What is the appropriate management for a child presenting with back pain?

Management of Back Pain in Children

In children presenting with back pain, immediately assess for clinical red flags—if none are present, initiate conservative management without imaging; if red flags exist, obtain plain radiographs of the symptomatic region first, followed by MRI with and without IV contrast if radiographs are negative or suspicion remains high. 1

Initial Risk Stratification Based on Red Flags

Clinical Red Flags Requiring Imaging

The presence of any of the following mandates diagnostic imaging 1, 2:

• Age < 5 years (any back pain in this age group is concerning) 3, 4, 5
• Pain duration > 4 weeks 1, 2, 4, 5
• Night pain or constant pain 1, 2, 3, 6
• Morning stiffness 1, 6
• Fever or systemic symptoms 1, 2, 6, 4
• Unintentional weight loss 1, 2, 6
• Neurologic deficits (motor weakness, sensory changes, bowel/bladder dysfunction) 1, 2, 6, 4
• Gait abnormalities 1, 6
• Radiating pain 1, 6
• Abnormal spinal curvature 1, 6
• Tachycardia or lymphadenopathy 1, 6
• Inability to bear weight 2

Management Without Red Flags

Conservative management is appropriate when no red flags are present 1:

• Relative rest and activity modification 4
• Home-based exercises and physical therapy 4
• Limited use of NSAIDs or acetaminophen 4
• Reassurance that most pediatric back pain is self-limiting 7, 8
• Close follow-up with return precautions for development of red flags 6
• Imaging is not indicated in this scenario 1

Imaging Algorithm When Red Flags Are Present

Step 1: Plain Radiographs

Obtain anteroposterior and lateral radiographs of the symptomatic spinal region as the initial imaging study 1, 2:

• Radiographs can identify spondylolysis, spondylolisthesis, Scheuermann disease, primary bone tumors, vertebral alignment abnormalities, and fractures 1, 3, 9
• Do not obtain oblique views—they double radiation exposure without adding diagnostic value 1, 2
• Radiographs have a 9-22% diagnostic yield when combined with thorough history and physical examination 1

Critical caveat: A negative radiograph does not exclude serious pathology 1, 2, 3, 6. At least 50% bone loss must occur before changes become visible on plain films 2.

Step 2: Advanced Imaging After Negative Radiographs

If radiographs are negative but red flags persist, proceed immediately to MRI 1:

• MRI of the spine area of interest without IV contrast OR without and with IV contrast is the appropriate next study 1
• MRI increases diagnostic yield by 25-34% beyond radiographs 1
• MRI is the only modality that directly visualizes the spinal cord, ligaments, intervertebral discs, and paraspinal soft tissues 2, 6

Step 3: Direct to MRI (Skip Radiographs)

Proceed directly to complete spine MRI without and with IV contrast when the clinical presentation strongly suggests 1, 3:

• Known or suspected infection (discitis, osteomyelitis, epidural abscess) 1, 3
• Known or suspected malignancy 1, 3
• Known or suspected inflammatory disease (juvenile idiopathic arthritis, spondyloarthropathy) 1, 3
• Progressive neurologic deficits requiring urgent evaluation 2, 6

Contrast administration is essential for detecting infection, inflammation, and neoplastic disease 1, 2, 3. Pre-contrast sequences must be obtained before gadolinium to allow accurate interpretation of enhancement patterns 2, 6.

Special Populations and Scenarios

Neonates and Infants < 4 Months

Use ultrasound of the spine as the initial imaging modality in this age group 1:

• Ultrasound is useful for evaluating spinal dysraphism when skin abnormalities are present (sacral dimple, discoloration, palpable lump, asymmetric gluteal cleft) 1
• Associated neurologic deficits (lower extremity weakness, abnormal movements, neurogenic bladder) warrant immediate evaluation 1
• Radiographs are not appropriate in this scenario 1

High-Risk Clinical Scenarios

Nighttime symptoms (pain, vomiting) are highly concerning for spinal neoplasm, which presents with persistent nighttime pain in 25-30% of pediatric cases 3, 6. Normal radiographs do not exclude neoplasm—proceed directly to complete spine MRI with and without contrast 3.

Constant pain in a 4-year-old child mandates immediate imaging evaluation because constant pain is a critical red flag indicating potential infection, malignancy, or inflammatory disease 3. Begin with plain radiographs, but maintain a low threshold for advancing to MRI if clinical suspicion remains high 3.

Alternative Imaging Modalities

Bone Scan with SPECT/CT

Tc-99m whole body bone scan with SPECT or SPECT/CT may be appropriate when 1, 2, 6:

• Clinical suspicion or initial radiography suggests spondylolysis 1, 2, 6
• Osseous neoplasms are suspected 1, 2
• Limitation: Does not adequately assess intraspinal or paraspinal soft-tissue disease 2, 6

CT Imaging

CT is reserved for patients unable to undergo MRI 2, 6:

• CT with IV contrast (targeted to area of interest) provides excellent bone detail and can detect paraspinal abscesses 2, 6
• CT is inferior to MRI for soft-tissue characterization 2, 6
• CT without IV contrast is appropriate for assessing osseous pathology when contrast is not needed 1

Common Pitfalls to Avoid

• Do not delay advanced imaging for a trial of conservative therapy when red flags are present 2, 6
• Do not skip imaging in children < 5 years with back pain—age alone justifies evaluation 3, 4, 5
• Do not order MRI with contrast alone—pre-contrast sequences are required for proper interpretation 2, 6
• Do not assume negative radiographs exclude serious pathology—maintain high suspicion and advance to MRI when indicated 1, 2, 3, 6
• Do not obtain oblique lumbar views—they add no diagnostic value and double radiation exposure 1, 2

Differential Diagnosis by Age and Presentation

Most Common Causes by Age 7, 4, 9

Children < 10 years: Diskitis and osteomyelitis are most common infectious causes 9. Primary spinal tumors (ependymoma, osteoid osteoma, aneurysmal bone cyst) are more common than metastatic disease 9.

Adolescents: Spondylolysis, spondylolisthesis, Scheuermann disease, intervertebral disk pathology, muscle strain, and apophysitis of the iliac crest are typical 1, 7, 4, 9. Spondyloarthropathies (ankylosing spondylitis) may present with morning stiffness 4.

Serious Pathology to Exclude 3, 7, 8, 5, 9

• Infection: Discitis, osteomyelitis, epidural abscess (fever, systemic toxicity, elevated inflammatory markers) 3, 8, 9
• Malignancy: Primary spinal tumors (Ewing sarcoma, osteoblastoma, osteoid osteoma, aneurysmal bone cyst), spinal cord tumors (ependymoma), lymphoma (nighttime pain, weight loss, lymphadenopathy) 3, 8, 9
• Inflammatory arthritis: Juvenile idiopathic arthritis, spondyloarthropathy (morning stiffness, systemic symptoms) 3, 4

Laboratory Testing

Obtain baseline inflammatory markers before imaging when infection or inflammatory disease is suspected 3:

• ESR, CRP, and complete blood count 3
• ESR ≥ 40 mm/hour, WBC ≥ 12,000 cells/mm³, and CRP > 2.0 mg/dL are predictive of septic arthritis 3
• Laboratory testing is not recommended for nonspecific low back pain without red flags 6