Evaluation of the child with back pain
- Peter A Nigrovic, MD
Peter A Nigrovic, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Robert Sundel, MD
Robert Sundel, MD
- Section Editor — Pediatric Rheumatology
- Associate Professor of Pediatrics
- Harvard Medical School
- William Phillips, MD
William Phillips, MD
- Section Editor — Pediatric Orthopedics
- Professor of Pediatrics and Orthopedics
- Baylor College of Medicine
Back pain is an uncommon presenting complaint in children. Although the etiology of back pain usually is benign, occasionally a significant congenital or acquired process is found. Of the latter, infectious, rheumatologic, and neoplastic processes are most likely to cause serious problems (table 1).
The evaluation of the child with back pain is reviewed here. The etiology of back pain in children and adolescents is discussed separately. (See "Back pain in children and adolescents: Causes".)
Despite presenting infrequently to the pediatric clinic, transient back pain is a relatively common occurrence in children, particularly after early adolescence [1-6]. One large Scandinavian survey including more than 5000 children and young adults found that 7 percent of 12-year-olds had experienced at least one episode of low-back pain, the cumulative incidence increasing to 50 percent by age 18 years (girls) and 20 years (boys) (figure 1). The prevalence on any given day was noted to be approximately 1 percent for 12-year-olds and 5 percent for 15-year-olds, rising to 10 percent by the early 20s (figure 2). Most children with back pain have mild, nondisabling symptoms and do not seek medical care. Noted associations include female gender, increased time spent watching TV, negative scores on affect scales, and a family history of back pain [8,9].
In the pediatric emergency department, back pain accounted for fewer than 0.4 percent of all visits in one inner-city series . Almost 90 percent of the children had symptoms for less than four weeks at the time of presentation. Approximately one-half of the episodes of back pain in all age groups were caused by musculoskeletal trauma, whereas the remainder were divided among infections (eg, urinary tract infection or viral illness; 9 percent), idiopathic pain (13 percent), sickle cell pain crisis (13 percent), and miscellaneous causes (6 percent). In the primary care setting, as well as in some specialty clinics, overloaded school backpacks are a potential cause of back pain in children, though prospective study has not invariably confirmed a correlation [11-13].
Back pain that persists or worsens over the course of time deserves careful attention. In one series, 32 of 61 children presenting to an orthopedic clinic with back pain had serious underlying pathology, including nine with either infection or tumor . A lower incidence of serious underlying pathology was documented by a musculoskeletal referral group, who found no infection and four tumors (benign or malignant) in 265 children with back pain, although some children with these conditions might have been diagnosed by the primary care clinician and therefore not referred . No data exist on the distribution of diagnoses in children with prolonged back pain seen by the primary care clinician. However, a survey of schoolchildren aged 11 to 14 years found that, among the 25 percent of children with back pain at initial evaluation, up to one-quarter also had pain at reevaluation one and four years later, suggesting that persistent pain is not only seen in the presence of severe organic pathology . Indeed, in this series, predictors of persistent pain were peer problems, short stature, and the presence of pain extending to areas outside the back.
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