Transcript Back Pain in Children” - Orthopaedic, Pediatric & Spine
“Back Pain in Children” Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana
“Back Pain in Children”
The problem with back pain in children is that little has been written Very little has been published concerning the incidence or causes of back pain in children Recently, we have now realized that children do have back pain
“Back Pain in Children”
Experience indicates that the complaint of back pain in children warrants careful evaluation This evaluation will lead one to an diagnosis of organic pathology Most importantly, a carefully planned strategy of evaluation so no significant problems are missed must be formulated
“Back Pain in Children”
It is ill-advised to make the diagnosis of stress or psychological problems until all possible organic causes have been excluded Likewise, the diagnosis of “growing pains” of the spine should not be rendered until a detailed workup is completed and no other causes noted
“Back Pain in Children”
“Medical History” Detailed history should be obtained with both the child and parent present Look at onset of symptoms, location, frequency, duration, and intensity Identify traumatic from those with a slow insidious onset
“Back Pain in Children”
Inquire about sports and other specific activities ‘Spondylolysis’ is frequently seen in those patients engaged in football, dance, or gymnastics This may also help one identify “overuse” syndromes
“Back Pain in Children”
Children who participate at a very high level and practice for many hours, support the diagnosis of stress fracture or overuse Symptoms that are interfering with normal activity or limits the child’s participation in sports or voluntarily gives up an activity is worrisome
“Back Pain in Children”
Night pain is important Can be associated with tumors, infection, and inflammatory conditions This mandates a complete and meticulous workup Symptoms that improve with bed rest leads one to the diagnosis of spondylolysis, spondylolisthesis, Scheuermann’s, and overuse
“Back Pain in Children”
Nature of the pain is important suchn as localized, diffuse, or radiating Localized seen with spondylolysis and tumors Diffuse seen with overuse problems, Scheuermann’s, or inflammatory Radicular suggests neurocompression
“Back Pain in Children”
Question family and child about changes in neurologic function Changes in balance and coordination must be evaluated Falls or recent stumbling are important to the diagnosis
“Back Pain in Children”
Question the child and family about weight loss, fever, lethargy, skin rashes, joint pains, and swelling Lymphomas, Leukemia, infections and rheumatologic conditions can present with a primary complaint of back pain
“Back Pain in Children”
“Physical Examination” General screening examination Spinal exam looks at posture, alignment, and skin patterns Midline skin defects, café-au-lait spots and cysts should be noted and can indicate underlying problems These can communicate with underlying neural structures
“Back Pain in Children”
Forward bending test is a critical part of the examination Look for thoracic or lumbar asymmetry, limited or asymmetric movement of the spine Listing or dysrhythmia or a rigid lumbar lordosis on forward bending will lead one to the cause for the back pain
“Back Pain in Children”
Detailed neurologic examination should be performed: motor, sensory and reflex’s Look for clonus or a Babinski sign Abnormal abdominal reflex is a subtle sign of spinal cord pathology Asymmetry or absence of the reflex has been associated with syringomyelia or spinal cord tumors
“Back Pain in Children”
“Radiographic Evaluation” AP and lateral radiograph’s Oblique radiographs are not necessary initially unless a suspicion exits Bone scan, CT scan and MRI are utilized as the specific differential is worked through
“Back Pain in Children”
“Bone Scan” Useful in finding tumors, discitis, and stress fractures Pinhole images are useful for tumor nidus such as osteoid osteoma or for a pars stress fracture Three-phase is used if vascularity is of a concern
“Back Pain in Children”
SPECT scan is utilized and is better for stress fractures of the spine and are more precise Help locate stress fractures if a plain bone scan is negative and there is a high suspicion on plain radiographs as well as differentiate unilateral from bilateral pars defects
“Back Pain in Children”
“CT Scan” Used as an adjunct to evaluate lesions seen on plain radiograph or bone scan Not a screening study Used for evaluating tumors, fractures, disc herniations, and spondylolytic lesions for healing or age for bracing decision making
“Back Pain in Children”
“MRI” Useful for evaluating the spinal cord, neural elements, tumors, and syringomyelia Not though a shot gun screening examination to replace all others Used best when the clinical signs and symptoms deem it appropriate
“Back Pain in Children”
Best for the evaluation of spinal cord tumors, syringomyelia, bone tumors, discitis, and disc herniations Not helpful in the evaluation of stress fractures though recent studies point to an increase sensitivity
“Back Pain in Children”
“Laboratory Evaluation” Used if suspicion exists for infection, rhematologic disease, lymphoma, or leukemia Useful tests include CBC, ESR, urinalysis, and lytes HLA B27, RF, RA, ANA if rheumatologic condition is suspected
“Back Pain in Children”
“Differential Diagnosis” Mechanical Developmental Inflammatory Neoplastic
“Back Pain in Children”
“Mechanical Disorders” Postural problems Muscular problems Overuse syndromes Herniated Nucleus Pulposis
“Back Pain in Children”
“Developmental Disorders” Spodylolysis Spondylolisthesis Scheuermann’s Disease
“Back Pain in Children”
“Inflammatory Disorders” Discitis Disc Space Calcification Osteomyelitis Rheumatologic Conditions JRA Ankylosing spondylitis
“Back Pain in Children”
“Neoplastic Disorders” Vertebral column Spinal cord/canal Muscle Metastatic tumors
“Back Pain in Children”
Incidence is variable in the population Fairbanks et al found an incidence of 26% Grantham et al reported an incidence of 11.5% Balague et al a 14% incidence of back pain that required medical attention
“Back Pain in Children”
Spondylolysis and spondylolisthesis are the most common causes of back pain in children 11% of children with back pain had a tumor identified: King et al Age gives a clue to the diagnosis too Under 10: discitis and tumor Over 10: spondylolysis, spondylolisthesis and Scheuermann’s
“Back Pain in Children”
“Spondylolysis/Spondylolisthesis” Nonspecific back pain Aggravated with activity Improved with rest Higher Incidence female and gymnast Ferguson et al: competitive football linemen
“Back Pain in Children”
Teitz et al reported incidence of 15 to 20% in dancers Recent study shows a high hereditary incidence of pars defect Wiltse et al and O’Hata et al Major presenting complaint: hamstring tightness and buttock discomfort with decrease flexibility lumbar spine
“Back Pain in Children”
“Scheuermann’s Disease” Second most common cause Pain that starts later in the day or after strenuous activity Poor posture Symptoms are aggravating but not limiting
“Back Pain in Children”
Obvious kyphosis on forward bend Radiographs show typical findings of wedging of three or more consecutive vertebral bodies and end-plate irregularities If symptoms and history do not match the radiographic findings, consider bone scan
“Back Pain in Children”
“Discitis” Seen patients from one to twelve years of age Long duration of symptoms May or may not be febrile Generally ill appearance Back pain, refusal to walk, abdominal pains can be seen as initial presentation
“Back Pain in Children”
Radiographs can confirm the diagnosis Bone scan helpful early in the course of the disease process ESR and WBC elevated MRI helpful to localize the lesion and the extent bone and soft tissue involvement Treatment variable: brace, antibiotics, rest
“Back Pain in Children”
“Tumors” Occur in the bone, along the spinal cord, and in the soft tissue Present with nonspecific complaints of back pain Night pain or pain unrelated to any activity Changes in coordination and bowel/bladder changes frequently seen
“Back Pain in Children”
Clinically show back listing or atypical scoliosis Left sided scoliosis is common with tumors Clonus, Babinski sign, or asymmetry of abdominal reflex can be seen MRI with and without gadolinium is the best test for the evaluation of the spinal cord and soft tissue
“Back Pain in Children”
Back pain is a fascinating area of pediatric orthopaedics Incidence of back pain in children is fairly high Vast majority never seek medical advice Those who do, the incidence of a definable cause of symptoms is quite high
“Back Pain in Children”
Careful, detailed medical and radiographic evaluation must be performed Imaging studies should be used when indicated But even with all this, after a diligent workup, one can expect to identify the cause in over 50% of the patients only
“Back Pain in Children”