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Back PaiResident PEM Lec
May 24, Brad Sobolewsk
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The case
4 y/o male with abdominal and lower back pain for 3 weeks t
in pain at day care
PMHx of seasonal allergies
No trauma or prior history of pain like this
Intermittent fevers for 3 weeks - 101-103F, not daily
Seen by PMD 2 weeks ago, Dx w/ constipation and started on M
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The case
Decreased PO for 2 days
Difficulty walking up stairs and picking things up off of the groun
Denies fatigue or weight loss
Tylenol helps (somewhat)
No respiratory, urinary or GI symptoms
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He walkslike an old
man
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Physical exam
General: alert, NAD, well appearing
HEENT: normal
Respiratory: normal
Cardiovascular: normal pulses and perfusion, no mur
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Physical exam
Gastrointestinal: abdomen soft, nontender, nondiste
positive bowel sounds, no organomegaly, normal rect
Lymph: Bilateral inguinal lymphadenopathy
Genitourinary: normal external genitalia
Skin: no rashes
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Physical exam
Neuro: sensation normal , normal reflexes, mildly ant
GCS=15, normal muscle strength
Spine: normal curvature, no point tenderness over sphe points to posterior hips as site of pain
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In summary
4 year old male with 3 weeks of intermittent fand low back pain who walks like an old man
What would you like to do?
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Back pain in children
Scandinavian study of 29,000 children
7% of 12 year olds experienced low back pain 50% have had back pain by age 20
Associations Female gender, increased TV time, negative aff
scores, family Hx
Leboeuf-Yde C; Kyvik KO Spine 199
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Point prevalence of low back pain, individuals aged 12 to 4
Leboeuf-Yde C; Kyvik KO Spine 199
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Epidemiology
Presenting complaint in 0.4% of ED visit
90% pain for
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50%
9%
13%
13%
6%
Muscular
Infection
Idiopathic
Sickle Cel
Miscellane
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Overloaded school
backpacks can causeback pain
Weight >15 percent of the
child's weight
AAP recommends
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Red flags
Young age (before puberty)
Fever
Acute trauma
Weight loss
Constant or nighttime pain
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Red flags
Sciatica
Repetitive microtrauma, especially lumbar hyperexte
History of malignancy or TB exposure
Bowel or bladder symptoms
Abnormal neurological examination
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Location
Nerve root - brief; sharp and shooting, increased by s
better supine
Severe, constant back pain, persisting at night, sugge
neoplasm, infection, or nerve root compression
Sciatica suggests herniated disc usually stops at th
Pain radiating below the knee true radiculopathy
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Concerning signs for spinal patho
Postural shift of the trunk
Neurologic abnormality
Limitation of motion
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Neuro exam pearls
Reflexes Knee L3-4, Posterior Tibialis L5, Ankle S1
Cant rise from squatting? Proximal muscles
Gastrocnemius strength (S1) rising up on the toes
Ankle dorsiflexion weakness L4 or L5 nerve root
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Neuro exam pearls
Sciatic pain may be increased by testing foot dorsifle
the knee extended - stretches the S1 or L5 root
Great toe extensor weakness is indicative of L5 nervinvolvement
Gluteus maximus weakness (S1) may cause buttock
Gluteus medius weakness (L5) may cause a lurchingwaddling (Trendelenburg) gait
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Straight leg raise
Detects nerve root impingement by herniated discs
Supine, uninvolved foot on table w/ knee at 45 degr
Raise effected side w/ ankle at 90 degrees
In adults sens 80% spec 40% (LOTS OF FALSE POSIT
Likely due to hamstring tightness
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Flex/Ex
Pain in flexion tumor,spondylolisthesis,herniation, discitis
Pain w/ extension
suggests spondylolysis
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Musculoskeletal causes
Fractures
Nonspecific sprains/strains
Spondylolysis Inherited or repetitive microtrauma (lumbar hyperextens Aching low back pain exaggerated by extension
Spondylolisthesis From bilateral spondylolysis
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Hold on a second,spondylowhatzit? Listhesis
Im confused by lots of lett
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Anatomy review
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Oblique scottie dog
Pars interarticularis
Located between the inferior and
superior articular processes of the
facet joint
In the transverse plane, it liesbetween the lamina and pedicle
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Spondylolysis
Defect in the pars interarticularis
Most common in L5
Stress fractures
6% of population
Most common cause ofspondylolisthesis in children
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Spondylolisthesis
Anterior displacement of a vertebrain relation to the vertebrae below
Due to a pedicle fracture
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Musculoskeletal
Scoliosis
Musculoskeletal pain is more common in patiescoliosis
One cohort of 2000 patients had 23% with painpresentation
Disc disease
Degenerative most common in L4-5, L5-S1 Very rare less than age 10
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Musculoskeletal
Scheuermann kyphosis (juvenile
kyphosis) anterior wedging of 5
degrees or greater in atleast three adjacentvertebral bodies, asmeasured on lateral spineradiographs
Onset in adolescence Inherited and common
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Infectious
Discitis
Vertebral osteomyelitis
Epidural abscess
Paraspinal abscess
Pyelonephritis
Pneumonia
PID
Endocarditis
Viral illness induced
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Inflammatory
Includes
ankylosing spondylitis, psoriatic arthritis, arthritis of inflabowel disease, and reactive arthritis
Symptoms
Morning stiffness & SI joint pain
HLAB-27 is common, but most back pain in HLAB-27
patients is not from sacroilitis
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Neoplastic
Constant pain, nocturnal pain, and duration of pain le
three months associated with tumors
#1 is osteoid osteoma benign, nocturnal pain reliev
NSAIDs - Can lead to scoliosis
Leukemia, lymphoma, Ewing sarcoma, neuroblastom
osteoblastoma, osteosarcoma, neurofibroma, and Lacell histiocytosis
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MiscellaneousSickle cell pain crisis
Syringomyelia
Cholecystitis
Pancreatitis
Ectopic pregnancy
Chronic pain syndromes 10-15% of Rheumatology referrals
Most are adolescents, isolated back pain uncommon
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Labs
Inflammatory or infection?
CBC, Blood culture, ESR, CRP, urine studies
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Radiography
Plain films
congenital or acquired pathology Usually include AP and lateral only Oblique view for pars (spondylolysis)
MRI Test of choice for evolving neurologic changes omalignancy
nonbony spinal tumors, discitis, and sacroiliac inflammation
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Osteoid osteoma
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Children with a short duration of sympto
preceding trauma of the back, a clear
musculoskeletal precipitant, normal neu
examination, and an otherwise benign
appearance can be managed conservatwithout laboratory or radiologic testing
B k h
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Back to the case
In the ED we obtained CBC, B/C, U/A, U/C, ESR, and
Abdominal and Spine XRays both normal
S 34L 55M 8E 3
13
385248.2
ESR 66
CRP 0.7
Renal, Cal, Mag, Pho
B k t th
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Back to the case
We consulted Ortho andRadiology and obtained
an MRI of the spine
L5-S1 discitis and S1
vertebral osteomyelitis
F ll
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Follow up
Admitted to General Pediatrics with Ortho and ID con
Dx of Osteomyelitis/discitis
Remained afebrile in hospital. ID consulted and recotreating with Clindamycin for 6 weeks via PICC
Ibuprofen, with Tylenol #3 for breakthrough pain
Weekly CBC with diff and CRP