What is the appropriate evaluation and management of back pain in pediatric patients?

Evaluation of Back Pain in Children

Begin with a detailed history and targeted physical examination to identify red flags; if red flags are present, obtain anteroposterior and lateral radiographs of the symptomatic spine region followed by MRI without and with IV contrast if radiographs are negative or non-diagnostic, but if no red flags exist, pursue conservative management without imaging. 1, 2

Clinical Red Flags Requiring Imaging

The presence of any of the following red flags mandates imaging evaluation 3:

• Constant pain, night pain, or radicular pain lasting ≥4 weeks 3, 4
• Abnormal neurological examination (motor weakness, sensory changes, reflex abnormalities) 3
• Morning stiffness with limited range of motion (suggests inflammatory condition) 3
• Fever with elevated inflammatory markers (suggests infection: discitis, osteomyelitis, epidural abscess) 3, 5
• Unintentional weight loss (suggests malignancy) 3
• Gait abnormalities (suggests neurological involvement or mechanical instability) 3
• Abnormal spinal curvature or alignment (suggests structural pathology) 3
• Tachycardia or palpable lymphadenopathy (suggests systemic infection or malignancy) 3
• Age <11 years with persistent pain 6

History and Physical Examination Components

Essential History Elements 1

• Timing and onset: acute versus insidious, duration of symptoms
• Location: cervical, thoracic, lumbar, or sacral
• Frequency and pattern: constant, intermittent, nocturnal
• Neurological symptoms: radicular pain, numbness, weakness, bowel/bladder dysfunction
• Activity-related factors: sports participation (especially hyperextension/hyperflexion activities), trauma history
• Constitutional symptoms: fever, weight loss, night sweats

Targeted Physical Examination 3

• Neurological screening: motor strength, sensory testing, deep tendon reflexes
• Palpation of spinous processes: point tenderness suggests focal pathology
• Spinal curvature and alignment assessment: scoliosis, kyphosis, lordosis
• Gait testing: observe for antalgic gait or neurological impairment
• Range of motion evaluation: flexion, extension, lateral bending, rotation
• Skin examination: midline skin abnormalities (dimples, hair patches, hemangiomas) suggest spinal dysraphism 1

Imaging Algorithm

Scenario 1: No Red Flags Present

No imaging is indicated. 1, 2

• Most pediatric back pain without red flags is self-limiting and responds to conservative management 2
• Thorough history and physical examination with conservative treatment is appropriate 1, 2
• Imaging in children with transient back pain, no neurological deficit, normal physical examination, and minor or no trauma history is unlikely to be beneficial 1

Scenario 2: Red Flags Present

Step 1: Obtain anteroposterior and lateral radiographs of the symptomatic spine region 1

• Radiographs remain the standard of care for initial imaging evaluation 1
• Prospective studies show 9-22% diagnostic yield when radiographs are combined with detailed history and physical examination 1
• Oblique views may be added if pars interarticularis defect (spondylolysis) is suspected, particularly in young athletes with low back pain 1
• Radiographs can identify: vertebral alignment abnormalities, primary bone tumors, spondylolysis, spondylolisthesis, Scheuermann disease 5, 7

Step 2: If radiographs are negative but red flags persist, proceed immediately to advanced imaging 3, 5

MRI without and with IV contrast of the symptomatic region is the preferred next step for: 3, 5

• Suspected infection (discitis, vertebral osteomyelitis, epidural abscess) - particularly with fever and elevated inflammatory markers 3, 5
• Suspected malignancy (primary bone tumors, spinal cord tumors, metastatic disease) 3, 5
• Suspected inflammatory arthropathy or sacroiliitis 5
• Neurological deficits or radicular symptoms 3
• Suspected spinal dysraphism when skin abnormalities are present 1

MRI is the only modality that directly visualizes the spinal cord, ligaments, intervertebral discs, and soft tissue pathology 3

Alternative advanced imaging:

• Tc-99m bone scan with SPECT or SPECT/CT may be appropriate for suspected spondylolysis or occult osseous pathology when MRI is contraindicated or unavailable 3, 4

Scenario 3: Overuse/Repetitive Activity Injuries (Young Athletes)

Obtain anteroposterior and lateral radiographs of the lumbar spine 1

• Back pain in young athletes and weightlifters most commonly involves spondylolysis and disc pathology 1
• Add oblique views to better visualize pars interarticularis defects 1
• If radiographs are negative but symptoms persist ≥4 weeks, proceed to MRI or bone scan with SPECT 3, 4

Common Etiologies by Age and Presentation

Young Athletes (Overuse Injuries) 1, 8

• Spondylolysis (most common in hyperextension sports: gymnastics, diving, football)
• Disc pathology (herniation, degenerative changes)
• Musculoligamentous injury

Children <10 Years 7, 6

• Discitis and osteomyelitis (most common infectious causes)
• Congenital disorders (spinal dysraphism, scoliosis)

Ages 5-20 Years 7

• Primary osseous neoplasms: Ewing sarcoma, aneurysmal bone cyst, osteoblastoma, osteoid osteoma
• Spinal cord tumors: ependymoma
• Scheuermann disease

Critical Pitfalls to Avoid

• Do not assume negative radiographs exclude pathology - radiographs have only 9-22% diagnostic yield, and serious pathology may not be visible on plain films 1, 3
• Do not delay imaging when immature granulocytes exceed 3% - this is highly specific for sepsis and may indicate vertebral osteomyelitis requiring urgent intervention 5
• Do not initiate conservative management when progressive neurological deficits are present - this requires urgent MRI and potential surgical intervention 3
• Do not obtain oblique lumbar spine views routinely - they double radiation exposure and are only useful for suspected spondylolysis 5
• Do not use CT as initial imaging - there is no literature supporting CT spine for initial evaluation of pediatric back pain 1

Laboratory Evaluation When Infection or Inflammation Suspected

Obtain the following when red flags suggest infection or inflammatory disease 5:

• Complete blood count with differential (evaluate for leukocytosis, immature granulocytes)
• C-reactive protein and erythrocyte sedimentation rate (inflammatory markers)
• Serum ferritin (if Adult-Onset Still's Disease suspected - levels >5× normal are highly suggestive)

Management Based on Findings

• If radiographs identify a cause: initiate specific treatment without additional imaging in most cases 1
• If history, physical examination, and conservative management improve symptoms: no additional imaging is needed 1
• If serious pathology is identified: treat the underlying condition rather than pursuing symptomatic management alone 2
• Urgent MRI without contrast is required for: suspected cauda equina syndrome or progressive neurological deficit 3