The Lowdown on Back Pain in Children and Adolescents

Mar 19, 2018

When should you worry?

References1. Yang S, Werner BC, Singla A, Abel MF. Low back pain in adolescents: a 1-year analysis of eventual diagnoses. J Pediatr Orthop. 2017;37:344-347.2. Brooks TM, Friedman LM, Silvis RM, et al. Back pain in a pediatric emergency department: etiology and evaluation. Pediatr Emerg Care. 2018;34:e1-e6.

Two recent studies looked at the etiology, presentation, and eventual diagnosis of back pain in children and adolescents. Scroll through the slides for the latest information and take-home messages.
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It is believed that low back pain (LBP) in adolescents often has a more serious cause than LBP in adults, with up to 84% of teenagers having a diagnosable underlying pathology. LBP that presents in adolescence may herald an underlying diagnosis of spondylolysis, spondylolisthesis, herniated lumbar disk, degenerative disk disease, Scheuermann kyphosis, fracture, scoliosis, tumor, or infection.

The prevalence of chronic LBP that occurs at least weekly is high in adolescents and has been demonstrated to be between 18% and 26%.¹

The PearlDiver Patient Records Database (http:// www.pearldiverinc.com; PearlDiver Inc., Fort Wayne, IN) was queried for International Classification of Diseases, 9th Revision (ICD-9) codes to identify patients aged 10 to 19 years with back pain from 2007 to 2010. Spondylolysis and spondylolisthesis both had a < 1% association with low back pain.

Most cases of low back pain in adolescents have no clear underlying cause. However, 18% of office visits in the study involved both laboratory and imaging evaluation.

The take-home message? The researchers believe that most low back pain in adolescents represents a pain condition rather than a spinal problem. Thus, they recommend that clinicians focus on common causes of low back pain in adolescents and utilize established treatments aimed at relief of pain when an underlying treatable pathology is absent.

Two hundred thirty-two medical records were identified as having a chief complaint of back pain and were subsequently reviewed; 177 records were included in the data analysis. A non-pathologic diagnosis of back pain was found in 76.8% of visits, with back pain (57.1%) and back or muscle strain (10.7%) as the most common diagnoses.

Pathologic back pain diagnoses accounted for only 2.3% of visits. The most common of these diagnoses included compression fracture without spinal cord involvement, spondylolysis with spondylolisthesis, scoliosis, and Schmorl’s nodes.

Neurologic symptoms were reported at extremely low rates: numbness was reported in 4.5% of visits, and weakness in 2.3% of visits.

Because pathologic diagnoses for back pain in children are rare, aggressive diagnostic approaches are warranted only when “red flag” symptoms such as fever and/or neurologic impairment are present. Even with pathologic etiologies, laboratory tests and CT and MRI scans are not very useful in making the diagnosis. Symptoms rarely correlate with the eventual diagnosis of back pain in children.

The take-home message? (1) Pathologic back pain is rare in children; (2) expensive and time-consuming diagnostic modalities are seldom helpful in making the diagnosis; and (3) a plain radiograph was more significantly associated with uncovering a pathologic diagnosis than laboratory tests, CT, and MRI.