PAIN: BACK

KAREN S. FARBMAN, MD, MPH

Back pain is an uncommon presenting complaint in younger children and warrants careful attention, because it can be a sign of significant pathology. Back pain becomes a more common complaint in the teenage years. While benign musculoskeletal problems are more likely in adolescents, the differential remains broad and continues to deserve careful attention. The differential diagnosis for back pain and its evaluation is discussed here.

DIFFERENTIAL DIAGNOSIS

Trauma to the back is a common cause of back pain. The trauma may be an isolated direct force to the back or a more complex mechanism leading to multiple trauma (see Chapters 119 Musculoskeletal Trauma and 120 Neck Trauma). Vertebral compression fracture and spinal epidural hematoma are significant traumatic injuries. Trauma to the back can also occur as a result of repetitive stress injuries by the athlete or worker. Children, especially adolescents, can have muscular back strain from lifting. They can also have lumbar disc herniation, which is less common in children than in adults. In contrast, injury to the vertebral pars interarticularis is more common in children, especially adolescents. Spondylolysis is a stress fracture or separation at the pars, usually in the lower lumbar vertebrae. While some populations or those with certain conditions (e.g., Scheuermann kyphosis) are at increased risk for spondylolysis, it can occur in anyone, and typically occurs from repetitive hyperextension of the back. Athletes such as figure skaters and gymnasts are notorious for such hyperextension maneuvers. When there is bilateral spondylolysis at the same level, this can allow for slippage of the vertebral body anteriorly. This is known as spondylolisthesis.

A high index of suspicion for infectious etiologies of back pain in children is important, because these may present even without the classic signs of infection such as fever or elevated markers of inflammation. Discitis is more common in the young child, especially under age 5. Vertebral osteomyelitis is more common among adolescents. Sacroiliitis can have a bacterial source. Epidural abscess is a collection of pus located between the bony spine and the dura surrounding the cord. This is an infectious emergency that can compromise the spinal cord and must be diagnosed without delay. Those who abuse intravenous (IV) drugs are at increased risk for epidural abscess. There are other nonspinal sources of back pain with infectious etiologies, including pyelonephritis, and pyomyositis of the back muscles. Myalgias of the back can be the result of other infectious or postinfectious etiologies, especially influenza. Infections that can refer pain to the back include pneumonia, pelvic inflammatory disease, and abdominal pathology such as appendicitis, cholecystitis, and pancreatitis.

A host of neoplastic causes, both benign and malignant, may present with back pain. Osteoid osteoma is a benign tumor and is the most common tumor in children to present with back pain. Localized back pain can also result from primary bony malignancies including Ewing sarcoma, osteosarcoma, and osteoblastoma, as well as bony metastases from other sites. Other nonbony solid tumors can lead to regional pain, including neuroblastoma, Wilms tumor, and rhabdomyosarcoma. Leukemia, lymphoma, and other marrow infiltrative processes can also lead to back pain.

Inflammatory arthritis (collagen vascular diseases) may present with back pain in children. These include ankylosing spondylitis, arthritis associated with inflammatory bowel disease, reactive sacroiliitis, and psoriatic arthritis.

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