Differential Diagnosis for Progressive Back Pain in a 12-year-old Boy
Single most likely diagnosis
- D. Spondylolisthesis: This condition is characterized by the forward displacement of a vertebra, often due to a defect in the pars interarticularis. The patient's symptoms, including progressive back pain that began during sports practice, pain radiating to the buttocks and legs, and a palpable step-off in the lumbosacral area, are consistent with spondylolisthesis. The pain being reproducible with lumbar extension and the presence of a step-off are particularly suggestive of this diagnosis.
Other Likely diagnoses
- B. Lumbar disc herniation: Although less common in children, lumbar disc herniation can occur, especially in young athletes involved in sports that involve heavy lifting, bending, or twisting, such as golf and diving. The patient's symptoms of back pain radiating to the buttocks and legs could be indicative of a herniated disc.
- C. Lumbosacral strain: Given the patient's participation in sports, a lumbosacral strain is a possible diagnosis. However, the presence of a step-off and the specific nature of the pain (reproducible with lumbar extension) make this less likely than spondylolisthesis.
Do Not Miss diagnoses
- E. Vertebral compression fracture: Although rare in children without underlying conditions such as osteogenesis imperfecta, a vertebral compression fracture could present with back pain and should be considered, especially if there's a history of significant trauma or osteoporosis.
- A. Ankylosing spondylitis: This chronic inflammatory disease can cause back pain and stiffness, but it typically presents with additional symptoms such as morning stiffness, improvement with exercise, and possibly other joint involvement or systemic symptoms. The patient's mother has rheumatoid arthritis, which might suggest a familial predisposition to autoimmune diseases, but ankylosing spondylitis is less likely given the acute presentation and specific findings.
Rare diagnoses
- Infectious spondylitis or discitis: These conditions are rare but can present with back pain and should be considered, especially if there are systemic symptoms such as fever, which is not present in this case.
- Tumors (e.g., osteoid osteoma, osteoblastoma): Although rare, spinal tumors can cause back pain in children. The absence of systemic symptoms, night pain, or significant weight loss makes this less likely, but it remains a consideration in the differential diagnosis of back pain in children.