I did a quick LexisNexis search and found this (sorry, I copying the entire thing since you need a password to access the link). You might be able to find some articles on pubmedcentral.com.
June 1, 2003
SECTION: PEDIATRICS; Pg. 51
LENGTH: 3521 words
HEADLINE: Back pain in children requires extensive workup -- Although not as prevalent as in adults, back pain in a pediatric population can be more serious.
BYLINE: Harish Hosalkar, MD, and John Dormans, MD
HIGHLIGHT:
Back pain is one of the most common reasons for adults to visit their physicians. Back pain is less common in children, however. In a study by Turner and colleagues, fewer than 2% of patients younger than 15 years of age had been seen by a physician for evaluation of back pain.1 Grantham et al, on the other hand, noted in their review of schoolchildren that 11.5% of adolescent boys had been seen by a physician for low back pain.2 Olsen et al found that the lifetime prevalence of back pain was less than one percent before the age of 10 but rose to 36% by age 15.3
BODY:
There is conflicting evidence regarding how often children presenting with back pain have significant pathology compared with adults. Many authors have reported that children presenting to a physician with back pain frequently have skeletal pathology as a cause of the pain.1,4 Other authors have observed the opposite and feel that most cases of back pain in children do not indicate any serious underlying problem.5 Compared to adults, the workup of a child with back pain often is more extensive at an earlier stage in the evolution of symptoms. The frequent causes of back pain in children are trauma, spondylolysis, spondylolisthesis, Scheuermann's kyphosis (osteochondrosis of the vertebrae), and infection. Other, less common, causes are included in the table on page 52.
In evaluating the child with back pain, the challenge for the orthopedist is to obtain a careful and accurate history and physical examination (most important) and, when necessary, select appropriate studies, laboratory tests, radiographs, and special diagnostic imaging studies to complete the workup without missing any organic causes.
Persistent or severe back pain in children should be taken seriously and often warrants further investigation. It is important to obtain a thorough history and characterize the pain. It is also important to perform a general systems review during evaluation, as many other medical problems may present with back pain. Any observations regarding weight loss, fever, lethargy, skin rashes, and joint pain and swelling should be recorded. The clinician must be aware that infections and tumors-including lymphomas-as well as spondyloarthropathies, can be the cause of back pain in children.
Diagnostic work-up
A complete diagnostic workup will help pinpoint the cause of back pain in children and will help the practitioner focus treatment appropriately.
Physical examination. A thorough physical examination of the patient is vital in the assessment of back pain.
Laboratory evaluation. Laboratory studies are often useful when infection, rheumatologic disease, Lyme arthritis, lymphoma, or leukemia are included in the differential diagnosis. Screening for most medical conditions can be accomplished using a complete blood count, sedimentation rate, C-reactive protein, urinalysis, electrolytes, and enzymes. Rheumatoid factor, antinuclear antibody, HLA-B27, and Lyme screening titers may be indicated if there are rheumatologic concerns.
Radiographs. High-quality plain radiographs should be ordered in cases of persistent or severe back pain and for cases with significant clinical findings. Radiographic evaluation usually begins with standing anteroposterior and lateral views of the entire spine on a three-foot cassette.6 Substituting standard chest or abdominal flat-plate radiographs is less effective.6 Plain films may reveal congenital anomalies with failure of formation and segmentation including lumbarization, Bertolotti's syndrome, and such abnormalities as scoliosis, spondylolisthesis, compression fractures, or destructive lesions. Unique radiographic features of the pediatric spine are listed in the table on page 51. Oblique views are useful to define defects (stress fractures) of the pars interarticularis. Generalized features like osteopenia should raise suspicion of systemic diseases necessitating further workup, such as DXA (dual x-ray absorptiometry) scans.
Advanced imaging
To further refine the diagnosis, other advanced imaging techniques are sometimes indicated.
Magnetic resonance imaging. This is an excellent modality for defining the spinal cord, nerve roots, soft tissue structures (including tumors), marrow involvement, edema, and infection abscesses. Cortical bone is not seen as well as with computed tomography, therefore spondylolytic defects are difficult to see on MRI. It is a study of choice in children with suspected infections, herniated nucleus pulposus, or suspected tumor involving the spine, spinal cord, or nerve roots. Clinicians must make a point to communicate clinical information and suspected differential diagnoses to the radiologists. Sedation is needed for infants and young children. MRI is a "slower study" than CT.
Radionuclide bone scan. A bone scan is sensitive in detecting pathologies causing increased bone turnover. Single-photon emission computed tomography (SPECT), a specific type of bone scanning, gives precise localization of the area of increased uptake where further imaging, if required, can be focused. A bone scan may be informative in cases of significant symptoms when plain radiographs are normal or inconclusive, and in suspected cases of stress fractures, diskitis, and tumors. It may also be helpful in defining other/additional foci away from the spine (as in the case of infection or tumor). Abnormalities on bone scan may be nonspecific in some cases. Thallium and positron-emission tomography (PET) scans can also help define tumor metastasis or the response of sarcoma to chemotherapy.
Computed tomography. CT scans are useful for visualizing bony architecture, particularly as an adjunct to plain radiographs or bone scans. Thin-slice CT may be necessary to diagnose small lesions, such as an osteoid osteoma or a stress fracture. Three-dimensional reconstructions are occasionally useful in cases of complex deformities, tumors, and vertebral fractures. Rarely (in the case of a child with previous surgery and hardware that precludes getting an MRI due to artifacts, for instance) CT may be combined with a myelogram to effectively delineate the pathology.
Differential diagnosis
A careful history and physical examination assist in arriving at a clinical impression and differential diagnosis. Imaging findings and laboratory data can help establish the diagnosis in most cases; biopsy is sometimes needed.
Spondylolysis and spondylolisthesis. These lesions are the most common structural causes of back pain in children and adolescents.1 Defects of the pars interarticularis cause spondylolysis (Figure 1), while displacement of a single vertebra or multiple vertebrae leads to spondylolisthesis (Figure 2).
Pain is often the presenting complaint. Frequently, associated hamstring tightness can cause a postural or gait abnormality. Pain is usually relieved by rest or activity limitation. Physical exam reveals some limitation of motion in the lumbar spine, and pain is exacerbated by extension of the lumbar spine. In severe cases of spondylolisthesis, a step prominence may be palpable over the defect. The radiolucent defect in the pars is sometimes visible on the lateral radiograph, but oblique views are best for identifying most defects with plain x-rays. A radionuclide bone scan with SPECT will demonstrate a focus of increased uptake if the lesion is active or healing. Thin-slice CT helps to further define the actual defect or fracture in the pars interarticularis.
For most patients with spondylolysis the treatment is rest, activity modification, and mild analgesics. In some cases of severe or nonresponsive pain, bracing with an antilordotic brace may offer relief.7 Once the pain abates, physical therapy may be useful to restore motion, stretch the hamstrings, and increase abdominal tone. Surgery is considered when there is recurrent pain and significant disability, progressive slip, or when slip is more than 50%. Indications for specific surgical interventions depend on pathology: we recommend tension-band wiring or single-level fusion for spondylolysis, and bilateral-lateral, anterior, and/or posterior fusion with/without instrumentation for spondylolisthesis.
Scheuermann's kyphosis. Often reported as the second most common cause of back pain in adolescents, this is a familial disorder most commonly affecting the thoracic spine and producing vertebral wedging, Schmorl's nodes, and kyphosis greater than about 45 degrees .1,4 Patients usually present with pain that begins after strenuous activity. On physical exam, the normal contour of the spine may be altered by the presence of increased thoracic kyphosis (Figure 3). There may be apical tenderness on deep palpation. Radiographs show anterior body wedging (greater than 5 degrees at involved levels) and mild scoliosis may be common.
Scheuermann's kyphosis can be differentiated from postural round back by the fact that the kyphosis does not reduce when the patient lies supine. Also, wedging of vertebrae and Schmorl's nodes are not seen on imaging of patients with postural round back.
Treatment of Scheuermann's kyphosis is usually symptomatic with analgesics, activity modification, and extension exercises. Bracing (a three-point extension orthosis that results in unloading of the anterior column of the spine) may be considered in growing children and can alter the natural history of the condition. This often results in partial reversal of vertebral wedging by restoration of anterior vertebral growth according to Heuter-Volkmann's law (decreased pressure on the growing epiphysis leads to increased growth).8 For progressive and severe deformities, spinal instrumentation and fusion may be necessary.
Lumbar herniated nucleus pulposus. Herniations occur rarely in children and adolescents and may have a different course and presentation than in adults.9 The usual complaints are back pain, sciatica, and tightness of the hamstrings. Secondary spinal deformity may occur (producing scoliosis or a list). Straight leg raising may be limited, and neurological changes are variable. Plain radiographs are frequently normal, although MRI studies are usually conclusive in establishing/confirming diagnosis. HNP must be differentiated from apophyseal ring fractures that are more common in children.5
Initial treatment should consist of rest, NSAIDs, and activity reduction. Unlike adults, many adolescents may fail conservative therapy.5 Persistent pain (unresponsive to conservative treatment for more than two to three months), severe pain, neurological involvement, or progressive disability is an indication to consider operative disk excision. Diskectomies are successful in approximately 90% of cases.5
Diskitis or vertebral osteomyelitis. Inflammation (and/or infection) of the disk space can involve the lower thoracic or upper lumbar spine in infants and children.10 Clinical features are age-related and are usually characterized by fever, irritability, and difficulty in walking. Constitutional symptoms like fever, weakness, generalized malaise, and loss of appetite are common. Abdominal pain may be a significant symptom if T8-L1 levels are involved. Vague and poorly localized symptoms may delay diagnosis.
Clinical exam often reveals a rigid spine with tenderness over the involved area. The patient typically walks with a forward-bent position. The ESR (erythrocyte sedimentation rate) and C reactive protein values are elevated; these are also useful in following the course of and response to treatment. Blood cultures often reveal the causative organisms, Staphylococcus aureus being the most common. Neurological symptoms should raise suspicion of an epidural abscess.
Plain radiographs may be normal for the first few weeks after the onset of symptoms; a bone scan may show increased uptake. Eventually, narrowing of the disk space and erosion or sclerosis of the end plates may be observed on plain radiographs. MRI can help to differentiate diskitis and osteomyelitis and is helpful in defining an epidural abscess.
Use of antibiotics concurrently with rest and immobilization usually expedites the resolution of symptoms. The ESR and C reactive protein values can be used to monitor the effectiveness of therapy, with the latter returning to normal earlier. Presence of an epidural abscess with neurologic symptoms is usually an indication for open drainage.
Tumors. Primary tumors of the spinal column are rare in children, and most are benign.11 Osteoid osteoma causes localized back pain that is worse at night and relieved by aspirin or other NSAIDs. Nonstructural scoliosis is common (about 50%). Plain radiographs may show areas of sclerosis, although diagnosis is best made using thin-slice CT scans. Prolonged use of NSAIDs forms the medical management, although surgical excision with nidus removal is curative.11 CT-guided trephine or burr removal, or radio frequency ablations are currently used in extremities but may not be routine in the spine.11 The surgical treatment of choice for spinal osteoid osteomas is open surgical excision. This procedure does not require the removal of the sclerotic reactive bone surrounding the lesion, but the entire tumor nidus must be removed. Reliable pain relief is achieved and the secondary scoliosis resolves in most cases.11
LCH (Langerhans cell histiocytosis) may involve the spine and usually occurs in younger children.12 It is a benign and self-limiting process that produces focal destruction of bone. Radiographs may show characteristic vertebral collapse (vertebra plana). A skeletal survey and bone scan are often indicated to look for other areas of involvement. CT-guided biopsy may be necessary for confirmation of diagnosis. Pain associated with solitary lesions usually responds to symptomatic treatment such as anti-inflammatory and analgesic medications, and may improve with use of a spinal orthosis. A supportive brace for comfort and to prevent deformity is indicated; the specific design of the brace will depend on the location of the lesion(s). The natural history of these lesions is spontaneous healing with lesions usually showing reconstitution of vertebral body height. Chemotherapy may be required for multifocal or systemic involvement.
Aneurysmal bone cysts are commonly located in the posterior elements of the spine; MRI shows an expansile lesion with thinning of the surrounding cortex, septations, and fluid-filled cysts.13 Management is often complex and may include preoperative selective arterial embolization, intralesional excision curettage, bone grafting, and fusion of the affected area.
Malignant tumors of the spine are rare in children but should be suspected in cases of persistent or severe back pain (especially night pain) not responding to rest and conservative care. Acute leukemia is the most prevalent cancer in young children and may be associated with a compression fracture with diffuse osteopenia on radiographs. Complete blood count with differential count and peripheral smear are often diagnostic. Bone marrow biopsy is usually needed for confirmation. Treatment should be specific to the type of leukemia present, and often involves chemotherapy and/or radiation.
Ewing's sarcoma is the most common primary malignant tumor of the spine in children. Patients present with back pain, increased sedimentation rate, and vertebral destruction with a soft tissue mass. Prompt staging and biopsy are indicated, followed by neoadjuvant chemotherapy and subsequent local control with either radiation or surgery.
Osteogenic sarcomas are rare in the axial skeleton (10% of all osteosarcoma cases) but, when present, carry a poor prognosis.11 The vertebral body is the site of involvement in most cases. After prompt staging and biopsy, treatment begins with neoadjuvant chemotherapy to eliminate the micrometastases and to potentially improve the chances for wide margins with local control surgery.
Nonorganic causes of back pain
A diagnosis of psychological problems should be made only on the basis of positive findings; organic causes must be excluded. Conversion disorders are unusual but do occur in children.14 Referral for psychological evaluation and potential treatment should be made when the clinician feels that there is a significant psychological component contributing to the presentation.
Conclusion
Back pain in children should be taken seriously, particularly when accompanied by systemic symptoms. Careful, detailed medical and radiographic evaluation must be performed and imaging studies should be used when indicated. With increasing awareness of the natural history of disorders that cause back pain in children, it will be possible to manage these patients effectively and appropriately.
Harish Hosalkar, MD, is the orthopedic fellow at The Children's Hospital of Philadelphia. John P. Dormans, MD, is chief of orthopedic surgery at the same institution and a professor of orthopedic surgery at the University of Pennsylvania.
References
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