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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Hakala P, Rimpelä A, Salminen JJ, et al. Back, neck, and shoulder pain in Finnish adolescents: national cross sectional surveys. BMJ 2002; 325:743.
- Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine (Phila Pa 1976) 2007; 32:2630.
- Masiero S, Carraro E, Celia A, et al. Prevalence of nonspecific low back pain in schoolchildren aged between 13 and 15 years. Acta Paediatr 2008; 97:212.
- Pellisé F, Balagué F, Rajmil L, et al. Prevalence of low back pain and its effect on health-related quality of life in adolescents. Arch Pediatr Adolesc Med 2009; 163:65.
- Jones GT, Macfarlane GJ. Predicting persistent low back pain in schoolchildren: a prospective cohort study. Arthritis Rheum 2009; 61:1359.
- Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr 2013; 13:14.
- Leboeuf-Yde C, Kyvik KO. At what age does low back pain become a common problem? A study of 29,424 individuals aged 12-41 years. Spine (Phila Pa 1976) 1998; 23:228.
- Balagué F, Skovron ML, Nordin M, et al. Low back pain in schoolchildren. A study of familial and psychological factors. Spine (Phila Pa 1976) 1995; 20:1265.
- Troussier B, Davoine P, de Gaudemaris R, et al. Back pain in school children. A study among 1178 pupils. Scand J Rehabil Med 1994; 26:143.
- Selbst SM, Lavelle JM, Soyupak SK, Markowitz RI. Back pain in children who present to the emergency department. Clin Pediatr (Phila) 1999; 38:401.
- Negrini S, Carabalona R, Sibilla P. Backpack as a daily load for schoolchildren. Lancet 1999; 354:1974.
- Mackenzie WG, Sampath JS, Kruse RW, Sheir-Neiss GJ. Backpacks in children. Clin Orthop Relat Res 2003; :78.
- Jones GT, Watson KD, Silman AJ, et al. Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatrics 2003; 111:822.
- Turner PG, Green JH, Galasko CS. Back pain in childhood. Spine (Phila Pa 1976) 1989; 14:812.
- Combs JA, Caskey PM. Back pain in children and adolescents: a retrospective review of 648 patients. South Med J 1997; 90:789.
- Feldman DS, Hedden DM, Wright JG. The use of bone scan to investigate back pain in children and adolescents. J Pediatr Orthop 2000; 20:790.
- Hollingworth P. Back pain in children. Br J Rheumatol 1996; 35:1022.
- Kellgren JH. On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin Sci 1939; 4:35.
- Schnebel BE. Spine. In: Care of the young athlete, Sullivan JA, Anderson SJ (Eds), American Academy of Orthopaedics, Oklahoma City, OK 2000. p.129.
- King HA. Back pain in children. Orthop Clin North Am 1999; 30:467.
- Acute low back problems in adults: assessment and treatment. Agency for Health Care Policy and Research. Clin Pract Guidel Quick Ref Guide Clin 1994; :iii.
- Beattie PF, Meyers SP, Stratford P, et al. Associations between patient report of symptoms and anatomic impairment visible on lumbar magnetic resonance imaging. Spine (Phila Pa 1976) 2000; 25:819.
- Staheli LT. Spine and pelvis. In: Fundamentals of Pediatric Orthopedics, 4th ed, Lippincott Williams & Wilkins, Philadelphia 2008. p.231.
- Jackson DW, Wiltse LL, Dingeman RD, Hayes M. Stress reactions involving the pars interarticularis in young athletes. Am J Sports Med 1981; 9:304.
- Masci L, Pike J, Malara F, et al. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. Br J Sports Med 2006; 40:940.
- Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992; 268:760.
- Gran JT, Husby G. HLA-B27 and spondyloarthropathy: value for early diagnosis? J Med Genet 1995; 32:497.
- Reveille JD. HLA-B27 and the seronegative spondyloarthropathies. Am J Med Sci 1998; 316:239.
- McGhee JL, Burks FN, Sheckels JL, Jarvis JN. Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculoskeletal pain as an indicator of rheumatic disease in children. Pediatrics 2002; 110:354.
- Miller R, Beck NA, Sampson NR, et al. Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain. J Pediatr Orthop 2013; 33:282.
- Borchers AT, Gershwin ME. Transverse myelitis. Autoimmun Rev 2012; 11:231.
- Kujala UM, Kinnunen J, Helenius P, et al. Prolonged low-back pain in young athletes: a prospective case series study of findings and prognosis. Eur Spine J 1999; 8:480.