Back Pain in Children and Adolescents
Download
Report
Transcript Back Pain in Children and Adolescents
Back Pain in Children and
Adolescents
Christine Hom, M.D
Division of Pediatric Rheumatology
New York Medical College
Back Pain
Back
pain in children - abnormal until proven otherwise!
75%
of children with back pain have an identifiable
etiology
Adolescents
more likely to have musculoskeletal pain or
lower back pain syndromes
Back Pain
In
children with back pain of >2 months’ duration:
– 33% had a post-traumatic etiology: occult fracture or
spondylolysis
– 33% had kyphosis or scoliosis
– 18% had a tumor or infection
Back pain in adolescents
In
a school based study of 446 adolescents aged 13-17y:
26%
of adolescents report some back pain, especially
related to sports
Male:Female
ratio 1:1
50% of tennis and soccer players
up to 85% of male gymnasts
Maneuvers
requiring posterior extension of the leg often
provoke lower back pain
Etiology of back pain
INFECTION
INFLAMMATION
MECHANICAL
ORTHOPEDIC
TRAUMA
MALIGNANCY
SYSTEMIC
OTHER
DISEASE
Etiology of back pain
INFECTION
– Sacroiliac infections
– Vertebral osteomyelitis
– Diskitis
– Pyelonephritis
– Potts disease
– Spinal epidural abscess
– Psoas abscess
Etiology of back pain
INFLAMMATION
– Ankylosing spondylitis
– Reiter’s syndrome
– Inflammatory bowel disease
– Spondyloarthropathy
– SEA syndrome
Etiology of back pain
MECHANICAL
– Musculoskeletal (sprain/strain)
– Herniated disc
ORTHOPEDIC/TRAUMA
– Spondylolisthesis
– Spondylolysis
– Scheuermann’s disease
– (Scoliosis)
– Vertebral compression fracture
Etiology of back pain
MALIGNANCY
– Spinal cord tumors (lipoma, teratoma)
– Bone tumors
Osteoid
osteoma
Ewing’s sarcoma
Vertebral osteosarcoma
– Neuroblastoma
– Leukemia
– Eosinophilic granuloma
– Aneurysmal bone cyst
Etiology of back pain
SYSTEMIC
DISEASE
– Secondary hyperparathyroidism
(Stones, bones, groans, moans)
– Sickle-cell anemia - back pain is common
– Osteoporosis
– Corticosteroid use
– Aseptic necrosis
– Nephrolithiasis
Etiology of back pain
OTHER
– Fibromyalgia
– Reflex sympathetic dystrophy
– Conversion disorder
– Pain amplification syndrome
– Psychogenic
Evaluation of back pain
HISTORY
and physical
– point tenderness
CBC,
ESR, SMA-20, urinalysis
Lyme titer
HLA-B27
Plain films, including oblique views
Bone scan
CT/MRI
Evaluation of back pain
WARNING
SIGNS
– Increasing pain
– Pain wakes child from sleep
– Function: usual activities impaired
– Weight loss
– Fever
– Bowel or bladder dysfunction
– Young age, < 4 yo
Diskitis
Typical
patient is 3-5 years old
Systemic findings: fever, irritability, abdominal
pain, anorexia
Rigid posture; refuses to flex lumbar spine
Elevated ESR
Plain films reveal irregular vertebral endplates
CT/MRI reveal decreased signal in disk and
increased in adjacent vertebrae
Usually hematogenous bacterial infection with
S. aureus (88% no organism on aspirate)
Vertebral Osteomyelitis
Older
children
Only accounts for 2-4% of osteomyelitis
Children appear more toxic: fever, irritability,
refusal to walk
Elevated ESR, sedimentation rate
Radiographs show destruction of vertebral
body
Organism usually recovered (S. aureus) on
aspirate
Spondylolysis/spondylolisthesis
Defect
of the pars interarticularis
Usually at L5
Scottie-dog appearance on plain film
– obtain oblique and lateral films
Complaints
of low back pain, worse with
palpation
Slippage of L5 on S1 is spondylolisthesis
in athletes with hyperextension of spine
Scheuermann’s disease
Juvenile
kyphosis
Painful
in 50% of cases
Usually
affects boys 13-17 years of age
75%
of cases affect the thoracic spine
Fixed
dorsal kyphosis
Compensatory
lumbar lordosis
Scheuermann’s disease
X-ray reveals Schmorl’s nodes and
vertebral wedging with irregular vertebral
endplates
Lateral
The
disease is self-limited with a benign
course
Treatment:
Nonsteroidal analgesics
– severe cases may require bracing with an external
Milwaukee brace for comfort
Enthesitis
Local
tenderness to palpation at insertions of
– tendon
– ligament
– capsule
On
–
–
–
–
–
–
–
physical exam:
Patella at 10 o’clock, 2 o’clock, 6 o’clock
Tibial tuberosity
Insertion of the Achilles tendon
Plantar fascia insertion onto calcaneus
Metatarsal heads
Greater trochanter of the femur
Anterior superior iliac spine
Juvenile ankylosing spondylitis
Chronic
arthritis of peripheral and axial skeleton
Enthesitis
Seronegative
(rheumatoid factor negative)
Extraarticular
manifestations: acute iritis, rarely low
grade fever, urethritis or diarrhea
ALL
have sacroiliac arthritis
Genetic
basis: 2-10% of HLA-B27 positive patients will
develop JAS
Juvenile ankylosing spondylitis:
New York AS criteria
expansion of lumbar spine
Pain at lumbar spine
Chest expansion 2.5 cm or less
AND
– radiographic demonstration of sacroiliac
arthritis (may be unilateral)
Juvenile ankylosing spondylitis
Iritis
– Acute
– Painful
– Photophobia
– Red eye
– Anterior nongranulomatous uveitis
– Few sequelae, but synechiae may develop
– Episodic course most commonly seen in
HLA-B27+ patients. If ANA positive, may
develop chronic uveitis similar to JRA
Juvenile ankylosing spondylitis
HLA-B27
– Class I major histocompatibility antigen
– varied presence in ethnic populations:
50%
of Canadian Haida Indians are HLA-B27+
only 2% of Japanese general population
– Incidence of JAS varies with HLA-B27
presence in a given population
– 10% risk of AS in children of HLA-B27+
patient with AS
– 20% risk of AS if they are also HLA-B27+
and male
Treatment of Juvenile AS
NSAIDs
– tolmetin sodium (Tolectin)
– indomethacin
Sulfasalazine
Intraarticular
steroid injections
Local steroid injections at entheses
Physical therapy
New
treatments include infliximab
(monoclonal anti-TNF) and etanercept
(sTNFR)
Juvenile ankylosing spondylitis
Children
often develop peripheral
arthritis years before axial involvement
Look for SEA syndrome: seronegative
enthesitis and arthropathy
Complaints of pain in buttocks, groin,
thighs, heels often predate frank
sacroiliac disease
JRA or JAS?
Male:Female
Age of onset
Back pain
Enthesitis
HLA-B27 +
ANA
RF
Iritis
JRA
JAS
1:4
5 yo
2%
Rare
15%
30-50%
15%
Chronic
7:1
>10 yo
100%
Common
90%
<5%
<5%
Acute
DEXA Scan of Lumbar spine
Look at Z-scores
Percentage of bone mass
relative to age matched controls
Does not tell risk of fracture
Risk of vertebral collapse more
likely in pediatric population,
rather than hip fracture
Treatment:
weight bearing exercise
calcium, Vitamin D suppl.
bisphosphonates
Pain amplification syndromes
Pain
out of proportion to clinical findings
Pain does not follow anatomical boundaries
With
autonomic findings
– Chronic regional pain syndrome
– Reflex sympathetic dystrophy
– Causalgia/Sudeck’s atrophy
With
painful tender points
– Fibromyalgia
Hypervigilant
– psychogenic/psychosomatic
Pain amplification syndromes
80%
are female
Median age 12 years
Mean duration of pain 1.6 years
Constant pain
Multiple locations
Lower extremity more often than upper
Role model for chronic pain
Personality: mature, excellent student, eager
to please, many extracurricular activities
Pain amplification syndromes
Mother
is the spokesperson and gives the
history including subjective complaints
Incongruent affect: la belle indifference
Marked disability despite a paucity of physical
findings
Other findings of headache, abdominal pain,
sleep disturbance and fatigue
Allodynia - pain disproportionate to stimulus
Pain amplification syndromes
Treatment
Physical therapy:
– Aerobic exercise daily
– Desensitization with toweling
– Range of motion exercises
Cognitive
behavioral therapy
– Progressive muscle relaxation
– Guided imagery
– Self-hypnosis
Pharmacotherapy
– Low dose amitriptyline or SSRI