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Orthopedics and Sports Medicine Case of the Month

July 2012: Back Pain

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Cora Breuner

Dr. Cora Collette Breuner presents a case of lower back pain in an adolescent, sharing tips on pertinent questions to ask when taking a history and discussing potential causes of back pain. She also discusses the importance of including physical therapy in the treatment of teens with lower back pain.

Patient History

A 17-year-old male presents with lower back pain for four months. There was no inciting trauma. His pain occurs daily, is worse in the midday and afternoon and occasionally affects his ability to fall asleep. It is a dull aching pain in the middle of his lower back. He has no paresthesias, no radiation of pain or shooting pain down the back of his legs. No fever, dysuria or rash. No weight loss or decrease in energy. No history of bowel or bladder incontinence. He takes ibuprofen at least two to three times per week with some pain relief. The pain is so severe that he has quit participating in any sport, including football and basketball.

He has a large backpack in which he carries all of his books back and forth to school. He studies three to four hours per night in his bed with a laptop. He has missed over 20 days of school this semester due to the pain. His parents are recently separated, and he spends every other weekend with his dad. In a discussion with him by himself, he admits that he had been sad about his parents’ separation, but his mood was better now and that his parents were actually “working things out.”

His back exam reveals that he is able to forward flex to 50 degrees. He can hyperextend and laterally rotate his back without pain. He has diffuse tenderness in the paraspinous region of L3, 4 and 5. No point tenderness over the spinous processes or over the sacroiliac joints. He has negative straight leg testing and normal reflexes, and there are no café au lait spots or other unusual cutaneous markings.

Diagnostic Imaging

Posteroanterior (PA) and lateral of the spine are normal.

Diagnosis

Paraspinous muscle spasm

Treatment

He was sent to physical therapy for core strengthening with a home exercise component. He requested a second set of books to be left at home to lighten his backpack. He modified his position while working on the laptop while studying so that he is actually sitting at a desk. After six weeks he was pain free and was able to remain in school and return to team sports.

Discussion

Back pain is seen often in children and adolescents. One large survey found that 7% of 12-year-olds had experienced at least one episode of low back pain, the cumulative incidence increasing to 50% by age 18 years (girls) and 20 years (boys). The prevalence on any given day was noted to be approximately 1% for 12-year-olds and 5% for 15-year-olds, rising to 10% by the early 20s. Most children with back pain have mild symptoms and do not seek medical care. Noted associations with back pain include female gender, excessive screen time (more than two hours per day of recreational screen time), heavy backpacks and a family history of back pain. The American Academy of Pediatrics recommends that a child’s backpack weigh no more than 10% to 20% of a child’s weight.

Back pain in the adolescent has a broad differential diagnosis. Taking a good history is imperative in narrowing the steps for further diagnostic testing in the workup and management. Diagnoses can vary from relatively benign entities such as paraspinous muscle sprain to more serious diagnoses, such as tumor, infection or an inflammatory process, that warrant medical or surgical intervention.

In this patient, there is much in the history that is reassuring. The history of worsening pain in the afternoon and no inciting trauma points toward the diagnosis of paraspinous muscle spasm.

There are features of a history that might be concerning; for example, night pain can be associated with spinal tumors, osteoid osteoma, osteoblastoma, eosinophilic granuloma, aneurysmal bone cyst, leukemia, Ewing's sarcoma or spinal cord tumors such as neurofibroma or astrocytoma. Infections such as osteomyelitis and diskitis can present with night pain, malaise and fever.

Back pain associated with diskitis commonly is associated with fever, anorexia, malaise and irritability in children younger than 10 years. Cessation of walking is noted in the child less than 3 years. A positive straight leg raising test result, caused by tight hamstrings, is common. Complete blood count and erythrocyte sedimentation rate are usually elevated, and Staphylococcus aureus is the most common organism associated with diskitis. Radiographic findings may be normal early (less than three weeks after the pain begins) but later show disk-space narrowing and end-plate changes.

A herniated disk is rare in the child and adolescent, and usually presents with pain radiating down one or both legs, pain with the Valsalva maneuver or stiffness. Most patients will have a positive straight leg raising test. Magnetic resonance imaging (MRI) is the test of choice for confirming this diagnosis.

Acute back pain may be the result of a vertebral fracture. This is usually caused by trauma from a motor vehicle crash or fall from a height, and is frequently associated with other injuries. Radiculopathy suggests a fracture (i.e., transverse fracture through the bone or disk) with spinal canal compromise. Spondylolysis (a type of stress fracture of the pars interarticularis) may result from chronic, repetitive microtrauma – it is often seen in young athletes, in particular in gymnasts, wrestlers and rowers.

Chronic pain (longer than three months) may be caused by entities such as Scheuermann’s kyphosis or inflammatory spondyloarthropathies. Importantly, chronic back pain may also be associated with psychological stress.

Scheuermann’s kyphosis is an osteochondrosis that presents as an abnormality of the vertebral epiphyseal growth plates. Vertebral wedging of five degrees or more on three adjacent vertebral bodies, end-plate changes or disk-space narrowing is usually noted on X-ray. Scheuermann’s kyphosis is rigid, and the pain is generally gradual in onset and worsens over months, and is worse toward the end of the day.

Inflammatory joint disorders (i.e., juvenile rheumatoid arthritis or ankylosing spondylitis) can also cause back pain in children and adolescents. Morning stiffness is often reported, and mobility may improve with moist heat such as from a hot bath or shower. Sacroiliac joint tenderness may be present, although nighttime pain is uncommon with inflammatory joint disorders.

In children/adolescents with stress-related pain, the physical exam of the back can be completely normal. Recent studies have shown a correlation between psychological and psychosocial stressors and lower back pain in the pediatric and adolescent population.

On physical examination, flexion of the spine increases the strain on the anterior elements of the spine, particularly the vertebral bodies and disk spaces. Pain with forward flexion is associated with diskitis, osteomyelitis and tumors of the vertebral body. Spine extension is associated with pain due to strain on the facet joints and the pars interarticularis. Spondylolysis and spinal stenosis are both associated with painful spine extension.

Pain with recent-onset scoliosis can be associated with intraspinal tumor, infections or syrinx. Concomitant signs and symptoms can include fever, weight loss, focal pain, and a positive straight leg raise test.

If the radiographic findings are normal, MRI, computed tomography (CT) or bone scan may be indicated. In cases where the diagnosis remains uncertain, obtaining laboratories may be helpful in narrowing down the differential. Table 1 provides a useful algorithm for the evaluation of the adolescent with low back pain.

Conclusions

Back Pain Case of the Month flowchart

Table 1. (MRI = magnetic resonance imaging; CT = computed tomography.) Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop 2006;26:354.

Low back pain in children and adolescents is extremely common. Taking a careful and thorough history can help the clinician tease out whether or not there is a component of stress that is causative in the adolescent with back pain. It is imperative that all other organic causes of back pain be appropriately evaluated before concluding that stress is the primary etiology. If organic causes are successfully ruled out, the patient/family should be steered toward other issues that should be addressed, such as proper sleep, diet and exercise. Consults to a physical therapist and to mental health professionals are often helpful in restoring the pediatric patient to a normal and healthy childhood.

References

  1. Szpalski M, Gunzburg R, Balague F, Nordin M, Melot C. A 2-year prospective longitudinal study on low back pain in primary school children. Eur Spine J. 2002;11:459–64.
  2. Skaggs DL, Early SD, D'Ambra P, Tolo VT, Kay RM. Back pain and backpacks in school children. J Pediatr Orthop. 2006;26:358–63.
  3. Diepenmaat AC, van der Wal MF, de Vet HC, Hirasing RA. Neck/shoulder, low back, and arm pain in relation to computer use, physical activity, stress, and depression among Dutch adolescents. Pediatrics. 2006;117:412–6.
  4. Jones GT, Watson KD, Silman AJ, Symmons DP, Macfarlane GJ. Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatrics. 2003;111(4 pt 1):822–8.
  5. Lynch AM, Kashikar-Zuck S, Goldschneider KR, Jones BA. Psychosocial risks for disability in children with chronic back pain. J Pain. 2006;7:244–51.
  6. Mustard CA, Kalcevich C, Frank JW, Boyle M. Childhood and early adult predictors of risk of incident back pain: Ontario Child Health Study 2001 follow-up. Am J Epidemiol. 2005;162:779–86.
  7. Hakala P, Rimpela A, Salminen JJ, Virtanen SM, Rimpela M. Back, neck, and shoulder pain in Finnish adolescents: national cross sectional surveys. BMJ. 2002;325:743.
  8. American Academy of Pediatrics. Backpack safety. Accessed June 24, 2012.
  9. Jones GT, McFarlane GJ. Epidemiology of low back pain in childhood and adolescents. Arch Dis Child. 2005;90(3):312-216.

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