What are the possible causes of chronic, non‑traumatic dorsolateral back pain in a child without tenderness on palpation?

Chronic Non-Traumatic Dorsolateral Back Pain in Children Without Tenderness

In a child with chronic, non-traumatic dorsolateral back pain that is non-tender on palpation, the most likely causes are mechanical/overuse injuries (particularly spondylolysis), followed by less common but serious etiologies including neoplasms, inflammatory conditions, and occult infections that must be systematically excluded. 1

Primary Differential Diagnosis

Mechanical/Overuse Causes (Most Common)

Spondylolysis is the leading mechanical cause of chronic back pain in children, particularly those involved in sports with repetitive spinal hyperextension 1, 2. The absence of tenderness on palpation does not exclude this diagnosis, as pain is typically activity-related rather than elicited by direct pressure 1.

• Apophyseal ring fractures can present similarly with chronic pain and minimal tenderness 1
• Scheuermann disease causes chronic thoracic or thoracolumbar pain, often without significant tenderness 1, 3, 4
• Disc pathology is less common in children but can occur, particularly in adolescents 1, 3

Serious Pathologies Requiring Exclusion

Despite the absence of tenderness, neoplasms must be considered when pain is chronic and non-traumatic 1:

• Osteoid osteoma and osteoblastoma are the most common primary bone tumors causing back pain in children aged 5-20 years, characteristically causing nighttime pain 3, 2
• Ewing sarcoma, aneurysmal bone cyst, and primary lymphoma are other osseous neoplasms that can present with chronic pain 3
• Spinal cord tumors (e.g., ependymoma) may present with pain before neurologic deficits develop 3

Occult infection can present without obvious tenderness initially 1, 2:

• Diskitis and osteomyelitis are most common in children under 10 years but can occur at any age 3, 4
• Infection should be suspected if there is any fever, night pain, elevated inflammatory markers, or decreased range of motion 2

Inflammatory spondyloarthropathy should be evaluated, particularly if there is morning stiffness, systemic symptoms, or family history of autoimmune disease 2

Clinical Red Flags Requiring Urgent Evaluation

The following features mandate immediate imaging and laboratory workup, even without tenderness 1, 5, 6:

• Persistent nighttime pain (suggests neoplasm or infection) 5, 2
• Pain duration >4 weeks without improvement 2, 6
• Constant pain rather than activity-related 6, 4
• Age <11 years with persistent pain 4
• Fever or weight loss 5, 2
• Morning stiffness (suggests inflammatory etiology) 5, 2
• Any neurologic symptoms or deficits 1, 6

Diagnostic Algorithm

Initial Evaluation Without Red Flags

No imaging is indicated initially if the child has no red flags, normal physical examination findings, and pain that is activity-related 1, 6. Conservative management with activity modification is appropriate 6.

Evaluation With Red Flags Present

Immediate imaging is mandatory when red flags are present 1, 6:

1. Plain radiographs (AP and lateral) of the symptomatic spine region as first-line imaging 5, 2

   • Sensitivity of 77.6% for spondylolysis when spondylolisthesis is present 1
   • Can identify Scheuermann disease, apophyseal fractures, and some neoplasms 1, 3

2. MRI without contrast is the preferred advanced imaging when radiographs are negative or equivocal, or when red flags suggest serious pathology 5, 2, 6

   • Detects marrow edema in early spondylolysis before fracture is visible 1, 2
   • Identifies neoplasms, infections, and inflammatory conditions 1, 2
   • Evaluates disc pathology and soft tissue abnormalities 1

3. SPECT/CT is highly sensitive for detecting spondylolysis when radiographs are negative with high clinical suspicion 5, 2

   • More sensitive than MRI for active spondylolysis in some studies 1
   • Useful for whole-body screening to detect multifocal pathology 1

4. Laboratory testing should include inflammatory markers (ESR, CRP) and complete blood count when infection or inflammatory conditions are suspected 2

Common Pitfalls

• Assuming absence of tenderness excludes serious pathology: Neoplasms and early infections may not cause point tenderness initially 1, 3
• Failing to obtain adequate history: Duration, timing (nighttime vs. activity-related), and impact on function are critical discriminators 1, 4
• Ordering imaging without red flags: This leads to unnecessary radiation exposure and incidental findings in most cases of self-limiting mechanical pain 1, 6
• Missing chronic spondylolysis: Wide, chronic pars defects may show negative bone scans, requiring MRI or CT for diagnosis 1