• Back pain refers to any condition in which a patient has complaints of discomfort of the thoracic, lumbar, or sacral spinal area.
• Back pain can result from a variety of causes, involving the bony or muscular structures of the back, intervertebral discs, spinal cord, or peripheral nerves.
• Inheritance patterns in some of the congenital (scoliosis, Scheuermann disease) and inflammatory/rheumatologic causes of back pain have been described.
• There is a 30% lifetime incidence of back pain in teenage children. Eight percent of adolescents report recurrent or chronic back pain. Discitis is seen almost exclusively in children under 5 years of age.

• Tethered cord

• Ankylosing spondylitis
• Enteropathic arthritis

• Tuberculosis
• Discitis

• “Musculotendinous” strain
• Spondylolysis (stress fracture of posterior vertebral elements)
• Spondylolisthesis (anterior displacement or “slip” of the vertebral body, associated with bilateral spondylolysis)
• Herniated disc
• Spinal epidural hematoma (traumatic or due to bleeding diathesis)

• Osteoid osteoma, osteoblastoma
• Eosinophilic granuloma
• Leukemia, lymphoma
• Osteosarcoma
• Ewing sarcoma
• Neurogenic
• Glioma
• Neuroblastoma
• Rhabdomyosarcoma

• Scheuermann disease (excessive kyphosis/“hunchback” due to abnormal bone growth causing “wedging” of the vertebral bodies)
• Painful scoliosis

• Pyelonephritis
• Pancreatitis

• Young age (less than 4 years old)
• Chronic interference with activity (e.g., school, sports, play)
• Duration of pain longer than 4 weeks
• Associated fever, weight loss, or other systemic symptoms
• Postural shift of trunk
• Any neurologic abnormality
• Limitation of spinal motion (e.g., bending forward, straight leg raise)
• Painful or left thoracic scoliosis

Question: Onset, duration, and frequency of pain?
Significance: Fleeting or short duration of pain is rarely serious.

Question: Interference with activity?
Significance: Often a marker of disease severity.

Question: Physical activity and trauma history?
Significance: Spondylolysis and spondylolisthesis are more commonly seen in children who repeatedly twist, bend, or hyperextend their spine (e.g., participate in gymnastics, diving, tennis, contact sports, weightlifting, etc.)

Question: Radiation of pain?
Significance: Pain that shoots down the legs is suggestive of neurologic involvement.

Question: Growth history?
Significance: Adolescents during growth spurts are more prone to musculotendinous strain.

Question: Previous history of scoliosis?
Significance: Idiopathic scoliosis is rarely painful or functionally limiting.

Finding: Inspect for any occult abnormalities
Significance: Sacral dimples, hair tufts, vascular anomalies, café au lait spots, or discrepancies in limb length.

Finding: With their feet together and knees and hips straight, observe the child from the back and side, both standing and bending over.
Significance: This evaluates the patient for scoliosis, kyphosis, and range of motion. Lumbar lordosis should “reverse” when the child bends over; if it does not, significant pathology should be suspected.

Finding: Palpate for any point or focal tenderness.
Significance: Fractures often manifest with point tenderness.

Finding: Assess lower extremity strength.
Significance: In young children, this may be evaluated by observing gait, heel- and toe-walking, and rising from a squat. A complete neurologic examination of the lower body, including examination of sensation and rectal tone, should be performed to rule out any neurologic involvement.

Finding: With the patient supine, examine the abdomen, deep tendon reflexes, and have the patient perform a straight leg raise.
Significance: Limitation in leg raise, abnormality of reflexes or clonus, or radiating pain is suggestive of neurologic abnormality. Muscle tone should also be assessed, as increased tone may cause limitation in leg raise.

• Standing hyperextension (bending backward) often reproduces the lower lumbar pain of spondylolysis. Hamstring tightness is also commonly seen.
• A bony “ledge”/step-off on palpation of the lumbar spine, or an anterior bony mass on rectal examination, are sometimes appreciated with spondylolisthesis.
• Asymmetry of lower extremity muscle circumference may be a sign of nerve impingement due to a herniated disc.

Test: Plain radiographs (AP and lateral, and if warranted, oblique and flexion/extension views) of the spine are indicated if any worrisome signs or symptoms are present.
Significance: Spondylolysis has the appearance of a “collar” (lucent line) on the “Scottie dog’s” neck.

Test: Bone or SPECT scan
Significance: More sensitive for occult or subtle lesions, and should be obtained if a serious etiology is clinically suspected.

Test: MRI
Significance: The preferred examination for suspected neurologic or disc injury.

Test: Blood tests (e.g., sed rate, HLA-B27, ANA, rheumatoid factor, blood culture)
Significance: Indicated only if infectious or rheumatologic etiologies are considered.

Test: Bacterial cultures (needle aspiration or open biopsy)
Significance: Positive in only 25% to 50% of discitis patients. Routine biopsy is, therefore, not recommended in cases of suspected discitis. Staphylococcal species are the most frequently recovered organism.

• If none of the warning signs are present, conservative management with rest, ice or heat (whichever is appropriate), acetaminophen or ibuprofen, physical therapy, and close follow-up is reasonable. A back brace may also be helpful.
• Conservative medical treatment is indicated for spondylolysis and spondylolisthesis of less than 50% slip. Surgical treatment is warranted for slip greater than 50% or persistent back pain.
• Anti-staphylococcal medications are indicated in cases of discitis. The choice between oral or intravenous medications depend on the severity of the patient’s symptoms.

• Patients managed conservatively should be re-evaluated within 2 weeks.
• All patients should be instructed to follow-up immediately for any worsening symptoms.

• When the child has recuperated, back muscle strengthening and hamstring stretching exercises may be helpful.
• When participating in sports, appropriate protective equipment should be used and proper technique should be emphasized.
• In gymnasts, training more than 15 hours per week has been associated with increased risk of injury.

• Missed diagnosis of a serious cause of back pain.
• Plain films are often normal, even in cases with serious causes.

Q: When can the child resume activity?
A: Children can resume activity or sports when they are pain free.

Q: Which children should have activity restrictions?
A: “High risk” children (e.g., those with spinal or bony abnormalities, or familial histories of spondylolysis) should avoid hyperextension and contact sports.

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Gerbino PG, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 1995;14(3):571–590.

Payne WK, Ogilvie JW. Back pain in children and adolescents. Pediatr Clin North Am 1996;43(4):989–917.

Sponseller PD. Back pain in children. Curr Opin Pediatr 1994;6(1):99–103.