Research Review: Exploring causes of back pain in young patients, part 2
Shawn ThistleFeatures Research
|Study title: Back pain in children and adolescents
Authors: Altaf F, Heran MKS, Wilson LF
Publication information: Bone & Joint Journal 2014; 96-B: 717–23.
The etiology of back pain in children is significantly different from that of adults and, although serious pathologies are rare, there are several that require consideration.
Continuing from last issue, this study reviewed the important causes of back pain in children and adolescents.
Intervertebral discs are more vascularized in children than in adults, which accounts for the higher rate of discitis in adolescence, versus overt vertebral osteomyelitis. Other common infectious causes of back pain in children are tuberculous osteomyelitis, epidural abscess and sacroiliac joint infections.
Discitis is a rare condition, with an estimated incidence of one to two cases in 30,000. It has a characteristic biphasic distribution, affecting toddlers and older adolescents. Discitis presents as general irritability, a refusal to walk or to stand due to abdominal pain, hamstring spasm or back pain and it may be associated with a limp. White cell count and C-reactive protein are generally normal; erythrocyte sedimentation rate is mildly raised; blood cultures are usually negative. MRI often confirms the diagnosis.
The spondyloarthropathies are a group of inflammatory rheumatic disorders characterized by axial and/or peripheral arthritis. The diseases in the group share a common genetic predisposition – namely, the HLA-B27 gene. Of the common spondyloarthropathies, Ankylosing Spondylitis (AS) is the most common, occurring in 0.2 to 1.2 per cent of the Caucasian population. Its initial symptoms can be noted in adolescence and early adulthood, such as dull pain over the lower back and buttocks, and morning stiffness eased by exercise and worsened with inactivity. Of concern is the frequent lengthy delay between symptom onset and diagnosis (often up to eight years), an issue clinicians should keep in the front of their minds with characteristic patients with this symptom pattern. AS usually responds well to non-steroidal anti-inflammatories (NSAIDs), although in more progressive/severe cases, tumour necrosis factor inhibitors have shown good results. Patients suspected of having AS, or other inflammatory disease, should be promptly referred to a rheumatologist.
Neoplastic disease of the spine, while rare in kids, can occur in both the posterior column (osteoid osteoma, osteoblastoma, aneurysmal bone cyst) and anterior column (eosinophilic granuloma, also known as histiocytosis X):
- Osteoid Osteoma: one per cent of all tumours and 11 per cent of all primary benign tumours in patients between 10 and 25; primarily located in the pedicle and lamina; back pain is usually present at night and relieved by aspirin and/or NSAIDs; definitive treatment is surgical resection.
- Osteoblastoma: one per cent of all primary benign tumours, 40 per cent are located in the spine; primarily located in the pedicle and lamina; NSAIDs are ineffective; tumours are often locally expansive and destructive; surgical treatment ranges from intralesional curettage to complete resection.
- Aneurysmal Bone Cyst: bubbly, cystic appearance with a thin rim of surrounding bone, in the posterior column of the spine and visible on plain films; treatment includes selective arterial embolization followed by either complete curettage or en bloc marginal excision. Radiotherapy has a limited role.
- Eosinophilic Granuloma (Histiocytosis X): a subgroup of syndromes related to abnormally functioning monocytes, macrophages and dendritic cells; present in 10 to 15 per cent of children with histiocytosis; back pain localized to area of granuloma formation (usually anterior vertebral body); plain films can show collapsed vertebrae, due to the lytic nature of the tumour; treatment options are controversial, as some patients undergo spontaneous resolution; surgery is reserved for patients with neurological deficits or polyostotic involvement.
Diagnosis and treatment of back pain in children can be challenging and requires a thorough history and examination. Appropriate imaging and diagnostic testing can rule out serious pathologies and facilitate referral for specialist intervention when required for neoplastic and rheumatological disorders.
Dr. Shawn Thistle is the founder and CEO of RRS Education (rrseducation.com), which helps busy clinicians integrate current research evidence rationally into practice. He also maintains a practice in Toronto, lectures at CMCC and provides chiropractic medicolegal consulting services. Reach him at: email@example.com
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