How to investigate back pain in a pediatric patient?

Investigation of Back Pain in Pediatric Patients

The initial approach to investigating pediatric back pain should include a thorough clinical assessment followed by radiographs of the spine area of interest only when clinical red flags are present. 1

Initial Clinical Assessment

History Taking - Key Elements

• Timing, onset, location, frequency of pain 1
• Presence of neurologic symptoms 1
• Psychological history 1
• Duration of pain (>4 weeks is a red flag) 1
• Night pain (red flag) 1
• Morning stiffness (red flag) 1
• Fever, unintentional weight loss (red flags) 1
• History of trauma or repetitive activities 1
• Sports participation, especially activities involving repetitive spinal loading 1

Physical Examination - Key Elements

• Neurological examination 1
• Palpation of spinous processes 1
• Assessment of spinal curvature 1
• Gait testing 1
• Range of motion 1
• Evaluation for skin abnormalities (potential indicator of spinal dysraphism) 1
• Assessment for lymphadenopathy (red flag) 1

Diagnostic Algorithm

Step 1: Identify Clinical Red Flags

Red flags requiring prompt imaging evaluation include:

• Morning stiffness 1
• Gait abnormalities 1
• Night pain 1
• Neurologic deficit 1
• Radiating pain 1
• Fever 1
• Unintentional weight loss 1
• Pain lasting >4 weeks 1
• Tachycardia 1
• Lymphadenopathy 1
• Abnormal spinal curvature 1

Step 2: Initial Imaging Decision

If NO Red Flags Present:

• No imaging is indicated 1
• Conservative management with follow-up is appropriate 1
• If symptoms improve with conservative management, no imaging is necessary 1

If Red Flags ARE Present:

• Begin with anteroposterior and lateral radiographs of the spine area of interest 1
  • Avoid oblique views unless specifically evaluating for pars interarticularis defects 1
  • Radiographs show 9-22% yield in accurate diagnosis when combined with history and physical examination 1

Step 3: Further Imaging Based on Radiograph Results and Clinical Suspicion

If Radiographs Are Negative but Red Flags Persist:

• MRI of the spine area of interest without IV contrast is the next appropriate study 1
  • MRI has demonstrated identifiable diagnoses in an additional 25-34% of cases after negative radiographs 1
  • MRI is superior for evaluating soft tissue pathology including spinal cord, intraspinal contents, and paraspinal soft tissues 1

For Suspected Bony Pathology (e.g., spondylolysis):

• Consider Tc-99m whole body bone scan with SPECT or SPECT/CT through the region of interest 1
  • Particularly useful for spondylolysis or osseous neoplasms 1

For Suspected Infection, Inflammation, or Neoplasm:

• MRI of the spine area of interest without and with IV contrast 1
  • Contrast is helpful when evaluating for infection, inflammation, or tumor 1

Common Causes of Pediatric Back Pain

• Mechanical causes (most common in adolescents) 2

  • Muscle strain 3
  • Spondylolysis/spondylolisthesis 2, 3
  • Disk herniation 2, 3
  • Scheuermann's kyphosis 2, 3

• Infectious causes (more common in children 2-12 years) 1

  • Discitis 2
  • Vertebral osteomyelitis 1

• Neoplastic causes 2

  • Primary osseous tumors (Ewing sarcoma, aneurysmal bone cyst, osteoblastoma, osteoid osteoma) 2
  • Spinal cord tumors 2

• Inflammatory causes 1

  • Juvenile idiopathic arthritis (most common in cervical spine) 1
  • Inflammatory myelopathies 1

Important Clinical Considerations

• Pediatric back pain is increasingly common (30-50% prevalence in recent studies) but serious underlying pathology is rare 1, 4
• The paradigm has shifted from routine imaging to more judicious use of diagnostic resources 1
• Historically, spondylolysis was considered the most common cause of pediatric back pain, but recent MRI studies show intervertebral disk pathology may be more common 1
• Back pain in younger children (<10 years) is more likely to have an organic cause requiring investigation 5, 6
• CT should be avoided as an initial imaging modality due to radiation exposure unless specifically indicated for evaluating osseous structures when MRI is contraindicated 1
• Laboratory testing (CBC, ESR, CRP) may be useful when infection or inflammation is suspected 1