Overview
Fast Facts
Disease Types
How Back Pain Occurs
Treatment Options
Psychological
Factors Related to Chronic Pain in Children
Conclusions
Getting
Help
Other Resources
Children and Pain Peer
Review Committee
Content
Editor:
|
Brenda
C. McClain, M.D., DABPM, New Haven, Conn.
|
Editorial
Review Board:
|
Deirdre
Logan, Ph.D., Philadelphia, Pa.
Joseph
D. Tobias, M.D., Columbia, Mo.
Haleh
Saadat, M.D., New Haven, Conn.
Victoria
Gocha Marchese, P.T., Ph.D., Memphis, Tenn.
Rollin
Gallagher, M.D., M.P.H.,
Philadelphia, Pa.
|
|
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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