Back Pain in Children and Adolescents
Back Pain in Children and Adolescents
Authors: Doreen Teoh, MD, FAAP, Fellow, Pediatric Emergency Medicine, Children’s Memorial Hospital, Northwestern University School of Medicine, Chicago, IL; and Steven E. Krug, MD, FAAP, Associate Professor of Pediatrics, Northwestern University School of Medicine; Director, Pediatric Emergency Medicine, Children’s Memorial Hospital, Chicago, IL.
Peer Reviewer: Steven M. Winograd, MD, FACEP, Attending Physician, Department of Emergency Medicine, Sturgis Hospital, Sturgis, MI, and Allegan General Hospital, Allegan, MI.
Although back pain is a common complaint in adults, it is uncommon in children and adolescents. However, the incidence of back pain increases with age and activity.1-4,6,7 Approximately 50% of females by age 18 have complained of back pain, and 50 % of males by age 20.1 Although some studies have shown an increased incidence of back pain in children who avoid sports, competitive athletes appear to be at greater risk of back pain, especially in sports with twisting and hyperextension movements such as gymnastics, cycling, tennis, and volleyball.3,4,6,23 Unlike adults who frequently have degenerative or mechanical origins of back pain, a child who complains of back pain must be considered to have significant pathology and should be further evaluated.2,3,5-7
— The Editor
Anatomy and Biomechanics
Each vertebra has an anterior portion, consisting of the body and intervertebral discs, and a posterior portion, composed of the dorsal arch. (See Figures 1, 2, and 3.) The arch is composed of the paired lateral pedicles and the posterior laminae. The foramen of the arch is the vertebral canal in which the spinal cord, meninges, and blood vessels traverse. Seven processes arise from the arch, a single posterior spinous process and the paired transverse, superior articular and inferior articular processes. The vertebrae articulate with each other at a cartilagious joint formed by the superior and inferior articular processes of adjacent vertebrae. The intervertebral disc lies between the vertebral bodies. The disc is composed of the nucleus pulposus which is surrounded by the annulus fibrosus. The anterior and posterior longitudinal ligaments connect the vertebrae anteriorly and posteriorly, respectively. The supraspinous, interspinous, and intertransverse ligaments connect the spinous and transverse processes. Between the laminae lie the ligamentum flavum. The paired intervertebral foramina are surrounded by adjacent vertebral bodies and intervertebral discs anteriorly, pedicles superiorly and inferiorly, and the synovial joint and superior and inferior articular processes posteriorly. Spinal nerves and blood vessels enter and exit the vertebral foramen through the intervertebral foramina.
The anterior portion of the spine functions as a shock absorber and enables the structure to bear weight. The posterior portion protects the spinal cord and allows for movement.20 The spine can flex anteriorly, bend laterally, extend and rotate. The intervertebral discs also permit a rocking motion.20 The ligaments stabilize the spine and minimize shearing forces.20 The paravertebral muscles provide balance and strength. 20 The vertebral column is typically divided into cervical, thoracic, lumbar, and sacral divisions. The cervical and lumbar spine are the most mobile and flexible and therefore are more vulnerable to traumatic back pain.5
Clinical Evaluation
History. The history should focus on the events surrounding onset of pain, the nature of the pain, its severity, changes in pain, concurrent systemic complaints, past medical illnesses, family history, and social history. (See Table 1.)
| Table 1. Important History |
| Medications |
| Previous trauma |
| Antecedent Streptococcal Pharyngitis |
| Cystic Fibrosis |
| Neurofibromatosis |
| Undescended Testes |
| Anorexia Nervosa |
| Ehlers-Danlos syndrome |
| Marfan syndrome |
| History of lumbar puncture |
| Family history of back pain |
Questions regarding the onset of the pain should include any activity engaged in at that time. A history of exercise, sports, trauma, or illnesses should be elicited. A history of the nature of the pain include its location, radiation, duration, frequency, character (constant vs intermittent), and factors which aggravate or relieve the pain.3,5,8 Pain severity can be assessed by limitation of activity (i.e., whether it interferes with school, play, or sports) if it is present at night, responds to pain medications or, if the child is able, asking the child to use a pain scale to rate the degree of pain.5,8 Changes in the location, nature or severity of pain may provide clues to the cause. Changes in any associated symptoms are also helpful. Important systemic complaints to elicit include fever, weight loss, malaise, change in bowel or bladder function, changes in gait, lower extremity weakness, numbness, tingling, stiffness or pain.3,5,8 Aspects of the history which are most concerning are the presence of constitutional symptoms, such as fever, weight loss, nausea, vomiting or diarrhea, pain awakening the child from sleep, interference with favorite activities, and symptoms that are persistent and progressive.21
Previous medical illnesses of importance include, previous fractures, antecedent streptococcal pharyngitis, cystic fibrosis, neurofibromatosis, undescended testes, anorexia nervosa, Ehlers-Danlos syndrome, Marfan syndrome, or a recent history of lumbar puncture. A family history of back pain is suggestive of an inherited disorder or susceptibility. The social history is important in the child who may be a victim of child abuse or have a psychogenic origin of back pain. Concurrent psychosocial diagnoses, such as depression, attempted suicide, physical or sexual abuse, pregnancy, drug abuse, anxiety and adjustment disorders, have been found in children with back pain.21
Physical Examination
A complete physical exam is required to evaluate the child with back pain. In addition to the back, the musculoskeletal and nervous systems must be carefully evaluated. Examination of the pelvis, flank, genitalia, abdomen and chest should not be omitted.5
Observation of the patient will provide a general assessment of the severity of illness.5 The patient should be observed from the back and sides and standing upright and bending forward.8 These positions will assess general posture, and may detect scoliosis, kyphosis, lordosis, asymmetry or other obvious deformity and stiffness.5,8 Idiopathic scoliosis usually does not cause back pain, but other disorders, such as bony tumors, spinal cord tumors, vertebral osteomyelitis, discitis, fracture, or limb length discrepancy, can cause scoliosis.5,9 Inspection of the back may reveal dimpling, sinus tracts, lipomas, hemangiomas, or hairy nevi which may indicate spina bifida occulta or other spinal abnormality.3,5,8 Cutaneous signs of systemic disease, such as café-au-lait spots, may be found on skin examination.
The back should then be carefully palpated. The location of pain should be determined by palpating the spinous processes of each vertebra, including the coccyx, all the ribs, and the surrounding soft tissues, especially the paraspinous muscles and the supraspinous and interspinous ligaments.5 Percussion may elicit flank tenderness in patients with pyelonephritis.3,8 Palpation of the sacroiliac joints and stress of this joint by flexing the hip to 90 degrees while adducting the leg across the midline (figure 4 position) or compressing the iliac crests can elicit pain.5 The iliac crest, iliac spine, ischial tuberosity, and greater trochanter should also be palpated.5
Range of motion should be assessed but may be difficult because of compensatory use of unaffected areas of the spine or the pelvis.5 Marking the skin overlying the spinous processes helps to overcome this difficulty.5 Flexion, extension, lateral bending, and rotation should be evaluated.5
Musculoskeletal evaluation should begin with an assessment of gait. Attention should paid to the posture, rate, stride length, width of the base, pelvic motion, and center of gravity.5 There are two phases of gait, stance and swing. Abnormalities of stance may indicate muscle weakness or neurologic deficits, while abnormalities of swing may indicate cord or vertebral column lesions.5
Leg length should be measured in the supine position from the anterior iliac crest to the medial malleolus.10 With the knees and hips flexed, relative knee heights can be measured to distinguish between femur and tibia length discrepancy.10 Discrepancies of up to 2 cm in mature individuals are generally well tolerated; of course, a taller person tolerates more discrepancy than a shorter person does.8,10 Sitting height can be estimated by subtracting leg length from height.23 Children with greater sitting heights may experience more back pain.23
The thighs and calves should be compared for symmetry of muscle bulk, tone and strength.5,8 Atrophy of one limb may be a sign of a tethered cord.8
Limitation of passive straight leg raising can indicate hamstring tightness or lower lumbar nerve root irritation.22 The degree of straight leg raising decreases with age and is greater in females compared to males.22 Limitation of straight leg raising suggests intraspinal pathology, discogenic pathology, spondylolysis, or spondylolisthesis.3,5,18
A neurologic exam should include a complete sensory exam (touch, pain, and position), deep tendon reflexes, and motor strength.5 If neurologic deficits are found, the level of the lesion should be identified. The cremasteric, abdominal, and anal reflexes may help in localizing the lesion.5
Diagnostic Evaluation
Laboratory tests should be directed toward areas of suspicion.8,11 General screening laboratory tests for suspected infectious, inflammatory, or neoplastic diseases include complete blood count and erythrocyte sedimentation rate.5 If a rheumatologic disorder is suspected, tests for HLA-B27, rheumatoid factor, antinuclear antibodies, complement subtypes, and lupus erythematosus preparation may be indicated.5 If an abdominal disorder is suspected, urinalysis, amylase, or biliary studies may be indicated.11 A bone marrow biopsy may be indicated if a neoplasm is suspected.21
Plain radiographs, including anteroposterior (AP), lateral, and oblique views, are useful screening tests in acute back pain, for fracture, tumor, or vertebral infection.3,5 Standing films will accentuate scoliosis, hypo- or hyperlordosis, signs of segmental instability, and spondylolisthesis.3,19 Spondylolysis and spondylolisthesis can be missed with just AP and lateral views, but oblique, flexion-extension, or traction-compression views will increase detection.3,19 Examination of leg length discrepancy is measured in weight-bearing radiographs as the difference between the highest points of the femoral heads on the horizontal plane.19 Frequently, plain radiographs do not identify the cause of back pain, and other radiographic tests are necessary.
A bone scan is useful for detecting areas of increased bone turnover, such as in mechanical stress, fractures, infections, or tumors.3,18 A positive bone scan may precede radiographic changes in disorders such as spondylolysis, discitis, and osteomyelitis.12,18 A bone scan will show areas of recent stress reaction or fracture, but not healed injuries.18 However, a bone scan frequently has poor resolution and does not provide details of location.3 Single photon emission computed tomography (SPECT) is more sensitive than the bone scan and can more accurately identify the site involved, but the lack of routine availability of SPECT has limited its utility.3,12 The main advantage of bone scan or SPECT is their ability to detect lesions earlier in their evolution and to determine the activity of abnormalities seen on radiographs.18
Computed tomography (CT) is useful for evaluation of a patient with a traumatic injury or for suspected lesions outside the spine.11 However, CT has limited capabilities in viewing the contents of the spinal canal; thus, magnetic resonance imaging (MRI) is best for the identification of suspected lesions of the spinal cord and intervertebral discs, but is less useful for evaluating bony abnormal lesions.3,11,12
Differential Diagnosis
The causes of back pain can be divided into traumatic, developmental, infectious, rheumatologic, neoplastic, referred, metabolic, and psychogenic origins. (See Table 2.)
| Table 2. Differential Diagnosis |
| Trauma Related |
| • Vertebral Fracture |
| • Herniated Intervertebral Disc |
| • Ligament Sprain |
| • Muscle Strain |
| • Overuse Syndromes |
| Developmental Disorders |
| • Spondylolysis |
| • Spondylolisthesis |
| • Scheuermann's Kyphosis |
| • Limb Length Discrepancy |
| • Spina Bifida Occulta |
| • Diastomatomyelia |
| • Anomalous Vertebral Articulations |
| Infectious Disorders |
| • Discitis |
| • Vertebral Osteomyelitis |
| • Pott's Disease |
| • Epidural Abscess |
| • Paravertebral Abscess |
| Rheumatologic Disorders |
| • Ankylosing Spondylitis |
| • Juvenile Rheumatoid Arthritis |
| • Lyme Disease |
| • Rheumatic Fever |
| • Dermatomyosisitis |
| • Systemic Lupus Erythematosus |
| • Scleroderma |
| • Henoch-Schonlein Purpura |
| Neoplastic Disease |
| • Osteoid Osteoma |
| • Osteoblastoma |
| • Aneurysmal Bone Cyst |
| • Eosinophilic Granuloma |
| • Ewing's Sarcoma |
| • Osteogenic Sarcoma |
| • Acute Lymphoblastic Leukemia |
| • Hodgkin's and Non-Hodgkin's Lymphoma |
| • Neuroblastoma |
| • Neurofibroma |
| • Dermoid |
| • Lipoma |
| • Astrocytoma |
| • Epidermoid Inclusion Cyst |
| • Schwannoma |
| • Ependymoma |
| • Metastases |
| Other Disorders |
| • Referred Pain |
| • Sickle Cell Vaso-occlusive Crisis |
| • Dissecting Aortic Aneurysm |
| • Pregnancy |
| • Conversion Disorder |
Trauma-Related Disorders. Trauma-related causes of back pain are uncommon in children.5 Sudden large forces as well as repeated stresses to the back can cause injury or overuse syndromes. High speed motor vehicle collisions and acrobatic sports are associated with acute vertebral trauma, especially cervical spine injury.4 However, cervical spine injury will not be discussed further in this article. (See Pediatric Emergency Medicine Reports "Pediatric Cervical Spine Injury: Navigating the Nuances and Minimizing Complications" 1996;1:83-94.)
Vertebral Fractures. Vertebral fractures are uncommon, but can occur in high impact, rapid deceleration activities such as skiing or in motor vehicle collisions.5 Children restrained solely with a lap belt are at risk for a chance fracture, a compression fracture of the lumbar vertebral body, and fractures of the pedicles, laminae, transverse processes, spinous processes, and facets.13 In addition to fractures, subluxations and distraction of facet joints with or without neurological injury have been described in children restrained with lap belts alone.13 Gymnasts who land with hyperflexion and rotation may sustain fractures of the facets.16 Patients suspected to have a vertebral fracture should be immobilized on a backboard, have appropriate radiographic evaluation, and have consultation with neurosurgery or orthopedics as indicated.14 Parenteral administration of steroids should be considered in patients with acute trauma to the spinal column and neurologic defects as a potential means of improving resolution of the neurologic deficit.14
Intervertebral Disc Herniation. Herniated intervertebral discs are rare in children.2,3,5,6,8,11 Disc herniations in children are more likely due to cumulative trauma than a single event.3 In the skeletally immature patient, a herniated disc sometimes occurs with the associated herniation of the adjacent cartilaginous growth plate, termed "slipped vertebral apophysis."8 Nearly two-thirds of adolescents affected complain of back pain, and another third complain of sciatica.5 The symptoms may worsen with straight leg raising, forward bending, sneezing, and coughing.3,8 Neurological examination is usually negative.8 Plain radiographs are typically normal except for scoliosis due to muscle splinting and spasm.3 MRI will confirm the diagnosis.4 Treatment for adults consists of decreased activity, NSAIDS, bracing and physical therapy.3,4,5 Those who do not improve with conservative therapy, and those who have bowel or bladder dysfunction or have a slipped apophysis, may benefit from epidural steroids or surgery.2,4,5
Overuse Syndromes. Lumbosacral strain is an injury of the extensor muscle-tendon units of the spine frequently diagnosed in adults, but encountered infrequently in children.6 Dancers and gymnasts who place repetitive stress on their backs are predisposed to musculoligamentous injury such as muscle strain, ligamentous sprain, apophyseal compression fractures, and disc degeneration.5,15 The stiff, reinforced seams of tight fitting blue jeans have also been proposed as a cause of coccygeal pain.26 Repetitive stress on the back has also been proposed as a cause for spondylolysis and Scheuermann’s kyphosis.4,5,17 Rest, strengthening, flexibility exercises, and physical therapy are recommended for overuse syndromes.4,8 However, if the back pain does not resolve within 3-4 weeks, another diagnosis should be suspected and further work-up pursued.4,8
Developmental Disorders
Spondylolysis and Spondylolisthesis. Spondylolysis and spondylolisthesis are the most commonly identifiable causes of low back pain in children.2,3,8 A defect or fracture of the isthmus of the pars interarticularis, the part of the spine between the superior and inferior articulations of the vertebrae, is termed spondylolysis.5,8 The pars interarticularis is the weakest part of the posterior vertebrae.2 Extremes of flexion and extension may accentuate the forces which can cause a fatigue fracture of the pars interarticularis; thus, excessive stress in sports is usually associated with these stress fractures.2-4 Gymnasts, dancers, figure skaters, hockey players, high jumpers, football linemen, and weight lifters have an increased incidence of spondylolysis.2-5,8 Spondylolysis is uncommon before age 5 and peaks by 20 years of age.3 These stress fractures tend to occur most frequently during growth spurts.2 Up to 35% of females and 5% of males may have this defect in the pars interarticularis.5 A family history of either spondylolysis or spondylolisthesis poses a greater risk for developing this disorder.3,4 Approximately 40% of Alaskan Eskimos have spondylolysis, and this disorder is also more common in patients with spina bifida occulta or transitional vertebrae.3,4,8 The most common site of spondylolysis is L5.2,5 Spondylolysis can be unilateral or bilateral.3 Unilateral spondylolysis may be asymptomatic.3
Spondylolysis may lead to spondylolisthesis, a slip of one vertebra over another anteriorly.5,8 This process starts with abnormal stresses which cause microfractures, eventually leading to overt fracture or spondylolysis.3 The intact side is then overloaded and stressed, leading to bilateral spondylolysis.3 This may then cause spondylolisthesis due to the unopposed anterior forces on the intervertebral discs.3 This disorder is most commonly seen at the level of L5 on S1.5 There also may be a genetic predisposition to spondylolisthesis, as approximately 27% of cases occur in first-degree relatives.3 Patients with another disorder thought to be related to vertebral stress, Scheuermann’s kyphosis, also have a higher incidence (30-50%) of spondylolisthesis.3
Typically, patients with spondylolisthesis present insidiously.2 Patients will usually have low back pain with radiation to the knee, tight hamstrings, and at least partial relief of symptoms with rest.3,5 The low back pain usually localizes to just below the level of the iliac crests.2 Approximately 10-15% of these children will complain of motor weakness, decreased sensation, or will have reflex deficits on physical examination.3 Children with spondylolisthesis may find some relief by leaning forward, which may stabilize the slipped vertebrae.5 On exam, there may be a palpable step-off or shortening of the torso or a horizontal crease between the costal margin and the iliac crest.2,5 Gait may also be affected, primarily the stride length.5
Diagnosis is made with plain radiographs, although bone scan, SPECT, CT and MRI are occasionally needed to help with diagnosis and follow-up.2-5,8 Spondylolysis can often be seen on AP and lateral views of the spine, but approximately 20% of unilateral spondylolysis will be missed with these views.3 Oblique films may demonstrate a pathognomonic finding, the Scottish terrier of La Chapele.3 A radiolucent line around the "terrier’s" neck indicates a defect of the pars interarticularis.3 In spondylolisthesis, plain radiographs will usually show the slippage of L5 on S1. Also, a rounding off of the superior surface of S1 or a trapezoidal-shaped body of L5 may be seen.5
If spondylolysis is clinically suspected, but not seen on plain radiographs, the next appropriate test would be a bone scan. An early stress fracture may have a positive bone scan without findings on plain radiographs.2,3 Bone scans can also be used to differentiate between healing chronic spondylolysis and nonunion of the pars interarticularis.3 SPECT is more sensitive and has better resolution than a bone scan, making it a better diagnostic tool.3,4
CT or MRI can be helpful in confirming the diagnosis, especially if results of radiographs are equivocal.5 In patients with back pain lasting longer than one year, CT can show a defect not apparent on plain films, which is more likely to represent nonunion.3 The CT scan should be taken parallel to the vertebral arch with 2-3 mm cuts in order to adequately visualize the pars interarticularis.3 In early presentation, MRI may be useful as it can show prespondylolytic lesions as hypointense areas on T1 images.3
Non-surgical therapy can result in healing in many cases, especially if started early in the course of disease, before spondylolisthesis.24 Conservative therapy includes analgesics, rest, immobilization, and when pain subsides, exercises to strengthen abdominal and paraspinal muscles.2,3 Abstaining from running, jumping, sudden changes in movement, and contact sports until the pain is gone and scan is normal is also recommended.2,3 Spondylolysis may take up to 9 months to heal.4 Bone scan, SPECT, CT, or MRI can be used to evaluate response to therapy.3 Surgery is indicated if pain is unrelieved by rest, immobilization, and NSAIDs, or if there is progression to subluxation, spondylolisthesis greater than 50%, or any significant neurologic findings.2,3 Posterolateral fusion is the usual procedure of choice, but a primary pars interarticularis repair may be appropriate in competitive athletes with acute spondylolysis.3,4
Scheuermann’s Kyphosis (Dorsolumbar Kyphosis). Scheuermann’s disease, or dorsolumbar kyphosis, is a fixed kyphotic deformity of the thoracolumbar junction.5,25 This disorder is the most common cause of back pain, at the level of the thoracolumbar junction.2,8 Patients with "flatter" spines (thoracic hypokyphosis and lumbar hypolordosis) who experience excessive lifting or repeated flexion or hyperextension of the lumbar spine appear to be at risk for developing this painful deformity.2,4,8 Proposed causes of Scheuermann’s disease include repeated trauma and stress, osteonecrosis of the ring apophysis, and osteochondritis.2,5 The ring apophysis is the site of attachment for the intervertebral disc annulus and lies on the outer ring of the vertebral end-plate.25 Large forces associated with heavy lifting can increase the pressure on the nucleus pulposus enough to damage the vertebral end-plates and create the characteristic radiological findings.25 One-third of symptomatic patients also have spondylolytic changes of the spine.2 Patients typically present around the pubertal growth spurt, 11 to 18 years of age, when there is a transient relative osteoporosis.17,5 The incidence of Scheuermann’s disease is greater in males than females.2,5,17 Overall, the incidence has been reported to range between 4% and 88%.5
Physical examination may reveal an exaggerated thoracic kyphosis, sometimes with a compensatory lumbar hyperlordosis and mild scoliosis, although the posture may be normal.2,8 The pain increases with activity, especially with forward flexion, and is relieved by rest.5,25 Tenderness of the involved vertebrae, flattening of the normal lumbar lordosis, stiffness of the lumbar spine, and paraspinous muscle spasm may also be elicited.4,5,25 Neurological exam is usually normal unless nerve root impingement from a concurrent posterolateral disc herniation is present.25
Diagnosis may be made by plain radiographs; with other radiological tests rarely needed.2 Scheuermann’s kyphosis, by definition, has three or more consecutive thoracic vertebrae with a 5-degree or greater kyphosis at each level.4 Characteristic radiological findings in Scheuermann’s disease are wedging of two adjacent vertebral bodies, increase in normal kyphosis greater than 40 degrees, "flat back," Schmorl’s nodes, decreased interertebral disc space, irregular vertebral end-plates, fragmentation of the epiphyseal rings and sclerosis of the adjacent vertebral margins.2,5,25 Schmorl’s nodes are herniations of the intervertebral disc upward or downward into the body of the adjacent vertebra.2 An anterior Schmorl’s node, or "limbus vertebra," is an anteroposterior herniation of the disc under the ring apophysis, separating a fragment of the apophysis, which appears as a triangular bone fragment separated from the vertebral body.2,25 Concomitant degenerative disc changes can be demonstrated on MRI.2
Treatment includes rest, avoiding heavy lifting, hyperextension bracing, strengthening, general stretching and hamstring stretching.4,25 Symptoms may resolve with conservative therapy in 4-6 weeks.4 However, the physical exertion must be advanced slowly and up to six months may be required before full activity is resumed.4,25 Only rarely is surgery indicated.25 The radiographic findings usually do not resolve.25
Anatomic Aberrations. Many anomalous articulations have been described as causes of back pain. An anomalous first rib arising from C7 with a midshaft pseudoarthrosis caused upper back pain in a teenage wrestler.27 Eleven patients with low back pain were found to have anomalous articulations of the transverse process of L5 with the sacrum and occasionally with the ilium.28 Unilateral absence of the L1 pedicle with hypoplasia of the L1 vertebral body and hypoplasia of unilateral inferior articular processes and pedicles at several levels has been proposed as a cause of back pain in a 10-year-old child.29 These anatomic abnormalities probably cause pain due to structural imbalance or altered biomechanics. However, idiopathic scoliosis usually does not cause back pain. Although 90% of scoliosis in children is idiopathic, other causes of scoliosis must be considered and ruled out.9 A patient with scoliosis and back pain should be investigated for causes of back pain as one would with any other child complaining of back pain.30 If that evaluation is negative, a diagnosis of idiopathic scoliosis can be made, as up to 32% of children with scoliosis have been noted to complain of some back pain.30 Despite the old wive’s tale, poor posture does not lead to back pain.31
Spina bifida occulta is a congenital disorder in which the two lateral halves of the vertebral arch fail to fuse.5 This disorder can cause hypermobility of the spine, back pain, and sciatica.5 On physical exam, hairy nevi, lipoma, hemangioma, dimpling, or sinus tract may be present.3,5,8 Diastematomyelia is an abnormal cleft of the spinal cord, associated with spina bifida.5 A bony spicule arising from a vertebral body projects into the anterior spinal cord, and creates the cleft.5 This bony spicule tethers the cord in place and prevents the normal migration of the spinal cord in the vertebral canal during growth; thus, progressive neurologic dysfunction results.5
Abnormalities of the soft tissues can also lead to back pain. A ruptured urachal cyst has been described as a cause of low back pain in an adolescent.32 Herniation of retroperitoneal fat or a peritoneal sac can occur in the superior or inferior lumbar space.33 A defect in the lumbodorsal fascia may allow herniation to occur.33 Patients with this disorder typically complain of low back pain associated with a tender mass, but should not have any sciatica or neurological symptoms.33 Obesity does not predispose one to this problem.33 Small hernias may be treated with injection of local anesthetic and methylprednisolone to reduce inflammation.33 Larger hernias should be treated surgically with excision of the incarcerated fat and repair of the fascial defect.33
Infectious Disorders
Numerous infectious disorders may present with a complaint of back pain; not only infections of one of the components of the vertebral column, but also systemic infections. The most common is discitis, an infection of the intervertebral discs. Vertebral osteomyelitis, Pott’s disease, and epidural abscess are other infectious disorders of the spinal column. Infections in the vicinity of the vertebral column, such as paravertebral abscess and pyomyositis of the paravertebral musculature, can also create back pain.38 Systemic infections such as Lyme disease and rheumatic fever can cause back pain as well.39,40
Discitis. Discitis is an infection of the intervertebral disc, which occurs primarily in younger children.2,5,8 The etiology and pathophysiology of this disorder is still debated, but likely starts in the vertebral end plate and travels to the disc.3,5,8 Younger children are at risk because of the increased vascularity of the disc at this age.8 There are two age peaks in which this disease is seen: 6 months-4 years and 10-14 years, with most cases occurring in children younger than 4 years.2,34 Girls are affected twice as often as boys.34 Patients usually present with fever, limp, refusal to walk, irritability, malaise, stiff back, and pain with any motion of the spine.2,3,5,8,34 Physical exam may reveal paravertebral muscle spasm, point tenderness, loss of lumbar lordosis, and tight hamstrings.3,5
Diagnostic tests used to evaluate discitis include both laboratory and radiologic evaluation; however, laboratory tests are not usually diagnostic of disease.5 Erythrocyte sedimentation rate may be elevated 50% of the time and white blood cell count is usually normal, but can be moderately elevated.5,8 Blood cultures are usually negative.5 Biopsies and cultures of the infected disc are rarely indicated.2,3 Seventy-five percent of biopsies and cultures of the disc yield no growth, but Staphylococcus aureus is the organism most commonly identified in positive cultures.5,8,34 Plain radiographs may be normal early in the course of disease.2,3,5,8 After two weeks, plain radiographs may show the characteristic findings of discitis, including narrowing of the disc space, adjacent vertebral body erosions, and end plate sclerosis.2,3,5,8 The first radiographic sign to appear is narrowing of the disc space, but this can take up to 2-4 weeks to develop.8,34 The most common disc space involved is L3-L4.2,34 Bone scan is helpful in diagnosis early in the course of the disease.2,3,5,8,34 A positive bone scan will show increased uptake in the disc space and in the end plates of the adjoining vertebrae.34 SPECT can identify the site and extent of involvement with better resolution.34 Contrast enhanced CT can show the erosive changes in the vertebral end plates as well as hyperemia of the disc.34 MRI has great sensitivity and specificity for discitis and can show changes in the disc early in the course of disease.34
The treatment of discitis remains controversial, especially with regard to the use of antibiotics. Most patients respond well to rest, antibiotics, and immobilization.3,8 Recovery without antibiotics is common.2 If antibiotics are given, they should cover Staphylococcus aureus.2,5,8 Treatment can be assessed by following clinical signs and the erythrocyte sedimentation rate.8 Long-term follow-up studies show that after healing, the vertebrae surrounding the affected disc commonly fuse and form a block vertebra.8
Vertebral Osteomyelitis. Vertebral osteomyelitis is less common than discitis and is usually less indolent.34 Although uncommon today, tuberculosis of the spine, or Pott’s disease, must not be forgotten because of the recent rise in the incidence of tuberculosis.2,5,8,34,35 Vertebral osteomyelitis typically presents with severe back pain and muscle spasm with a marked systemic reaction, and may mimic discitis.2,5 The vertebral body is the usual location of infection; however, the spinous process can be the primary location, typically with a more subtle presentation.36
Vertebral osteomyelitis typically originates from hematogenous seeding of the highly vascular metaphyseal region of the vertebral body or secondary ossification center in the spinous process.36 Unlike discitis, spinal osteomyelitis more frequently has abnormal laboratory findings such as increased white blood cell count, elevated ESR and positive blood cultures.5 The most commonly isolated organism is Staphylococcus aureus.2,5,34 Aspiration or biopsy of the suspicious vertebra may be required for a bacteriologic diagnosis.2,36
Radiographic changes of vertebral osteomyelitis occur late in the course of disease.2 The earliest change is focal bone loss in the superior or inferior region of the involved vertebrae adjacent to the cartilage end plate.34 Patchy osteoporosis of the affected vertebra, disc space narrowing, frank destruction of the end plates, and extension of the lytic lesion into the vertebral body or vertebral collapse are noted after a few weeks.5,34 A bone scan may become positive weeks before any radiographic changes are seen.2,34 Typically, a bone scan will demonstrate increased uptake in the involved vertebra in both blood-pool and delayed images.34 Tagged white blood cell studies have poor sensitivity for vertebral osteomyelitis.34 CT may also reveal osteolytic changes of the involved vertebra before they become apparent on plain radiographs.34 CT can also show other intraspinal or extraspinal involvement, such as a paravertebral mass, epidural collection of pus, or psoas abscess.34 MRI is both sensitive and specific.34 It can demonstrate paravertebral involvement not identified on plain radiographs or CT.34
Treatment includes rest, antibiotics and occasionally surgery.2,5 Delaying antibiotics in the emergency department for needle biopsy of the affected vertebra or adjacent paraspinous abscess is not unreasonable.5 This procedure provides an opportunity to culture the offending organism and conduct susceptibility tests.5 Patients should be hospitalized for initial intravenous antibiotics.5 If the infecting organism and its susceptibility are known, the patient may be able to complete the 6- to 8-week course of antibiotics with home IV therapy.5
Spinal tuberculosis occurs in fewer than 1% of patients with tuberculosis, but is the site of 60% of all tuberculosis bone and joint infections.35 It has an insidious course with a gradual, variable presentation and usually involves several adjacent vertebrae.8,35 Children as young as 2 months of age have been reported with Pott’s disease.35 Patients may present with back pain, paraparesis, kyphosis, fever, sensory disturbance and bowel and bladder dysfunction.8,35 Frequently, concurrent pulmonary disease is not present.35 A history of tuberculosis or positive skin test is helpful, but not always found.35 The eryhrocyte sedimentation rate (ESR) is not uniformly elevated as well.35 Because mycobacteria are fastidious organisms, culturing this organism is difficult; however, DNA amplification may aid in faster identification of tuberculosis.35 Radiographic changes may not be visible for up to eight weeks and include rarefaction of vertebral end-plates, narrowing of disc spaces, anterior wedging, and bone destruction.35 CT or MRI with myelogram may be useful to show the extent of bone involvement, any intramedullary or extramedullary involvement and any soft tissue infection.35 Patients should be treated with at least two antituberculous drugs for at least 12 months.35 A third antituberculous drug in the initial 2-6 months of therapy is also advised.35 Surgical intervention may be needed to drain paraspinal abscesses, decompress neural elements, graft bone, correct spinal deformity, and/or stabilize the spine.8,35
Epidural Abscess. Although uncommon, epidural abscess should be considered, because, if not treated, it could result in permanent neurologic sequelae or death.2,5,37 The thoracic vertebrae is most often affected, but the lumbar region is also commonly involved.5,37 The abscess usually forms in the spine, extradural fat, or connective tissue and originates from the adjacent vertebral body or through hematogenous spread.37 The most common presenting complaint is severe back pain, exacerbated by movement.5,37 Muscle spasm and tenderness at the level of the abscess, signs of systemic toxicity, and fever are also seen with epidural abscess. Many patients already have signs of neurologic compromise, such as lower extremity motor and/or sensory deficits and urinary retention, at presentation.2,5,37 Clinically, the presentation of an epidural abscess can be quite similar to that of discitis.5
Laboratory and radiographic examinations can help in differentiating this disorder from discitis. Laboratory tests usually reveal a normal white blood cell (WBC) count and elevated ESR.5,37 Plain radiographs show soft tissue swelling and sometimes vertebral body collapse.37 Myelography can show complete or partial obstruction at the level of the pain.37 An emergent MRI may be used to define the abscess.5,37 The most commonly isolated organism is Staphylococcus aureus.2,5,37 Other Staphylococcal and Streptococcal species and Escherichia coli have been found.37
Treatment with surgical drainage and parenteral anti-staphylococcal antibiotic therapy is indicated.2,5 Patients can make a full recovery, particularly if the abscess is in the lumbar region.37 However, death, paraplegia, or incontinence results in approximately two-thirds of patients.37 Recurrence of the abscess has also been reported.37
Rheumatologic Disorders
In general, rheumatologic causes of back pain in children are uncommon. The most common rheumatologic causes of back pain are ankylosing spondylitis, juvenile rheumatoid arthritis, dermatomyositis, and rheumatic fever.5 Scleroderma, systemic lupus erythematosus, Henoch-Schönlein purpura and Lyme disease sometimes cause back pain.5,39
Ankylosing Spondylitis. Ankylosing spondylitis is a disease usually affecting adult males, but can be seen in children as young as 6 years of age.5 However, children with ankylosing spondylitis rarely complain of back pain.2 Historical clues to diagnosis include a family history of spondyloarthropathy, personal or family history of psoriasis, inflammatory bowel disease, or acute anterior uveitis.2 The pain usually disturbs sleep, is worse in the morning, and is associated with stiffness which improves with movement.2 Typically, the pain and stiffness begin in the sacroiliac joints and gradually ascend the spinal column.5 In addition to back pain, patients often complain of peripheral arthritis, fever, anorexia, anemia, and growth retardation.2,5 On exam, decreased chest expansion, diffuse tenderness in the affected area and symmetrical restriction of lumbar spinal movements are found.2,5 Frequently, the HLA-B27 tissue marker is positive, especially in Caucasian patients.2,4 Other laboratory tests, such as ESR, C-reactive protein, immunoglobulin G and A, have poor specificity.5 Radiographs may show early sclerosis of the sacroiliac joints, but may be difficult prior to fusion of the epiphyses.2,4 Treatment consists of rest, gentle mobility, and anti-inflammatory medication.4 As this is a chronic condition, referral for long-term rheumatologic care is appropriate.4
Juvenile Rheumatoid Arthritis. Juvenile rheumatoid arthritis (JRA) can affect the cervical or lumbar regions, but most commonly the former.4,5 Up to one-half of patients with polyarticular JRA will complain of neck pain and stiffness.5 Systemic signs such as fever, growth retardation, weight loss, rashes and arthritis of one or more larger peripheral joints are also found.5 Frequently on examination, patients will have atrophy of the paraspinous muscles and significantly limited range of motion.5 Laboratory tests are not always helpful, because the rheumatoid factor is frequently negative and antinuclear antibodies are present only 50% of the time.4,5 Mild to moderate anemia and leukocytosis may also be present, but these findings are nonspecific.5 Radiographs are negative early in the course of disease, but with time can show some diffuse osteoporosis.4 Later, decreased disc space width and loss of cervical lordosis may be revealed.5 Atlanto-axial instability on flexion-extension radiographs or cervical apophyseal fusion are late findings.4 As with ankylosing spondylitis, treatment is with rest, gentle mobility, anti-inflammatory agents, and referral for rheumatologic care.4
Neoplastic Disease. Neoplasia is a rare but important part of the differential diagnosis of back pain.2,3,5,8 Tumors causing back pain can be malignant or benign, and arise primarily from the bony or neural components of the spine.2,3,5,8 Benign tumors of bony origin, usually the vertebral bodies, are the most common.2
Benign Vertebral Tumors. The most common benign bony tumors are osteoid osteoma and osteoblastoma.3,5 These are thought to be part of the same disease continuum.2,8 Males are affected twice as often as females.43 Characteristically, these tumors involve the posterior and lateral elements of the vertebral column, namely the transverse and spinous processes, pedicles and laminae; however, they can also involve the whole vertebral body.2,5,41,43 An osteoid osteoma is usually less than 1 cm in diameter, has a radiolucent center (the nidus) with surrounding reactive bone sclerosis.2,41,43 Osteoblastoma is a larger version of the same.2,41,43 Osteoid osteomas comprise 11% of all benign bony tumors and the spine is involved in 10% of cases.43
Patients typically present with initial spinal pain, followed by point tenderness, neck tilt, or scoliosis.41,43 Some will experience radiation of pain to a limb or the trunk, shoulder pain, stiffness, or paraparesis.2,3,5,41,43 The pain is often worse at night and can be severe enough to awaken the child from sleep.2,3,8,43 Signs of cord compression can be seen with cervical and thoracic lesions.2,41 The pain may precede radiographic changes; thus, plain radiographs have poor sensitivity, but will eventually show sclerosis of the posterior elements.2,5,42,43 The bone scan will identify lesions not seen on plain radiographs, but cannot differentiate between these lesions and other lesions such as osteogenic sarcoma, aneurysmal bone cyst, and osteomyelitis.2,5,41,42,43 A positive bone scan with a negative gallium scan differentiates osteoid osteoma/osteoblastoma from osteomyelitis.42 CT best identifies the extent of the lesion and can identify the location of the nidus.5,42 Treatment with NSAIDs usually controls the pain.3,41 These lesions sometimes resolve spontaneously over several years, but can recur.2,5,8,41 However, complete excision of the lesion is the most consistently effective treatment.41
Another benign vertebral tumor is an aneurysmal bone cyst. Although rare, one-fifth of these lesions involve the spine.2 The posterior elements are the most common sites involved, but can also affect the ribs and adjoining vertebrae.2,3,43 Patients typically affected are adolescents, and may present with pain, but sometimes complain of a painless scoliosis or restriction of movement.2 In early stages, pain is not a common finding in aneurysmal bone cysts.42 These tumors may be present for long periods of time before the onset of symptoms, triggered by a fracture, vertebral collapse, or hemorrhage.3 If the lesion expands to involve several adjacent vertebrae, increased extradural pressure and neurological deficit may result.2 On exam, swelling may be palpable and a neurological deficit may be present.2 Aneurysmal bone cysts may be mistaken for osteoblastomas.42 In radiographs, aneurysmal bone cysts are larger, and are more osteolytic and expansile than osteoblastoma.42 A bone scan will show an area of increased uptake at the level of the lesion.2 MRI can show the degree of soft tissue spread and neural compression.2 Angiography can identify any arteriovenous shunting that may be present.2 Treatment includes excision of the lesion.2,3
Eosinophilic granuloma is another benign bone tumor that may affect the spine. It is a localized version of Histiocytosis X, but if several adjacent vertebrae are involved, systemic Histiocytosis X should be suspected.2 Patients typically present in adolescence with back pain, usually thoracic in origin, of a few weeks duration.2 Neurologic deficits are rare.2,8 Plain radiographs demonstrate a well-circumscribed area of osteolysis, frequently with collapse of the vertebra plana or flattening of the vertebra.2,8 Vertebral regrowth may occur in some young children with isolated lesions, even without treatment.2,8 Soft tissue involvement requires radiotherapy and surgery for bony impingement.2 Systemic Histiocytosis X requires chemotherapy. 2
Malignant Vertebral Tumors. Ewing’s sarcoma is the most common malignant tumor of the vertebrae.2 It is a malignant and extremely destructive tumor.5,42 The vertebral body is most commonly affected, but the posterior elements can also be involved.5,42 Patients may present with pain, fever, leukocytosis, and elevated ESR, which can be mistaken for osteomyelitis.2,5 In addition, radiographs may show the moth-eaten bony changes typical of bone infection.2
Osteogenic sarcoma is an extremely rare malignant lesion of the spine.5 Unfortunately, it cannot easily be distinguished from the benign osteoblastoma clinically or radiographically. 5,42 Vertebral osteogenic sarcoma is secondary to irradiation in almost all cases.42
Acute lymphocytic leukemia is the most common malignancy of childhood. One-half to two-thirds have bony lesions at diagnosis.45 Leukemic involvement of the spine is much less commonly found than that of long bones.45 Severe back pain and vertebral collapse can be seen with leukemic involvement of the spine.45 Most patients will have abnormal peripheral blood smears, but occasionally, a normal peripheral count is seen.45 Radiographs may show diffuse osteopenia, generalized osteoporosis, or vertebral collapse.45
Non-Hodgkin’s and Hodgkin’s lymphoma can arise in the spine or metastasize to the spine.2 Patients may present with progressive, persistent back pain and tenderness, with or without swelling or palpable mass, pain at night, fever, sweats, and weight loss.46 Radiographs demonstrate two types of lesions, osteolytic or osteoblastic, which may occur alone or more commonly as multiple lesions.46 Some lesions appear mixed and some have an associated paravertebral swelling.46 Vertebral collapse with neurological impairment is uncommon.46
Metastases to the spine from a variety of malignancies can cause back pain. Neuroblastoma, Wilm’s tumor, lymphoma, leukemia, and testicular cancer have been described to metastasize to the spine.5,47 Patients will typically also have systemic complaints characteristic of the primary malignancy.5
Intraspinal Tumors. Most intraspinal tumors are benign and slow growing.2,5,48 These tumors can be extradural, intradural but extramedullary, or intramedullary.48 Almost one-half are extradural tumors, such as neuroblastoma and sarcoma, which spread from nearby bone or through the intervertebral foramina.2,48 Almost one-quarter are intradural but extramedullary tumors, such as neurofibromas, dermoids, and lipomas.2,48 The remaining quarter are intramedullary tumors, mostly slow growing astrocytomas.2,48 At least 40% of patients will present with back pain which can radiate to the adjacent dermatome.2,48 Other presenting complaints include motor weakness, limp, gait disturbance, night pain, head tilt, torticollis, kyphosis, scoliosis, and bowel or bladder dysfunction.2,48 Plain radiographs often show bony abnormalities, but CT and MRI are better for defining the tumor.5,48
Another benign intraspinal tumor to consider is the exceedingly rare epidermoid inclusion cyst. These may develop after lumbar puncture, but can be congenital in origin.44 Skin abnormalities, such as a sinus tract, are present in 30% of congenital dermoids.44 ESR, plain radiographs, and bone scans will be normal.44 MRI can demonstrate a well-circumscribed mass in the subarachnoid space, which may compress some neural elements.44 Treatment is surgical excision.44
Tumors of the cauda equina account for 1% of central nervous system tumors and can lead to severe disability.49 Most tumors of the cauda equina are schwannomas or ependymomas.49 Patients commonly complain of low back pain with or without sciatica, nocturnal pain, sensory dysfunction, loss of autonomic supply leading to edema, coldness or ulcers, and sphincter dysfunction.49 Plain radiographs characteristically show changes in the bony spinal canal, such as erosion, scalloping and widening of the canal.49 CT and MRI can better define the tumor mass.5,49 Treatment is excision of the tumor and radiation if not completely excised.49
Other Disorders
Back pain may be a manifestation of a disease process in nearby organs or of systemic processes. Inflammation of the retroperitoneal or posterior peritoneal organs is the most common source of referred pain.5 Pancreatic, duodenal, hepatic, splenic, renal, ovarian, or uterine diseases can present with pain referred to the lower back. Tenderness of the costovertebral angle may be due inflammation of the kidneys from pyelonephritis or nephrolithiasis. Hematocolpos due to an imperforate hymen has been reported as a cause of back pain.8 Pneumonia, pneumothorax, rib fracture, and other diseases of the thorax can refer pain to the upper back. A dissecting aortic aneurysm may present with thoracic or lumbar back pain.50 A vaso-occlusive crisis of sickle cell disease may present as back pain due to ischemia or infarction of the vertebral column or adjacent organs in the thorax or abdomen. Back pain is a common complaint of pregnancy, both ectopic and intrauterine. Back pain is experienced in one-third of women during labor.
Oseoporosis or osteomalacia are disorders which may predispose the vertebrae to trauma. Stress fractures may be seen in children with osteoporosis due to diseases such as malnutrition, disuse, or anorexia nervosa.5 Patients with anorexia nervosa may develop osteoporosis which cannot be predicted by laboratory values.51 Osteomalacia may result from diseases such as vitamin-D deficiency, renal disease, and hyperparathyroidism.5 Irradiation of the back can result in abnormal bone growth resulting in an asymmetrical spine and back pain.5 Diseases with progressive muscular weakness, such as muscular dystrophy and spinal muscular atrophy, can result in mechanical back pain due to a lack of physical support of the spinal column.5
Nonorganic or psychogenic origins of back pain are seen frequently in adults, but less commonly in children.5 Conversion disorder is most commonly seen in pubescent girls.2 Bizarre or grossly exaggerated signs and symptoms should arouse the suspicion of a psychogenic component of back pain.2 Major depression and psychosis is rarely the sole cause of back pain.2 Conversion hysteria may be seen concurrently with an organic disease causing back pain.2 These patients should be managed carefully, avoiding overinvestigation while not dismissing the complaints as purely psychosomatic.2 Treatment should include psychological support, avoidance of rest, and graded physical activity.2
Summary
All children who present with a complaint of back pain should receive an evaluation for significant pathology. The evaluation of the child who gives a history of acute trauma should include plain radiographs. Likewise, the child who participates in activities which may cause repetitive stress to the spine may also benefit from a radiographic evaluation with plain radiographs. Fever should raise the suspicion for infectious, rheumatologic, and neoplastic disorders. A bone scan or SPECT scan may be helpful in the diagnosis of these disorders, especially early in the course of disease, as they will demonstrate areas of inflammation before radiographic changes are evident. In addition to radiologic studies, children with fever also require laboratory screening including a CBC and ESR, blood cultures, and rheumatologic studies (e.g. ANA, HLA-B27, etc.). The presence of tenderness of the costovertebral angles is suspicious for pyelonephritis or nephrolithiasis and a urinalysis should be obtained. Concurrent abdominal pain suggests possible inflammatory disorders of the pancreas, liver, spleen, duodenum, ovaries, or uterus. Thoracic back pain associated with respiratory complaints may signal the presence of pneumonia, pneumothorax, or rib fracture. Any evidence of neurologic deficit warrants a CT or MRI and neurosurgical consultation. Finally, in the absence of an organic cause, a psychosocial evaluation can reveal a conversion disorder, anorexia, or psychosomatic origin of back pain. (See Figure 4.)
References
1. Leboeuf-Yde C, Kyvik KO. At what age does low back pain become a common problem: A study of 29,424 individuals aged 12-41 years. Spine 1998;23:228-234.
2. Hollingsworth P. Back pain in children. Brit J Rheumatol 1996;35:1022-1028.
3. Payne WK, Ogilvie JW. Back pian in children and adolescents. Pediatr Clin North Am 1996;43:899-917.
4. Gerbino PG, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 1995;14:571-590.
5. Krug SE. Back Pain. Reisdorff EJ, Roberts MR, Wiegenstein JG, eds. In: Pediatric Emergency Medicine. Philadelphia: WB Suanders; 1993.
6. Micheli LJ, Wood R. Back pain in young athletes. Arch Pediatr Adolesc Med 1995;149:15-18.
7. Turner PG, Green JH, Galasko CSB. Back pain in childhood. Spine 1988;13:812-813.
8. Sponseller PD. Evaluating the child with back pain. Am Fam Physician 1996;54:1933-1941.
9. Ogilvie JW. Diagnosis and treatment of spinal deformities: What to do for the patient with scoliosis. Postgrad Med 1988;84:147-153.
10. Dahl MT. Limb length discrepancy. Pediatr Clin North Am 1996;43:849-865.
11. Corneli HM. Pain-Back. Fleisher GR, Ludwig S, eds. In: Textbook of Pediatric Emergency Medicine. Baltimore: Williams and Wilkins; 1993.
12. Mandell GA. Imaging in the diagnosis of musculoskeletal infections in children. Curr Probl Pediatr 1996;26:218-237.
13. Johnson DL, Falci S. The diagnosis and treatment of pediatric lumbar spine injuries caused by rear seat lap belts. Neurosurg 1990;26:434-441.
14. Alexander RH, Proctor HJ. Advanced Trauma Life Support Course for Physicians, 5th ed. Chicago: American College of Surgeons; 1993.
15. Sward L, Hellstrom M, Jacobsson B, et al. Acute injury of the vertebral ring apophysis and intervertebral disc in adolescent gymnasts. Spine 1990;15:144-148.
16. McCormack RG, Athwal G. Isolated fracture of the vertebral articular facet in a gymnast. Am J Sports Med 1999;27:104-106.
17. Fisk JW, Baigent ML, Hill PD. Scheuermann’s disease: Clinical and radiological survey of 17 and 18 year olds. Am J Physical Med 1984;63:18-30.
18. Papaniicolaou N, Wilkinson RH, Emans JB, et al. Bone scintigraphy in young athletes with low back pain. Am J Radiol 1985;145:1039-1044.
19. Friberg O. Functional radiography of the lumbar spine. Ann Med 1989;21:341-346.
20. Reuler JB. Low back pain. Western J Med 1985;143:259-265.
21. Combs JA, Caskey PM. Back pain in children and adolescents: A retrospective review of 648 patients. Southern Med J 1997;90:789-792.
22. Mierau D, Cassidy JD, Yong-Hing K. Low-back pain and straight leg raising in children and adolescents. Spine 1989;14:526-528.
23. Fairbank JCT, Pynsent PB, van Poortvliet JA, et al. Influence of anthropometric factors and joint laxity in the incidence of adolescent back pain. Spine 1984;9:461-464.
24. Morita T, Ikata T, Katoh S, et al. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg 1995;77B:620-625.
25. Wilcox PG, Spencer CW. Dorsolumbar kyphosis or Scheuermann’s disease. Clin Sports Med 1986;5:343-352.
26. Stoshak ML, Mortimer EA. Jean Seam Coccygodynia. Pediatr 1985;76:138.
27. Karageanes SJ, Jacobs AW. Anomalous first rib in a high school wrestler. Clin J Sports Med 1998;8:240-242.
28. Jonsson B, Stromqvist B, Egund N. Anomalous lumbosacral articulations and low-back pain: Evaluation and treatment. Spine 1989;14:831-834.
29. Mizutani M, Yamamuro T, Shikata J. Congenital absence of a lumbar pedicle. Spine 1989;14:890-891.
30. Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg 1997;79A:364-368.
31. Dieck GS, Kelsey JL, Goel VK, et al. An epidemiologic study of the relationship between postural asymmetry in the teen years and subsequent back and neck pain. Spine 1985;10:872-877.
32. Ambrozic A, Praprotnik S, Rozman B. Unusual occurrence of acute low back pain in a patient with ruptured urachal cyst. Brit J Rheumatol 1998;37:1354-1355.
33. Light HG. Hernia of the inferior lumbar space: A cause of back pain. Arch Surg 1983;118:1077-1080.
34. Mandell GA. Imaging in the diagnosis of musculoskeletal infections in children. Curr Probl Pediatr 1996;26:218-237.
35. Nussbaum ES, Rockswold GL, Bergman TA, et al. Spinal tuberculosis: A diagnostic and management challenge. J Neurosurg 1995;83:243-247.
36. Buoncristiani AM, McCullen G, Shin AY, et al. An unusual cause of low back pain: Osteomyelitis of the spinous process. Spine 1998;23:839-841.
37. Statham P, Gentleman D. Importance of early diagnosis of acute spinal extradural abscess. J Royal Society Med 1989;82:584-587.
38. Wolfe MW, Bennett JT. Pyomyositis with toxic shock syndrome presenting as back pain and fever: A case report and literature review. Am J Orthopedics 1997;26:135-137.
39. Demaerel P, Crevits I, Casteels-Van Daele M, et al. Meningoradiculitis due to borreliosis presenting as low back pain only. Neuroradiol 1998;40:126-127.
40. Marzullo MJ, Shetty AK. A 14-year old boy with back pain. Clin Pediatr 1998;37:437-440.
41. Amacher AL, Eltomey A. Spinal osteoblastoma in children and adolescents. Child’s Nerv Syst 1985;1:29-32.
42. Azouz EM, Kozlowski K, Marton D, et al. Osteoid osteoma and osteoblastoma of the spine in children. Pediatr Radiology 1986;16:25-31.
43. Horsfield D, MacVicar D. A painful adolescent back. Radiography 1987;53:249-252.
44. Luerssen TG, Azzarelli B, Edwards-Brown M, et al. Back pain in an 8-year old boy. Pediatr Neurosurg 1998;28:207-211.
45. Meehan PL, Viroslav S, Schmitt EW, Jr. Vertebral collapse in childhood leukemia. J Pediatr Orthop 1995;15:592-595.
46. Clark A, Stanish WD. An unusual cause of back pain in a young athlete: A case report. Am J Sports Med 1985;13:51-54.
47. Cole RP. Low back pain and testicular cancer. BMJ 1987;295:840-841.
48. Cole G. Intraspinal tumours. Arch Dis Child 1988;63:1007-1008.
49. HogenEsch RI, Staal MJ. Tumors of the cauda equina: The importance of an early diagnosis. Clin Neurol Neurosurg 1988;90:343-348.
50. York MJ, Dimon JH. Idiopathic dissecting aortic aneurysm associated with pain in the back in an adolescent. J Bone Joint Surg 1988;70A:1418-1421.
51. Brotman AW, Stern TA. Osteoporosis and pathologic fracture in anorexia nervosa. Am J Psychiatry 1985;142:495-496.
Physician CME Questions
30. The most common location of spondylolisthesis is:
a. between T12 and L1.
b. between L1 and L2.
c. between L3 and L4.
d. between L4 and L5.
e. between L5 and S1.
31. The most common pathologic cause of upper back pain is:
a. spondylolysis.
b. ankylosing spondylitis.
c. Scheuermann’s kyphosis.
d. Ewing’s sarcoma.
e. intervertebral disc herniation.
32. The most commonly isolated microorganism isolated in discitis is:
a. Streptococcus pyogenes.
b. Staphylococcus aureus.
c. Candida albicans.
d. Mycobacterium tuberculosis.
e. Escherichia coli.
33. Which test would likely be negative early in the course of discitis?
a. Plain radiographs
b CT
c. MRI
d. SPECT
e. Bone scan
34. A plain radiograph reveals a 75 mm area of bony sclerosis with a radiolucent center. This is characteristic of which disease?
a. Scheuermann’s kyphosis
b. Spondylolysis
c. Vertebral osteomyelitis
d. Osteoid osteoma
35. Spondylolisthesis is accentuated in which view on plain radiograph?
a. AP
b. Lateral
c. Oblique
d. Standing
36. Where is the weakest part of the vertebra?
a. Pars interarticularis
b. Spinous process
c. Vertebral body
d. Transverse process
37. Which diagnosis is not a cause of back pain?
a. Pyelonephritis
b. Spondylolysis
c. Idiopathic scoliosis
d. Leg length discrepancy
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