Children and Pain Peer Review Committee

Overview

While back pain is perhaps the most common pain complaint of adults and all adults have had back pain at some time in their life, back pain is much rarer in children and may be the initial symptom of an underlying disease process.  This is especially true in younger children (i.e., before the teenage years) who are less like to experience an overuse injury such as those that occur during strenuous exercise.  While overuse injuries do occur, typically these types of injuries immediately follow strenuous exercise or an acute traumatic event, heal quickly (2-3 days), and are not associated with any other symptoms.  If you or your child is unable to determine if the child has had an acute injury or overuse injury or if the child has back pain associated with other symptoms such as fever, bowel or bladder dysfunction, or sensory/motor problems of the extremities (e.g., the child loses strength or sensation in an arm or leg), take your child to the doctor to be evaluated immediately. 

Although the exact incidence of back pain in children is not known, there is a gradual increase with age.  Unlike adults, children are rarely if ever disabled by back pain and in more than 50% of patients, a definable cause for the back pain can be found.¹  Causes of back pain, besides the spine and muscles of the back, may be related to one of several organ systems including the heart, lung, kidneys, gastrointestinal tract or the central nervous system.  Signs and symptoms in children that may suggest an underlying problem and the need for further diagnostic testing to rule out a significant disease process include:

• no possibility of trauma or overuse;
• arthritis and joint pain;
• change in activity level or the child tires easily;
• pain that awakens the child from sleep;
• no improvement with simple analgesics (e.g., acetaminophen [Tylenol], ibuprofen [Advil]);
• pain changes (i.e., gets better or worse) with changes in the child's position;
• fever;
• appetite changes;
• loss of bowel or bladder control;
• gait problems; or
• motor weakness.

While many of these signs and symptoms may occur with simple musculoskeletal strain resulting in back pain, their presence also may suggest an underlying problem or disease and the need for further tests.  Most importantly, if an underlying pathology such as a tumor or infection is responsible for the back pain, early diagnosis may facilitate treatment and improve the eventual.  The child's doctor will conduct a thorough history and physical examination and, when indicated, diagnostic laboratory (e.g., blood tests) and radiologic studies (e.g., x-ray, CT scan) to diagnose the child's condition.  Depending on the diagnosis, potential therapies including specific medications may be indicated in the treatment of back pain.

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Fast Facts

�         Unlike the adult population in whom back pain may be the most common pain report, children rarely complain of back pain.

�         In the adolescent age group, back pain may be related to similar causes as in adults including acute musculoskeletal strain or overuse injury.

�         There is a gradual increase of reports of back pain in children as children age. 

�         Back pain is exceedingly uncommon in the pre-teenage years. If a young child has back pain, he or she should be evaluated by a qualified health care professional immediately.

�         Back pain in children who have a fever, changes in bowel or bladder dysfunction, or changes in strength or sensation requires immediate evaluation.

�         Unlike the adult population, some identifiable cause for back pain is found in more than 50% of pediatric-aged patients.

�         The causes of back pain in infants and children vary considerably based on the patient's age.

�         If an underlying condition, such as a tumor or infection, is responsible for the back pain, early diagnosis may facilitate treatment and improve the eventual outcome. 

�         Disease processes of several organ systems (digestive, kidney, lungs, heart) outside of the spinal column may be responsible for or result in back pain.

�         Back pain due to a traumatic event or overuse injury typically is improved with rest and simple analgesics in two to three days.

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Disease Types

Regardless of the cause, back pain in children can range from mild to severe to incapacitating.  Children also have significant variations in how often pain may occur and how long they pain may last.  One useful classification is the separation of back pain and its causes into one of four categories.² 

�         Mechanical problems, including musculoskeletal problems, an overuse injury, direct traumatic injury, or a ruptured disc.

�         Developmental abnormalities, including spondylolysis and spondylolisthesis.

�         Inflammatory and infectious diseases, including diskitis, vertebral osteomyelitis, juvenile rheumatoid arthritis.

�         Neoplastic disorders, including primary or metastatic, primary: vertebral column or muscle.

Mechanical derangements are most common in the adult population, but also can occur in the pediatric-aged patient, especially the adolescent.  Typically, a child with a mechanical derangement will have no abnormal findings on his or her x-ray evaluation, no localizing neurologic abnormality, and will have participated in exercise, physical activity or experienced a trauma.  With rest and simple analgesics, the pain subsides in two to five days.  Poor posture, although frequently brought up as a potential cause of back pain, is rarely the problem.  Disc problems, which are relatively common in the adult population, can occasionally be seen in children.  In one series, only five of 6,500 patients treated for herniated discs were younger than 16 years of age.³  When suspected, magnetic resonance imaging (MRI) will indicate a herniated disc as well as determine other potential causes of back pain.

Developmental abnormalities also can result in back pain.  Spondylolysis and Spondylolisthesis are among some of the more common developmental causes for back pain in children. Spondylolysis involves a stress fracture in one of the bones (i.e., vertebrae) that make up the spinal column and spondylolisthesis is a condition in which a stress fracture weakens the vertebral bones and causes slippage of one vertebral body on another.  These injuries are most common in children 10 years old and older and rarely seen in children younger than 10.  Both disorders are most common in children who participate in sports associated with significant hyperextension of the vertebral column such as ballet.  The pain is generally localized over the area of the injury and does not lead to loss of sensation or strength in the legs.  Treatment includes rest, ending the physical activity that may have caused the injury, simple analgesics (i.e., acetaminophen [Tylenol], ibuprofen [Advil]), and bracing.  Extreme cases may require surgical intervention.

A second development abnormality which results in back pain in adolescents is Scheuermann's disease or juvenile kyphosis. Although the exact cause of the disease has not been determined, researchers believe it results from an abnormality or interruption of the blood supply to key areas of the vertebral bodies. This lack of blood causes necrosis (i.e., death of the tissues in the area) and progressive forward curvature of the spine.  The area involved is most commonly the thoracic area (that part of the spine that is in the chest cavity), but the lower back or lumbar area also can be involved.  Parents may notice that their child has "poor posture" and is walking "hunched" over while the children frequently complain of pain especially late in the day.  The diagnosis is confirmed by simple x-ray examination of the spine.  If the deformity is not significant, limitation of physical activity and physical therapy combined with simple analgesics is all that is recommended.  Bracing may help in more severe cases.

The third category of developmental abnormalities includes both infectious and auto-immune disorders such as juvenile rheumatoid arthritis.  Given the potential complications and loss of function associated with these problems, experts recommend the child receives prompt medical evaluation.  These disorders may occur in younger patients and frequently are associated with fever. It is especially important to have a child evaluated by a physician promptly when back pain occurs in children younger than 12 years of age or when the child has back pain and a fever.  Infectious disorders may involve a disc, which lies between each of the vertebral bodies (diskitis) or the vertebral body itself (vertebral osteomyelitis).  These infections of the disc or bone result from bacteria that pass from the bloodstream during an infection into the bone or disk.  With either disorder, the child's symptoms may include generally feeling poorly, irritability and poor appetite in addition to fever.  Diskitis is more common in children younger than 8 to 10 years old while vertebral osteomyelitis is more common in children older than 8 to 10 years of age.  In either case, a doctor will determine the diagnosis by taking a bone scan, a diagnostic procedure that will show abnormalities before they would appear on routine x-ray studies.⁴  The child may then undergo a biopsy of the disc or vertebral body to identify the organism causing the infection and help guide antibiotic therapy.  Additional therapies include immobilization with bracing or casting as well as prolonged antibiotic therapy (i.e., four to eight weeks).

 The final category of disorders resulting in bone pain is neoplastic or cancerous lesions.  Such lesions may have originated in the bone itself or may have spread from another site (i.e., metastatic disease).  Not all tumors of the vertebral bodies and spine are malignant.  Back pain may be caused by benign lesions such as osteoid osteoma, hemangioma and giant cell tumors.  Depending on the type of tumor, treatment may include removing the tumor surgically or radiation and/or chemotherapy for malignant lesions.  In most cases, a biopsy of the lesion is necessary to determine what kind of tumor is causing the back pain and to help your doctor decide the appropriate treatment for the tumor.  If the lesion is found to be malignant, your child's doctor may advise a more extensive work-up to determine the source of the metastatic disease.

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 How Back Pain Occurs

Be sure to visit How Back and Neck Pain Happen to learn about the anatomy of the back and how back or neck pain happens.  In general, back pain results from any of the structures in and around the bony confines of the vertebral canal including the nerves, the bones of the vertebral canal, or the muscles.  During a thorough history and physical examination, your child's doctor will evaluate the type of pain your child is experiencing, determine where the pain is located, if it radiates to other areas of the back or legs, what makes the pain better or worse, and identify tenderness of the muscle or bone.  For example, pain that radiates along a nerve root or is exacerbated by straight leg raising is more likely caused by entrapment of a nerve root as seen with a disc problem or a mass encroaching on the nerve roots within the vertebral canal.  If the child has a history of bowel or bladder dysfunction, it is also likely that the child has nerve root problems of the lower part (sacral area) of the spinal canal, a disc problem, or a mass encroaching on the nerve roots within the vertebral canal.  If a child has a history of generalized systemic complains such as fatigue, loss of appetite, fever, or other joint complaints, he or she may have an illness such as juvenile rheumatoid arthritis, an ongoing infection such as diskitis or vertebral osteomyelitis, or a malignancy.  While many of these disorders can be controlled or treated, a prompt diagnosis may increase the likelihood of a successful outcome. 

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 Treatment Options

Effective treatment begins with an accurate diagnosis of the condition.  After conducting a history and a thorough physical examination, the doctor may recommend further tests such as x-rays, computed tomography scanning (CT scans), magnetic resonance imaging (MRIs), or a radioisotope bone scan.  The treatment the child's physician recommends depends on the cause of the back pain.  For overuse injury or many of the development abnormalities, stopping physical activity with simple analgesics is all that may be required.  Bracing or surgical intervention may be required for more advanced problems.  Antibiotics will be required for back pain caused by infections while some combination of surgical removal of a tumor and radiation and/or chemotherapy will be needed for malignant problems. 

Regardless of the cause, some form of pain reliever may be required in most cases.  Treatment may begin with simple analgesics given when the child complains of back pain.  Although many of these medications, including acetaminophen (Tylenol) and ibuprofen (Advil) are available over-the-counter, they are effective in treating pain of different causes and should not be underestimated.⁵  These medications are available in different forms, including suppository forms of acetaminophen, when nausea and vomiting prevent the child from taking them by mouth.  When the rectal route for acetaminophen is chosen, the dose for the initial administration is increased from the 10-15 mg/kg commonly used orally to 30-40 mg/kg.⁶  If your child does not find relief with acetaminophen, other medications may be recommended or prescribed.  Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen also are key in treating pain in children with collagen vascular disorders such as juvenile rheumatoid arthritis.  In fact, 50% to 70% of patients report a significant improvement in their arthritis and require no other therapy.  Pain of juvenile rheumatoid arthritis that fails to response to salicylates or NSAIDs may require additional therapy with other agents including hydroxy-chloroquinine, gold (oral or injectable), methotrexate, d-penicillamine or corticosteroids.  Given that all of these medications can have significant adverse effects, their administration should be closely supervised by a physician trained in their use and rheumatologic diseases of children.

 Although simple analgesics are effective in the majority of patients with back pain, additional therapies may be required in specific patients.  For chronic disorders, the prolonged use of opioids is not recommended because of the potential for dependency; however, patients with severe pain from back problems regardless of the etiology may require short-term use of oral opioids (codeine, hydrocodone, or oxycodone) or even intravenous opioids until a diagnosis is established and appropriate therapies initiated.

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 Conclusions

�         Back pain in adults is a common occurrence, but back pain is much rarer in children.

�         Back pain in children can have many causes. If your child's back pain lasts more than a few days or your child has a fever, bowel or bladder dysfunction, or loses strength or sensation in an arm or leg, the child should be evaluated by a physician.

�         Persistent back pain should be treated to prevent psychosocial and developmental problems in the child.

�         Back pain may be classified as one of the following four categories:

�         Mechanical problems, including musculoskeletal problems, an overuse injury, direct traumatic injury, or a ruptured disc.

�         Developmental abnormalities, including spondylolysis and spondylolisthesis.

�         Inflammatory and infectious diseases, including diskitis, vertebral osteomyelitis, juvenile rheumatoid arthritis.

�         Neoplastic disorders, including primary or metastatic, primary: vertebral column or muscle.

�         Treatment options for back pain in children vary and depend on the cause of the back pain.

�         For overuse injury or many of the development abnormalities, stopping physical activity with simple analgesics is all that may be required. 

�         Bracing or surgical intervention may be required for more advanced problems. 

�         Antibiotics will be required for back pain caused by infections while some combination of surgical removal of a tumor and radiation and/or chemotherapy will be needed for malignant problems.

�         Regardless of the cause of the pain, some form of pain reliever may be required in most cases.  Treatment may begin with simple analgesics given when the child complains of back pain. 

References

1.             King H.  Back pain in children.  Pediatr Clin North Am 1984;31:1083-1095.

2.             Bunnell WP.  Back pain in children.  Ortho Clin North Am 1982;13:587-604.

3.             Webb JS, Svein HJ, Kennedy RLJ.  Protruded lumbar intervertebral disks in children.  JAMA 1954;154:1153-1157.

4.             Feldman DS, Hedden DM, Wright JG.  The use of bone scan to investigate back pain in children and adolescents.  J Pediatr Ortho 2000;20:790-795.

5.             Weak analgesics and non-steroidal anti-inflammatory agents in the management of children with acute pain.  Pediatr Clin North Am 2000;47:527-544.

6.             Hamalainen ML, Hoppu K, Valkeila E, et al.  Ibuprofen or acetaminophen for the acute treatment of migraine in children: A double-blind, randomized, placebo-controlled, crossover study.  Neurology 1997;48:103-107.

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 Other Resources

Journal articles

1.         King H.  Back pain in children.  Pediatr Clin North Am 1984;31:1083-1095.

2.         Bunnell WP.  Back pain in children.  Ortho Clin North Am 1982;13:587-604.

3.         Grattan-Smith PJ, Ryan MM, Procopis PG.  Persistent of severe back pain and stiffness are ominous symptoms requiring prompt attention.  J Pediatr Child Health 2000;36:208-212.

4.         Gunzburg R, Balague R, Nordin M, et al.  Low back pain in a population of school children.  Eur Spine J 1999;8:439-443.

5.         Mason DE.  Back pain in children.  Pediatr Annals 1999;28:727-738.

6.         King HA.  Back pain in children.  Ortho Clin North Am 1999;30:467-474.

7.         Combs JA, Caskey PM.  Back pain in children and adolescents: a retrospective review of 648 patients.  South Med J 1997;90:789-792.

8.         Payne WK 3rd, Ogilvie JW.  Back pain in children and adolescents.  Pediatr Clin North Am 1996;43:899-917.

9.         Tyrrell PN, Cassar-Pullicine VN, Eisenstein SM, et al.  Back pain in childhood.  Ann Rheu Dis 1996;55:789-793.

10.        Selbst SM, Lavelle JM, Soyupak SK, et al.  Back pain in children who present to the emergency department.  Clin Pediatr 1999;38:401-406.

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