gymnasts and football linemen who must repeatedly twist and hyperextend the lumbar spine.
Treatment focuses on reduction of hyperextension activity, rest, nonsteroidal anti-inflammatory medication, central trunk stabilization exercises, and possibly 2 to 4 months of bracing.
Surgery is rarely helpful in repairing the gap, and will often heal through fibrosis rather than normal bone bridging the gap.
When the child is young at the time the pars fracture (spondylolysis) occurs, then it may progress to a slipped vertebra called a spondylolisthesis.
slipped vertebra
Spondylolisthesis is the condition in which one vertebra slips forward on the vertebra below. The most common level is near the bottom of the lumbar spine at the fourth or fifth lumbar vertebrae. Most of these slipped vertebrae are mild and require very little treatment, but some can be painful and can progress to the point where they result in severe compression of the spinal nerves.
The important part of treatment in the younger patient is prevention consisting of close observation for signs of progression that can lead to significant disability. In the adolescent, treatment may include central trunk stabilization and bracing. Surgery to stabilize the spine will be considered in severe cases.
Infection
Infection of the disc space (discitis) in young children can cause back pain. This condition typically affects children between the ages of 1 and 5, although older children, adolescents, and adults can also be affected.
Symptoms of discitis in children may include the following.
• Low back pain or spinal stiffness
• Refusal to wander or run
• Walking with a limp
• Lean forward with a straight spine when reaching for something on the ground
To treat discitis, your child may need several days of bed rest and antibiotics given through the bloodstream (intravenously or IV) or in pill form. In some cases, older children may need a cast or brace to immobilize the spine (for comfort) if the infection reduces the disc space. Surgical drainage of the infection is rarely needed.