By Omar Gabbar
Back pain is fairly prevalent in healthy children and adolescents, with one study showing 12% of 11 year olds reporting back pain increasing to 50% of 15 year olds reporting back pain1. Also, a cross-sectional study, performed in a Danish population, showed a dramatic increase in the prevalence of low back pain in the early teen years2.
In 78% of children and adolescents with back pain, no underlying cause will be identified3. However, soft-tissue strains and activity in adolescents are usually the result of bad posture and carrying heavy school bags.
The most important thing is to identify the causes that are associated with serious pathology, and the clinician needs to exclude serious pathology without instilling fear into the patient and/or parents. Tumours, such as Ewing’s, and infection (discitis) top the bill of serious pathology—osteoid osteoma and eosinophilic granuloma causing vertebrae plana are benign causes of back pain. The diagnosis by exclusion starts with careful clinical examination. If the history and physical examination suggest underlying pathology, radiography, complete blood count, erythrocyte sedimentation rate, and a C-reactive protein measurement should be performed. Follow-up magnetic resonance imaging, computed tomography, or SPECT scanning may be needed depending on the suspected cause. It is generally accepted that the following factors warrant immediate evaluation: patient age younger than four years, persistent symptoms, self-imposed activity limitations, systemic symptoms, increasing discomfort, persistent night-time pain, and neurologic symptoms4.
Patients who are more likely to have a serious pathology will require referral to specialists who deal with the diagnosed pathology, and subsequent management will vary according to the underlying diagnosis.
If non-specific back pain is suspected, treatment may include home-based exercise, physical therapy, or non-steroidal anti-inflammatory drugs. In particular, education and prevention are the main treatments with a focus on posture and psychosocial factors5. Back education programmes are effective in reducing risk factors for long-term back pain, but whether this benefit is sustained in later life requires further investigation.
Back pain in the child is divided into non-specific and specific pain. Although back pain common is in children and adolescents, it should be assessed carefully with good clinical history and examination with the suspected serious pathology investigated through MRI, and SPECT scan if needed as this will allow appropriate treatment initiated without delay.
1. Harreby et al; Eur Spine J 1999; 8: 444–50
2. Burton et al. Spine 1996; 21: 2323–28
3. Bhatia et al. J Pediatr Orthop 2008; 28: 230–33
4. Rodriguez et al. Am J Neuroradiol 2010; 31: 787–802
5. Vidal et al. Eur Spine J 2013; 22: 782–87
Omar Gabbar is at University Hospitals of Leicester NHS Trust, Leicester, UK