Back Pain in Children and Adolescents

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Back Pain in Children and Adolescents

• Christine Hom, M.D
• Division of Pediatric Rheumatology
• New York Medical College

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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

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Back Pain

• In children with back pain of gt2 months
  duration
• 33 had a post-traumatic etiology occult
  fracture or spondylolysis
• 33 had kyphosis or scoliosis
• 18 had a tumor or infection

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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
• MaleFemale ratio 11
• 50 of tennis and soccer players
• up to 85 of male gymnasts
• Maneuvers requiring posterior extension of the
  leg often provoke lower back pain

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Etiology of back pain

• INFECTION
• INFLAMMATION
• MECHANICAL
• ORTHOPEDIC
• TRAUMA
• MALIGNANCY
• SYSTEMIC DISEASE
• OTHER

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Etiology of back pain

• INFECTION
• Sacroiliac infections
• Vertebral osteomyelitis
• Diskitis
• Pyelonephritis
• Potts disease
• Spinal epidural abscess
• Psoas abscess

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Etiology of back pain

• INFLAMMATION
• Ankylosing spondylitis
• Reiters syndrome
• Inflammatory bowel disease
• Spondyloarthropathy
• SEA syndrome

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Etiology of back pain

• MECHANICAL
• Musculoskeletal (sprain/strain)
• Herniated disc
• ORTHOPEDIC/TRAUMA
• Spondylolisthesis
• Spondylolysis
• Scheuermanns disease
• (Scoliosis)
• Vertebral compression fracture

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Etiology of back pain

• MALIGNANCY
• Spinal cord tumors (lipoma, teratoma)
• Bone tumors
• Osteoid osteoma
• Ewings sarcoma
• Vertebral osteosarcoma
• Neuroblastoma
• Leukemia
• Eosinophilic granuloma
• Aneurysmal bone cyst

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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

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Etiology of back pain

• OTHER
• Fibromyalgia
• Reflex sympathetic dystrophy
• Conversion disorder
• Pain amplification syndrome
• Psychogenic

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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

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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, lt 4 yo

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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)

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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

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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

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Scheuermanns 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

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Scheuermanns disease

• Lateral X-ray reveals Schmorls nodes and
  vertebral wedging with irregular vertebral
  endplates
• The disease is self-limited with a benign course
• Treatment Nonsteroidal analgesics
• severe cases may require bracing with an external
  Milwaukee brace for comfort

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Enthesitis

• Local tenderness to palpation at insertions of
• tendon
• ligament
• capsule
• On physical exam
• Patella at 10 oclock, 2 oclock, 6 oclock
• Tibial tuberosity
• Insertion of the Achilles tendon
• Plantar fascia insertion onto calcaneus
• Metatarsal heads
• Greater trochanter of the femur
• Anterior superior iliac spine

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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

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Juvenile ankylosing spondylitisNew 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)

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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

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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

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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)

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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

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JRA or JAS?
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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. bisphosphonat
es
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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/Sudecks atrophy
• With painful tender points
• Fibromyalgia
• Hypervigilant
• psychogenic/psychosomatic

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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

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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

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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

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