Back Pain in Children and Adolescents Christine Hom, M.D Division of Pediatric Rheumatology New York Medical College.

Back Pain in Children and Adolescents

Christine Hom, M.DChristine Hom, M.D

Division of Pediatric RheumatologyDivision of Pediatric Rheumatology

New York Medical CollegeNew York Medical College

Back Pain

Back pain in children - abnormal until proven otherwise!Back pain in children - abnormal until proven otherwise!

75% of children with back pain have an identifiable 75% of children with back pain have an identifiable etiologyetiology

Adolescents more likely to have musculoskeletal pain or Adolescents more likely to have musculoskeletal pain or lower back pain syndromeslower back pain syndromes

Back Pain

In children with back pain of >2 months’ duration:In children with back pain of >2 months’ duration:

– 33% had a post-traumatic etiology: occult fracture or 33% had a post-traumatic etiology: occult fracture or spondylolysisspondylolysis

– 33% had kyphosis or scoliosis33% had kyphosis or scoliosis

– 18% had a tumor or infection18% had a tumor or infection

Back pain in adolescents

In a school based study of 446 adolescents aged 13-17y:In a school based study of 446 adolescents aged 13-17y:

26% of adolescents report some back pain, especially 26% of adolescents report some back pain, especially related to sportsrelated to sports

Male:Female ratio 1:1Male:Female ratio 1:1 50% of tennis and soccer players50% of tennis and soccer players up to 85% of male gymnastsup to 85% of male gymnasts

Maneuvers requiring posterior extension of the leg often Maneuvers requiring posterior extension of the leg often provoke lower back painprovoke lower back pain

Etiology of back pain

INFECTIONINFECTION INFLAMMATIONINFLAMMATION MECHANICALMECHANICAL ORTHOPEDICORTHOPEDIC TRAUMATRAUMA MALIGNANCYMALIGNANCY SYSTEMIC DISEASESYSTEMIC DISEASE OTHEROTHER

Etiology of back pain

INFECTIONINFECTION– Sacroiliac infectionsSacroiliac infections– Vertebral osteomyelitisVertebral osteomyelitis– DiskitisDiskitis– PyelonephritisPyelonephritis– Potts diseasePotts disease– Spinal epidural abscessSpinal epidural abscess– Psoas abscessPsoas abscess

Etiology of back pain

INFLAMMATIONINFLAMMATION– Ankylosing spondylitisAnkylosing spondylitis– Reiter’s syndromeReiter’s syndrome– Inflammatory bowel diseaseInflammatory bowel disease– SpondyloarthropathySpondyloarthropathy– SEA syndromeSEA syndrome

Etiology of back pain

MECHANICALMECHANICAL– Musculoskeletal (sprain/strain)Musculoskeletal (sprain/strain)– Herniated discHerniated disc

ORTHOPEDIC/TRAUMAORTHOPEDIC/TRAUMA– SpondylolisthesisSpondylolisthesis– SpondylolysisSpondylolysis– Scheuermann’s diseaseScheuermann’s disease– (Scoliosis) (Scoliosis) – Vertebral compression fractureVertebral compression fracture

Etiology of back pain

MALIGNANCYMALIGNANCY– Spinal cord tumors (lipoma, teratoma)Spinal cord tumors (lipoma, teratoma)– Bone tumorsBone tumors

Osteoid osteomaOsteoid osteoma Ewing’s sarcomaEwing’s sarcoma Vertebral osteosarcomaVertebral osteosarcoma

– NeuroblastomaNeuroblastoma– LeukemiaLeukemia– Eosinophilic granulomaEosinophilic granuloma– Aneurysmal bone cystAneurysmal bone cyst

Etiology of back pain

SYSTEMIC DISEASESYSTEMIC DISEASE– Secondary hyperparathyroidismSecondary hyperparathyroidism

(Stones, bones, groans, moans)(Stones, bones, groans, moans)

– Sickle-cell anemia - back pain is commonSickle-cell anemia - back pain is common– OsteoporosisOsteoporosis– Corticosteroid useCorticosteroid use– Aseptic necrosisAseptic necrosis– NephrolithiasisNephrolithiasis

Etiology of back pain

OTHEROTHER– FibromyalgiaFibromyalgia– Reflex sympathetic dystrophyReflex sympathetic dystrophy– Conversion disorderConversion disorder– Pain amplification syndromePain amplification syndrome– PsychogenicPsychogenic

Evaluation of back pain

HISTORY and physicalHISTORY and physical– point tendernesspoint tenderness

CBC, ESR, SMA-20, urinalysisCBC, ESR, SMA-20, urinalysis Lyme titerLyme titer HLA-B27 HLA-B27 Plain films, including oblique viewsPlain films, including oblique views Bone scanBone scan CT/MRICT/MRI

Evaluation of back pain

WARNING SIGNSWARNING SIGNS– Increasing painIncreasing pain– Pain wakes child from sleepPain wakes child from sleep– Function: usual activities impairedFunction: usual activities impaired– Weight lossWeight loss– FeverFever– Bowel or bladder dysfunctionBowel or bladder dysfunction– Young age, < 4 yoYoung age, < 4 yo

Diskitis Typical patient is 3-5 years oldTypical patient is 3-5 years old Systemic findings: fever, irritability, abdominal Systemic findings: fever, irritability, abdominal

pain, anorexiapain, anorexia Rigid posture; refuses to flex lumbar spineRigid posture; refuses to flex lumbar spine Elevated ESRElevated ESR Plain films reveal irregular vertebral endplatesPlain films reveal irregular vertebral endplates CT/MRI reveal decreased signal in disk and CT/MRI reveal decreased signal in disk and

increased in adjacent vertebraeincreased in adjacent vertebrae Usually hematogenous bacterial infection with Usually hematogenous bacterial infection with

S. aureus S. aureus (88% no organism on aspirate)(88% no organism on aspirate)

Vertebral Osteomyelitis

Older childrenOlder children Only accounts for 2-4% of osteomyelitisOnly accounts for 2-4% of osteomyelitis Children appear more toxic: fever, irritability, Children appear more toxic: fever, irritability,

refusal to walkrefusal to walk Elevated ESR, sedimentation rateElevated ESR, sedimentation rate Radiographs show destruction of vertebral Radiographs show destruction of vertebral

bodybody Organism usually recovered (S. aureus) on Organism usually recovered (S. aureus) on

aspirateaspirate

Spondylolysis/spondylolisthesis

Defect of the pars interarticularisDefect of the pars interarticularis Usually at L5Usually at L5 Scottie-dog appearance on plain filmScottie-dog appearance on plain film

– obtain oblique and lateral filmsobtain oblique and lateral films

Complaints of low back pain, worse with Complaints of low back pain, worse with palpationpalpation

Slippage of L5 on S1 is Slippage of L5 on S1 is spondylolisthesisspondylolisthesis in athletes with hyperextension of spinein athletes with hyperextension of spine

Scheuermann’s disease

Juvenile kyphosisJuvenile kyphosis

Painful in 50% of casesPainful in 50% of cases

Usually affects boys 13-17 years of ageUsually affects boys 13-17 years of age

75% of cases affect the thoracic spine75% of cases affect the thoracic spine

Fixed dorsal kyphosis Fixed dorsal kyphosis

Compensatory lumbar lordosisCompensatory lumbar lordosis

Scheuermann’s disease

Lateral X-ray reveals Schmorl’s nodes and Lateral X-ray reveals Schmorl’s nodes and vertebral wedging with irregular vertebral vertebral wedging with irregular vertebral endplatesendplates

The disease is self-limited with a benign The disease is self-limited with a benign coursecourse

Treatment: Nonsteroidal analgesicsTreatment: Nonsteroidal analgesics– severe cases may require bracing with an external severe cases may require bracing with an external

Milwaukee brace for comfortMilwaukee brace for comfort

Enthesitis Local tenderness to palpation at insertions ofLocal tenderness to palpation at insertions of

– tendontendon– ligamentligament

– capsulecapsule On physical exam:On physical exam:

– Patella at 10 o’clock, 2 o’clock, 6 o’clockPatella at 10 o’clock, 2 o’clock, 6 o’clock– Tibial tuberosityTibial tuberosity– Insertion of the Achilles tendonInsertion of the Achilles tendon– Plantar fascia insertion onto calcaneusPlantar fascia insertion onto calcaneus– Metatarsal headsMetatarsal heads– Greater trochanter of the femurGreater trochanter of the femur– Anterior superior iliac spineAnterior superior iliac spine

Juvenile ankylosing spondylitis Chronic arthritis of peripheral and axial skeletonChronic arthritis of peripheral and axial skeleton

EnthesitisEnthesitis

Seronegative (rheumatoid factor negative)Seronegative (rheumatoid factor negative)

Extraarticular manifestations: acute iritis, rarely low Extraarticular manifestations: acute iritis, rarely low

grade fever, urethritis or diarrheagrade fever, urethritis or diarrhea

ALL have sacroiliac arthritisALL have sacroiliac arthritis

Genetic basis: Genetic basis: 2-10% of HLA-B27 positive patients 2-10% of HLA-B27 positive patients

will develop JASwill develop JAS

Juvenile ankylosing spondylitis:New York AS criteria

expansion of lumbar spineexpansion of lumbar spine Pain at lumbar spinePain at lumbar spine Chest expansion 2.5 cm or lessChest expansion 2.5 cm or less

ANDAND– radiographic demonstration of sacroiliac radiographic demonstration of sacroiliac

arthritis (may be unilateral)arthritis (may be unilateral)

Juvenile ankylosing spondylitis

IritisIritis– AcuteAcute– PainfulPainful– PhotophobiaPhotophobia– Red eyeRed eye– Anterior nongranulomatous uveitisAnterior nongranulomatous uveitis– Few sequelae, but synechiae may developFew sequelae, but synechiae may develop– Episodic course most commonly seen in HLA-B27+ Episodic course most commonly seen in HLA-B27+

patients. If ANA positive, may develop chronic patients. If ANA positive, may develop chronic uveitis similar to JRAuveitis similar to JRA

Juvenile ankylosing spondylitis

HLA-B27HLA-B27– Class I major histocompatibility antigenClass I major histocompatibility antigen– varied presence in ethnic populations:varied presence in ethnic populations:

50% of Canadian Haida Indians are HLA-B27+50% of Canadian Haida Indians are HLA-B27+ only 2% of Japanese general populationonly 2% of Japanese general population

– Incidence of JAS varies with HLA-B27 presence in a Incidence of JAS varies with HLA-B27 presence in a given populationgiven population

– 10% risk of AS in children of HLA-B27+ patient with 10% risk of AS in children of HLA-B27+ patient with ASAS

– 20% risk of AS if they are also HLA-B27+ and male20% risk of AS if they are also HLA-B27+ and male

Treatment of Juvenile AS NSAIDsNSAIDs

– tolmetin sodium (Tolectin)tolmetin sodium (Tolectin)– indomethacinindomethacin

SulfasalazineSulfasalazine Intraarticular steroid injectionsIntraarticular steroid injections Local steroid injections at enthesesLocal steroid injections at entheses Physical therapyPhysical therapy

New treatments include infliximab New treatments include infliximab (monoclonal anti-TNF) and etanercept (monoclonal anti-TNF) and etanercept (sTNFR)(sTNFR)

Juvenile ankylosing spondylitis

Children often develop peripheral Children often develop peripheral arthritis years before axial involvementarthritis years before axial involvement

Look for SEA syndrome: seronegative Look for SEA syndrome: seronegative enthesitis and arthropathyenthesitis and arthropathy

Complaints of pain in buttocks, groin, Complaints of pain in buttocks, groin, thighs, heels often predate frank thighs, heels often predate frank sacroiliac diseasesacroiliac disease

JRA or JAS?

JRA JAS

Male:Female 1:4 7:1

Age of onset 5 yo >10 yo

Back pain 2% 100%

Enthesitis Rare Common

HLA-B27 + 15% 90%

ANA 30-50% <5%

RF 15% <5%

Iritis Chronic Acute

DEXA Scan of Lumbar spineDEXA Scan of Lumbar spine

Look at Z-scoresLook at Z-scores

Percentage of bone mass Percentage of bone mass relative to age matched controlsrelative to age matched controls

Does not tell risk of fractureDoes not tell risk of fracture

Risk of vertebral collapse more Risk of vertebral collapse more likely in pediatric population, likely in pediatric population, rather than hip fracturerather than hip fracture

Treatment: Treatment: weight bearing exerciseweight bearing exercisecalcium, Vitamin D suppl.calcium, Vitamin D suppl.bisphosphonatesbisphosphonates

Pain amplification syndromes Pain out of proportion to clinical findingsPain out of proportion to clinical findings Pain does not follow anatomical boundariesPain does not follow anatomical boundaries

With autonomic findingsWith autonomic findings– Chronic regional pain syndromeChronic regional pain syndrome– Reflex sympathetic dystrophyReflex sympathetic dystrophy– Causalgia/Sudeck’s atrophyCausalgia/Sudeck’s atrophy

With painful tender pointsWith painful tender points– FibromyalgiaFibromyalgia

HypervigilantHypervigilant– psychogenic/psychosomaticpsychogenic/psychosomatic

Pain amplification syndromes 80% are female80% are female Median age 12 yearsMedian age 12 years Mean duration of pain 1.6 yearsMean duration of pain 1.6 years Constant painConstant pain Multiple locationsMultiple locations Lower extremity more often than upper Lower extremity more often than upper Role model for chronic painRole model for chronic pain Personality: mature, excellent student, eager to Personality: mature, excellent student, eager to

please, many extracurricular activitiesplease, many extracurricular activities

Pain amplification syndromes Mother is the spokesperson and gives the Mother is the spokesperson and gives the

history including subjective complaintshistory including subjective complaints Incongruent affect: la belle indifference Incongruent affect: la belle indifference Marked disability despite a paucity of physical Marked disability despite a paucity of physical

findingsfindings Other findings of headache, abdominal pain, Other findings of headache, abdominal pain,

sleep disturbance and fatiguesleep disturbance and fatigue Allodynia - pain disproportionate to stimulusAllodynia - pain disproportionate to stimulus

Pain amplification syndromesTreatmentTreatment

Physical therapy: Physical therapy: – Aerobic exercise dailyAerobic exercise daily– Desensitization with towelingDesensitization with toweling– Range of motion exercisesRange of motion exercises

Cognitive behavioral therapyCognitive behavioral therapy– Progressive muscle relaxationProgressive muscle relaxation– Guided imagery Guided imagery – Self-hypnosisSelf-hypnosis

PharmacotherapyPharmacotherapy– Low dose amitriptyline or SSRILow dose amitriptyline or SSRI