Low Back Pain in Children

Aka: Low Back Pain in Children, Pediatric Low Back Pain, Back Pain in Children, Pediatric Back Pain

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II. Epidemiology

  1. Low Back Pain is common in school age children, affecting at one point nearly 50% (esp. adolescents)
    1. Most cases resolve spontaneously and only one third of cases seek medical attention
    2. Kjaer (2011) BMC Musculoskelet Disord 12(1):98 [PubMed]

III. History

  1. Duration
    1. Acute: <2-3 months of back pain
    2. Chronic: >2-3 months of back pain
  2. Modifying factors
    1. Back flexion or extension
    2. Morning stiffness (Spondyloarthropathy)
  3. Contributing conditions
    1. Immunocompromised state (Diskitis)
    2. Malignancy
    3. Sickle Cell Anemia
    4. Back injuries (e.g. MVA)
    5. Hyperextension sports (e.g. swimming, gymnastics): Spondylolysis
    6. Family History of Rheumatologic Disorders
  4. Red flags
    1. Fever
    2. Night pain
    3. Bowel or Bladder dysfunction
    4. Young age (esp. <4 years old)
    5. Urinary tract symptoms

IV. Exam: Focused Pediatric Back Pain exam

  1. See Low Back Exam for a general back exam for children and adults
  2. Spine alignment abnormalities
    1. Scoliosis
    2. Kyphosis
    3. Leg Length Discrepancy (>2 cm is abnormal)
  3. Provocative Maneuvers
    1. Back forward flexion
    2. Back hyperextension (painful in Spondylolysis)
    3. FABER Test (Sacroiliac joint testing)
    4. Straight Leg Raise test or Slump Test
    5. One Legged Hyperextension or Stork Standing Test (Spondylolysis, sacroiliac disease)
    6. Spinous process tenderness (e.g. Spondylosis, malignancy, Diskitis)
    7. Quadriceps Tightness (Thomas Test) or Hamstring Tightness (also seen in Spondylolysis)
  4. Neurologic Exam
    1. See Pediatric Limp
    2. Toe and Heel Walking
    3. Ataxia
    4. Toe raises on one leg (set of 10 on each side)
    5. Dermatomal Sensation exam
    6. Upper Motor Neuron Deficit (spasticity, hyperreflexia)
    7. Lower Motor Neuron Deficit (atrophy, Flaccid Paralysis, hyporeflexia)
    8. Myopathy (symmetric proximal weakness)
  5. Skin changes
    1. Cafe Au Lait spots (Neurofibromatosis)
    2. Midline Hypertrichosis or Hemangioma (Cutaneous Signs of Dysraphism)

V. Differential Diagnosis: Urgent Back Pain

  1. See Low Back Pain Red Flag
  2. Spinal Infection (e.g. Spinal Osteomyelitis, Spinal Epidural Abscess or Discitis)
  3. Spinal Malignancy (e.g. Osteoid Osteoma, Osteoblastoma, Leukemia, Ewing's Sarcoma)
  4. Septic Sacroiliitis
  5. Syringomyelia
  6. Tethered Cord Syndrome
  7. Transverse Myelitis

VI. Differential Diagnosis: Timing

  1. Acute back pain (<2-3 months)
    1. Low back strain or low back spasm
    2. Herniated intervertebral disc
    3. Spondylolysis
    4. Slipped Vertebral apophysis
    5. Vertebral Fracture
  2. Chronic back pain (>2-3 months): Diagnosable lesion in >85% of childhood cases
    1. Idiopathic Scoliosis
    2. Scheuermann's Kyphosis
    3. Spondyloarthropathy
      1. Juvenile Rheumatoid Arthritis
      2. Ankylosing Spondylitis
    4. Persistent acute cases
      1. Occult Fracture
      2. Spondylolysis
      3. Spinal Infection
      4. Spinal malignancy
      5. Iliac Crest Apophysitis
    5. Functional Back Pain (Diagnosis of exclusion
      1. Functional back pain may occur in older teens, but is rare in age <9 years
      2. Fibromyalgia
  3. Night-time back pain
    1. Infection (e.g. Spinal Osteomyelitis, Diskitis)
    2. Malignancy (e.g. Osteoid Osteoma, Osteoblastoma, Leukemia, Ewing's Sarcoma)

VII. Differential Diagnosis: Modifying factors

  1. Back pain with spinal flexion
    1. Herniated intervertebral disc
    2. Slipped Vertebral apophysis
  2. Back pain with spinal extension
    1. Spondylolysis
    2. Spondylolisthesis
    3. Posterior arch injury (pedicle or lamina)

VIII. Differential Diagnosis: Back pain with associated findings

  1. Fever
    1. Infection (e.g. Diskitis)
    2. Malignancy
  2. New-onset Scoliosis
    1. Idiopathic Scoliosis
    2. Herniated intervertebral disc
    3. Infection
    4. Malignancy
    5. Syrinx
  3. Urinary changes
    1. Pyelonephritis
  4. Bone pain
    1. Sickle Cell Anemia

IX. Imaging

  1. Lumbosacral Spine XRay
    1. Indications
      1. Low Back Pain persists >4 weeks
      2. Night pain
      3. Radiating pain
      4. Neurologic findings
    2. Views
      1. Lumbosacral Spine XRay Anteroposterior and lateral Views are standard
      2. Oblique Views had been part of Spondylolysis evaluation, but are no longer recommended
        1. Additional radiation without significant diagnostic benefit
        2. Tofte (2017) Spine 42(10): 777-82 [PubMed]
  2. Spine MRI
    1. Indicated in persistent localized pain with non-diagnostic XRay
    2. Consider for the evaluation of spinal malignancy, Spinal Infection, disc Herniation, acute Spondylolysis
  3. Spine CT
    1. MRI is preferred instead
    2. Consider in acute Trauma where Vertebral Fracture is suspected, but XRay is nondiagnostic
  4. Bone scan
    1. MRI is preferred instead
    2. Consider in non-diagnostic MRI with diffuse pain, esp. if malignancy or infection are suspected

X. Labs

  1. Indications
    1. Inflammatory or Rheumatologic Condition (e.g. Spondyloarthropathy, Juvenile Rheumatoid Arthritis)
    2. Spinal malignancy
    3. Spinal Infection
  2. Initial
    1. Complete Blood Count
    2. Erythrocyte Sedimentation Rate (ESR)
    3. C-Reactive Protein (CRP)
    4. Urinalysis (if urinary tract symptoms)
  3. Additional tests to consider
    1. Blood Cultures
    2. Antinuclear Antibody testing
    3. Rheumatoid Factor
    4. HLA-B27
    5. Lyme Disease Test
    6. Antistreptolysin O

XI. Management

  1. Evaluate red flag findings on history and examination
    1. See Low Back Pain Red Flag
    2. Night Pain
    3. Systemic symptoms or signs
    4. Neurologic deficits
    5. Self-limited activities
    6. Low Back Pain persists >4 weeks
  2. Manage specific causes identified on evaluation
    1. See Spondylolysis and Spondylolisthesis
    2. See Scheuermann's Kyphosis
    3. See Scoliosis
    4. See Lumbar Disc Herniation
  3. Empirically treat nonspecific Low Back Pain, strain or spasm
    1. See Low Back Pain Management
    2. NSAIDS
    3. Home Exercises
    4. Consider Physical Therapy
      1. Stretch tight hamstrings and quadriceps
      2. Consider Core Muscle Exercises or pilates

XII. Prevention

  1. Limit back pack weight to no more than 10-20% of child's weight

XIII. References

  1. Thompson in Nelson (2004) Pediatrics, Chapter 669
  2. Achar (2020) Am Fam Physician 102(1):19-28 [PubMed]
  3. Bernstein (2007) Am Fam Physician 76(11):1669-76 [PubMed]
  4. Selbst (1999) Clin Pediatr 38:401-6 [PubMed]

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