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Back Pain in Children

 

Unlike adults, children will present differently when experiencing a serious or minor spine related condition, and many will not have as their initial symptom, back pain.  It is more likely that a child with back pain will have a more significant underlying condition and must be evaluated immediately by a spine specialist.

 

Children who have just finished their first growth spurt, and are experiencing back pain must be evaluated.  There are many other symptoms in children that should alert the parents or the physician that a closer evaluation should be completed.  This includes:

·         Reduced physical activity or problems with walking

·         Weight loss

·         Fever or night sweats

·         Leg pain

·         Urinary or bowel issues

·         Difficulty sleeping, 

 

 

Cause of Back Pain in Children

 

Childhood and Teenage obesity is currently on the rise in America, and coupled with reduced physical activity, muscle strain or sprains has become an ever increasing cause of low back pain in children.  Increasing physical activity and exercise coupled with weight loss and diet control will help to 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 the more serious causes is important. Always see a doctor if your child's back pain lasts for more than several days or progressively worsens.

 

 

The History:

Along with the physical examination, the history provides the physician a wealth of information and becomes the focal point by which the source of the problem is identified.  Providing your child’s doctor as much information about he or she’s medical history, complaints, changes in activity patterns, and the presence of other symptoms or unusual behavior are important and must not be taken lightly, and will help direct the physicians plan for diagnostic studies.

 

General medical Questions:

  • What is the overall health of your child including diseases or medical issues?
  • What is your family history of disease?
  • Any recent accidents, falls, or other trauma?
  • Are there issues with their urination or bowel movements?

 

Sports or Activity Related Questions:

  • Has your child stopped playing or their activity level has dropped?
  • What are their primary and secondary sports or recreational activity?
  • 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 into the legs?
  • How long have they been experiencing these symptoms?
  • How did it start?
  • Is the pain worse at night?
  • Was the onset of the symptoms slow or occurred suddenly?

 

 

The Physical Examination:

The physical examination is a very important part of the process and should not be glossed over.  This will include a very detailed musculoskeletal examination of the spine and the extremities looking for neurologic issues, muscular imbalance weakness or atrophy.

 

Your child will be asked to change into a gown with the back exposed followed by a simple initial evaluation of their ability to walk, stand, bend, and sit.  Their posture will be scrutinized followed by a hands on musculoskeletal evaluation of there spine and extremities.  This includes a sensory evaluation, motor testing for strength, reflex examination or other signs of spinal cord compression, and a vascular testing.

 

This part of the evaluation is intended to be exhaustive and will help provide clarity for the surgeon, thus narrowing his possible list of conditions or causes. From here the spine surgeon will be able to focus his diagnostic testing to further narrow the potential causes.

 

 

Diagnostic Studies:

  1. Plain X-rays: Standard baseline x-rays may include a scoliosis series, or regional films of the cervical, thoracic, or lumbar spine at various angles.
  2. Bone Scans: This is a very sensitive test but is not specific for any specific diagnosis.  This allows the surgeon to focus their diagnostic options.  If the test is negative, we will often order a MRI.  If the test shows a “hot” spot, we will often order a CT scan and focus in on the area of increased activity.  They can detect infections, tumors, and fractures with a special camera.
  3. Magnetic Resonance Imagint(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 the disc space. 
  4. Computed Tomography (CT) scan: This is a specialized X-rays machine that allows the surgeon to see bone details at a much better resolution than the MRI in three-dimensions.

 

Laboratory Tests:

Laboratory tests may include a complete blood-cell count and other test which look for signs of local or system-wide inflammation.

 

 

Treatment for Back Pain

 

Treatment is tailored to the cause.  Once the more serious conditions have been excluded, then the conservative treatment if possible will become the main focus of treatment and includes, weight loss, exercise, physical therapy, non-steroidal anti-inflammatory, and if necessary limited use of narcotics.

 

 

 

Common Causes of Low Back Pain in Children:

 

Rounded Back

Scheuermann's kyphosis, is a round back deformity of the thoracic (mid back at chest level) spine and can be a significant source of pain in the teenager population which coincides with the patients second growth spurt.  The vertebrae become wedged, causing rounding of the back or a hunched posture. Scheuermann's kyphosis is more common in boys than girls and usually occurs between 14 and 17 years of age.

 

Treatment for this condition consist of bracing, serial casting for the young stiff curves, exercise, physical therapy, anti-inflammatory medication 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 a spondylolysis.  This is a known cause of back pain in children and adolescents, but is often asymptomatic and can remain so for many years after the initial fracture.

 

These spondylolysis stress fractures can occur during the childs growth spurts or is related to sports activity related to repeated hyperextension activity.  Those at greatest risk include gymnast and football lineman who repeatedly must twist and hyperextend the lumbar spine.

 

The treatment is centered about reducing hyperextension activity, rest, nonsteroidal anti-inflammatory medication, core trunk stabilization exercises, and possibly 2-4 months of bracing.

 

Surgery is rarely helpful in fixing the gap and often it will heal via fibrosis as opposed to a normal bone that bridges the gap.

 

When the child is young at the time the pars fracture (spondylolysis) occurs, then it can progress into a slipped vertebrae called a spondylolisthesis.

 

 

Slipped Vertebra

Spondylolisthesis is the condition where one vertebra slips forward over the vertebra below.  The most common level is close to the bottom of the lumbar spine at the fourth  or fifth lumbar vertebra.  The majority of these slipped vertebra are mild and require very little treatment, but a few can be painful and may progress to the point where it results 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 which can lead to significant disability. In the adolescent, treatment can include core trunk stabilization, and bracing.  Surgery to stabilize the spine in serious cases will be considered.

 

 

Infection

Infection of the disk space (diskitis) in young children, can lead to back pain. This condition typically affects children between the ages of 1 and 5 years, although older children, teenagers, and adults can also be affected.

 

Symptoms of diskitis in children may include the following.

 

• Low back pain or spine stiffness

• Refusal to ambulate or run

• Walking with a limp

• Bending forward with a straight spine when reaching for something on the floor

 

To treat diskitis, the child may need several days of bed rest and antibiotics taken through the blood stream (intravenous, or IV) or in tablets. In some cases, older children may need casting or bracing to immobilize the spine (for comfort) if infection narrows the disk space. Surgical drainage of the infection is rarely needed.

Information provided by the American Academy of Orthopedic Surgeons