Back Pain in Children and Adolescents

Non-organic back pain signs in children with amplified musculoskeletal pain involving the back

BACKGROUND

Traditionally, back pain in childhood was presumed to be organic. However, children with amplified musculoskeletal pain syndrome (AMPS) commonly experience back pain. Our objective was to assess the frequency of non-organic back pain signs in children with amplified pain experiencing back pain and to determine if a difference existed between those with diffuse AMPS and those with localized AMPS.

METHODS

Retrospective cross-sectional cohort study of children ≤ 18 years old with AMPS and back pain presenting for an initial consultation to a pediatric rheumatology subspecialty pain clinic from 2009 to 2021. Data from an existing patient registry was combined with abstracted data from the electronic medical record including demographics, clinical characteristics, and physical exam findings. We used Fisher's exact test or Wilcoxon rank-sum test, as appropriate, to compare clinical findings among patients with localized versus diffuse AMPS.

RESULTS

At total of 334 patients with AMPS had back pain. The majority (62%) had diffuse AMPS. The most common non-organic back pain signs were failure to guard back when going from supine to sitting, presence of allodynia, and an incongruent affect. Positive straight leg raising test, and overreaction were rare. Patients with localized AMPS were more likely to have a positive straight leg raising test (P = 0.01). Patients with diffuse AMPS were more likely to have allodynia and an incongruent affect (both P < 0.01).

CONCLUSIONS

The most common non-organic back pain signs in children with AMPS involving the back include incongruent affect, allodynia, and failure to guard the back when sitting up. Almost a third had a positive passive rotation and axial loading test. A positive straight leg raising test was rare and disappeared with distraction. These tests may help establish a diagnosis of amplified pain in children with back pain.

The association between the site of back pain and number of painful sites with daily activities, seeking healthcare, and medication use among school adolescents

Introduction

The potential consequences of back pain (BP) are poorly described in adolescents. This study evaluated the association between BP sites (neck, thoracic and low back) and number of painful sites with missed school classes, interference in physical activities, seeking healthcare, and medication use among school adolescents.

Methods

This cross-sectional study included 350 students (5th to 9th grade) of a public school in Brazil. Information on BP site and outcomes were self-reported. Logistic regression analyses were performed.

Results

Participants reporting at least one painful site in spine were 74.9% (n = 262), with mean age of 12.73 ± 1.67 (55.7% were girls). Most of them reported pain in two sites (n = 100; 28.6%) and the most frequent pain site was neck (n = 223; 63.7%). Thoracic and low BP were associated with missing school classes, interference in physical activities, seeking healthcare, and medication use, while neck pain showed no association. The number of painful sites was associated with daily activities and healthcare with those gradients increasing with the number of painful sites.

Conclusion

Thoracic and low BP were associated with daily activities, seeking healthcare, and medication use in early adolescence.

Clinical presentation and imaging findings in juvenile-onset back pain: a ten-year hospital-based retrospective analysis in Douala (Cameroon)

Introduction

Studies exploring the clinical and imaging characteristics of juvenile-onset back pain (JOBP) are scarce. The purpose of this study was to assess the clinical presentation, imaging findings, and factors associated with JOBP.

Methods

A retrospective record-based study was conducted among all pediatric cases presenting to the Rheumatology unit of the Douala General Hospital, Cameroon, from January 2014 to December 2023. The study did not include children whose back pain began after 16 years of age.

Results

Of the 216 records of patients under 18 examined, 67 children (31 girls) were diagnosed with JOBP. The median age was 15 [13-16] years. More than two-third of the children included in this study had chronic pain (n = 46; 68.65%). Pain was mild to moderate in intensity in 48 children (71.6%). Radiculopathy was present in 10 children (14.92%). The most common location of back pain was the lumbar region (n = 64; 95.52%). Some children experienced pain in more than one location. The location of the pain was not associated with gender, duration of the pain, radiculopathy, or practice of a competitive sport (p > 0.05). Musculoskeletal abnormalities on imaging were found in 38 children (62.29%). In multivariate analysis, peripheral joint involvement [aOR = 0.253 (0.073-0.878); p = 0.030] and mild pain intensity [aOR = 0.077 (0.014-0.422); p = 0.003], were independently associated with the presence of musculoskeletal abnormalities on imaging.

Conclusion

JOBP affects a third of children and adolescents of our clinic population. The common musculoskeletal abnormalities found on spine imaging are disc diseases and scoliosis.

Clinical examination and imaging resources in children and adolescent back pain

Back pain is a relatively common complaint in children and adolescents. The pediatric patient presenting with back pain can often be challenging, and there are many well-known organic diagnoses that should not be missed. In younger children, an organic cause of back pain can often be found. However, back pain in older children and adolescents is often "non-specific." The differential diagnosis of back pain in children includes neoplasms, developmental, and inflammatory conditions. Basic steps should include an in-depth anamnesis, a systematic physical examination, and standard spine radiographs (anteroposterior and lateral). Nevertheless, advanced diagnostic imaging and laboratory studies should be included when indicated to avoid missing or delaying a serious diagnosis. If other types of imaging tests are necessary (magnetic resonance imaging, computed tomography, bone scan, or single photon emission computed tomography), they should be guided by diagnostic suspicion.

Evaluation and Treatment of the Child with Acute Back Pain

Back pain is common, in up to 30% of children, increasing with age. Eighty percent is benign, mechanical type, improving within 2 weeks of conservative care. Required for those not improving is in-depth evaluation, including MRI, laboratory, and peer consultations. Spondylolysis and spondylolisthesis comprise almost 10% of pediatric back pain, often caused by lumbar hyperextension activities and treated conservatively in most cases. Osteoid osteomas and osteoblastomas constitute the most common benign spinal tumors in childhood. Aggressive and malignant tumors of the spine are rare but when present require tertiary care referral and a comprehensive oncology team for optimal life-sustaining outcomes.