Backpain in children

Diagnostic and therapeutic approach

Guy Fabry

Department of Orthopaedics, Pellenberg, K.U.Leuven

Backpain in children is not unfrequent. Studies in the eighties showed that only 15% of backpain in children revealed no specific cause. In the nineties however reports show that up to 78% of backpain in children have no specific diagnosis. The pattern of low backpain in children is thus changing, to a more adult pattern of backpain.

In order of frequency the major causes of backpain are: functional or posttraumatic, without objective findings; spondylolysis or spondylolisthesis, Scheuermans’ disease; infection or tumor and disc herniation, finally rheumatoid spondylitis. A careful history and physical examination are the key. Important are also rightly indicated technical exams. Attention should especially be paid to the child’s complaint, with some suspicion to the parents description of the problem.

1. Functional low backpain

One should be alert when complaints and symptoms do not match a classic known pattern. A typical backpain can be caused by functional or psychologic problems. Studies show that this type of backpain is mostly seen in girls older than 12 years of age, with backpain history in the family, and who are doing a lot of sports or no sports at all.

Posttraumatic backpain is also relatively frequent especially when a compensation case is hanging. In these cases it is very often the parents who are telling how much pain the child has.

The clinical examination in functional backpain shows usually no typical symptoms. Complaints are vague and also the localization is not typical. Radiographic and scintigraphic analyses are normal.

Before concluding however that the child presents with functional backpain a thorough anamnesis and exam is necessary.

2. Spondylolysis and spondylolisthesis

Spondylolysis is an interruption in the pars interarticularis. It may be bilateral. An anterior displacement of the vertebra above can lead to spondylolisthesis.

A spondylolysis is very often caused by a stress fracture, following certain sport activities, especially gymnastics. The localization is mostly on the level L5.

The clinical exam shows usually rather localized low backpain and in cases of listhesis a set-off is sometimes felt at the level L4-L5.

Backpain is exaggerated in extension of the vertebral column.

A radiographic analysis is best seen on a _ view. A CT-scan is sometimes necessary to show the defect.

In an acute or posttraumatic fracture a bone scintigraphy sometimes shows a hot spot on the side of the defect. Sometimes the other side is also positive due to an impending stress fracture.

Treatment depends on the duration of symptoms and degree of activity of the child. In an acute stress fracture immobilization during two - three months with a brace might be indicated hoping that the defect will heal. Personally however I have not seen very many defects heal.

Usually they become an asymptomatic pseudarthrosis. When after a period of rest symptoms disappear, the sportactivities can be resumed, according to the remaining pain.

A spondylolisthesis can also be painless. If however the listhesis is progressive and pain remains an arthrodesis is indicated. In less severe cases a posterior fixation is adequate. In sever spondylolisthesis or spondyloptosis an anterior approach is necessary.

3. Scheuermans’ disease

Scheuermans’ disease is an osteochondrosis of mainly the thoracic vertebrae.

Although sometimes the lumbar vertebrae can be affected.

Clinically the disease mainly shows an increasing hyperkyphosis or in cases of lumbar affection a decrease in lumbar lordosis.

Pain is usually not the main symptom. Although in lumbar Scheuermans’ disease, pain is more frequently present.

Treatment depends on the evolution of the deformity and is usually done by a brace. Very seldomly an anterior and posterior arthrodesis is indicated.

If pain is a problem, physical therapy is usually enough to improve the symptoms.

4. Discitis

An infection of the intervertebral disc is not so frequent but poses very often a diagnostic problem. A discitis in a child is usually not immediately appearing. The child may be feverish, restless and refrain from walking.

Very typical is a stiff back: the child can not bend foreward and instead flexes hips and knees to reach the floor.

A laboratory exam shows often an increased sedimentation rate and CRP.

A radiographic analysis usually shows initially no changes. After 2 or 3 weeks however a narrowing of the disk space can be seen. An isotope scan is a better analysis to have an early diagnosis. Treatment consists usually of antibiotics, although not every one agrees about this. We usually give an antibiotic course of 3 to 4 weeks. The child is immobilized in a brace or sometimes in a pantaloon cast if the discitis is in the lumbar area. Immobilization can take up to 6 weeks. Ambulation is allowed according to pain. Very often a synostosis of the adjacent vertebrae occurs in later years, usually without symptoms.

5. Tumors

A primary tumor of the spine is very seldom. Pain is the most prominent symptom and sometimes neurologic abnormalities can be found.

The pain is often more at night and not related to activity. The most frequent tumors are benign: osteoid osteoma, eosinophilic granuloma, benign osteoblastoma and aneurysmal bone cyst. Malign tumors are more frequently metastases and much less frequently a Ewing’s tumor or an osteogenic sarcoma.

Typical is the osteoid osteoma with pain at night improving after taking Aspirine. On clinical examination very often a slight scoliosis is seen.

A painful scoliosis should always direct us to an underlying pathology as an osteoid osteoma.

The osteoid osteoma is not always seen on a regular X-ray. An isotope scan is the best way to visualize it, followed by CT-scan for the perfect localization. Treatment consists usually always in a surgical removal of the nidus.

6. Disc herniation

Disc herniation may be seen in adolescents but is much less frequent than in adults. The levels are usually L4-L5 or L5-S1. Symptoms are comparable with the adult disease with a positive straight leg raising test and antalgic posture of the spine. Sometimes only tight hamstrings are found, without the typical pain.

An MRI is the best method to visualize a possible hernia.

The initial treatment is mainly conservative with rest, but in most cases of adolescent disc herniation a surgical removal is necessary.

7. Rheumatoid spondylitis

Finally we should mention the rheumatoid spondylisis usually in the adolescent boy. It is rather seldom, but one should think of this disease in cases of backpain, usually in the morning, with stiffness.

Sometimes other joints are also affected. Blood tests with especially an elevated HLA B27 and a positive family history are frequent.

Treatment should be in accordance with the rheumatologist.