Back Pain in Children and Adolescents

Report
Back Pain in Children and
Adolescents
Christine Hom, M.D
Division of Pediatric Rheumatology
New York Medical College
Back Pain
 Back
pain in children - abnormal until proven otherwise!
 75%
of children with back pain have an identifiable
etiology
 Adolescents
more likely to have musculoskeletal pain or
lower back pain syndromes
Back Pain
 In
children with back pain of >2 months’ duration:
– 33% had a post-traumatic etiology: occult fracture or
spondylolysis
– 33% had kyphosis or scoliosis
– 18% had a tumor or infection
Back pain in adolescents
 In
a school based study of 446 adolescents aged 13-17y:
 26%
of adolescents report some back pain, especially
related to sports
 Male:Female
ratio 1:1
 50% of tennis and soccer players
 up to 85% of male gymnasts
 Maneuvers
requiring posterior extension of the leg often
provoke lower back pain
Etiology of back pain
 INFECTION
 INFLAMMATION
 MECHANICAL
 ORTHOPEDIC
 TRAUMA
 MALIGNANCY
 SYSTEMIC
 OTHER
DISEASE
Etiology of back pain
 INFECTION
– Sacroiliac infections
– Vertebral osteomyelitis
– Diskitis
– Pyelonephritis
– Potts disease
– Spinal epidural abscess
– Psoas abscess
Etiology of back pain
 INFLAMMATION
– Ankylosing spondylitis
– Reiter’s syndrome
– Inflammatory bowel disease
– Spondyloarthropathy
– SEA syndrome
Etiology of back pain
 MECHANICAL
– Musculoskeletal (sprain/strain)
– Herniated disc
 ORTHOPEDIC/TRAUMA
– Spondylolisthesis
– Spondylolysis
– Scheuermann’s disease
– (Scoliosis)
– Vertebral compression fracture
Etiology of back pain
 MALIGNANCY
– Spinal cord tumors (lipoma, teratoma)
– Bone tumors
 Osteoid
osteoma
 Ewing’s sarcoma
 Vertebral osteosarcoma
– Neuroblastoma
– Leukemia
– Eosinophilic granuloma
– Aneurysmal bone cyst
Etiology of back pain
 SYSTEMIC
DISEASE
– Secondary hyperparathyroidism
(Stones, bones, groans, moans)
– Sickle-cell anemia - back pain is common
– Osteoporosis
– Corticosteroid use
– Aseptic necrosis
– Nephrolithiasis
Etiology of back pain
 OTHER
– Fibromyalgia
– Reflex sympathetic dystrophy
– Conversion disorder
– Pain amplification syndrome
– Psychogenic
Evaluation of back pain
 HISTORY
and physical
– point tenderness
 CBC,
ESR, SMA-20, urinalysis
 Lyme titer
 HLA-B27
 Plain films, including oblique views
 Bone scan
 CT/MRI
Evaluation of back pain
 WARNING
SIGNS
– Increasing pain
– Pain wakes child from sleep
– Function: usual activities impaired
– Weight loss
– Fever
– Bowel or bladder dysfunction
– Young age, < 4 yo
Diskitis
 Typical
patient is 3-5 years old
 Systemic findings: fever, irritability, abdominal
pain, anorexia
 Rigid posture; refuses to flex lumbar spine
 Elevated ESR
 Plain films reveal irregular vertebral endplates
 CT/MRI reveal decreased signal in disk and
increased in adjacent vertebrae
 Usually hematogenous bacterial infection with
S. aureus (88% no organism on aspirate)
Vertebral Osteomyelitis
 Older
children
 Only accounts for 2-4% of osteomyelitis
 Children appear more toxic: fever, irritability,
refusal to walk
 Elevated ESR, sedimentation rate
 Radiographs show destruction of vertebral
body
 Organism usually recovered (S. aureus) on
aspirate
Spondylolysis/spondylolisthesis
 Defect
of the pars interarticularis
 Usually at L5
 Scottie-dog appearance on plain film
– obtain oblique and lateral films
 Complaints
of low back pain, worse with
palpation
 Slippage of L5 on S1 is spondylolisthesis
  in athletes with hyperextension of spine
Scheuermann’s disease
 Juvenile
kyphosis
 Painful
in 50% of cases
 Usually
affects boys 13-17 years of age
 75%
of cases affect the thoracic spine
 Fixed
dorsal kyphosis
 Compensatory
lumbar lordosis
Scheuermann’s disease
X-ray reveals Schmorl’s nodes and
vertebral wedging with irregular vertebral
endplates
 Lateral
 The
disease is self-limited with a benign
course
 Treatment:
Nonsteroidal analgesics
– severe cases may require bracing with an external
Milwaukee brace for comfort
Enthesitis
 Local
tenderness to palpation at insertions of
– tendon
– ligament
– capsule
 On
–
–
–
–
–
–
–
physical exam:
Patella at 10 o’clock, 2 o’clock, 6 o’clock
Tibial tuberosity
Insertion of the Achilles tendon
Plantar fascia insertion onto calcaneus
Metatarsal heads
Greater trochanter of the femur
Anterior superior iliac spine
Juvenile ankylosing spondylitis
 Chronic
arthritis of peripheral and axial skeleton
 Enthesitis
 Seronegative
(rheumatoid factor negative)
 Extraarticular
manifestations: acute iritis, rarely low
grade fever, urethritis or diarrhea
 ALL
have sacroiliac arthritis
 Genetic
basis: 2-10% of HLA-B27 positive patients will
develop JAS
Juvenile ankylosing spondylitis:
New York AS criteria

expansion of lumbar spine
 Pain at lumbar spine
 Chest expansion 2.5 cm or less
 AND
– radiographic demonstration of sacroiliac
arthritis (may be unilateral)
Juvenile ankylosing spondylitis
 Iritis
– Acute
– Painful
– Photophobia
– Red eye
– Anterior nongranulomatous uveitis
– Few sequelae, but synechiae may develop
– Episodic course most commonly seen in
HLA-B27+ patients. If ANA positive, may
develop chronic uveitis similar to JRA
Juvenile ankylosing spondylitis
 HLA-B27
– Class I major histocompatibility antigen
– varied presence in ethnic populations:
 50%
of Canadian Haida Indians are HLA-B27+
 only 2% of Japanese general population
– Incidence of JAS varies with HLA-B27
presence in a given population
– 10% risk of AS in children of HLA-B27+
patient with AS
– 20% risk of AS if they are also HLA-B27+
and male
Treatment of Juvenile AS
 NSAIDs
– tolmetin sodium (Tolectin)
– indomethacin
 Sulfasalazine
 Intraarticular
steroid injections
 Local steroid injections at entheses
 Physical therapy
 New
treatments include infliximab
(monoclonal anti-TNF) and etanercept
(sTNFR)
Juvenile ankylosing spondylitis
 Children
often develop peripheral
arthritis years before axial involvement
 Look for SEA syndrome: seronegative
enthesitis and arthropathy
 Complaints of pain in buttocks, groin,
thighs, heels often predate frank
sacroiliac disease
JRA or JAS?
Male:Female
Age of onset
Back pain
Enthesitis
HLA-B27 +
ANA
RF
Iritis
JRA
JAS
1:4
5 yo
2%
Rare
15%
30-50%
15%
Chronic
7:1
>10 yo
100%
Common
90%
<5%
<5%
Acute
DEXA Scan of Lumbar spine
Look at Z-scores
Percentage of bone mass
relative to age matched controls
Does not tell risk of fracture
Risk of vertebral collapse more
likely in pediatric population,
rather than hip fracture
Treatment:
weight bearing exercise
calcium, Vitamin D suppl.
bisphosphonates
Pain amplification syndromes
 Pain
out of proportion to clinical findings
 Pain does not follow anatomical boundaries
 With
autonomic findings
– Chronic regional pain syndrome
– Reflex sympathetic dystrophy
– Causalgia/Sudeck’s atrophy
 With
painful tender points
– Fibromyalgia
 Hypervigilant
– psychogenic/psychosomatic
Pain amplification syndromes
 80%
are female
 Median age 12 years
 Mean duration of pain 1.6 years
 Constant pain
 Multiple locations
 Lower extremity more often than upper
 Role model for chronic pain
 Personality: mature, excellent student, eager
to please, many extracurricular activities
Pain amplification syndromes
 Mother
is the spokesperson and gives the
history including subjective complaints
 Incongruent affect: la belle indifference
 Marked disability despite a paucity of physical
findings
 Other findings of headache, abdominal pain,
sleep disturbance and fatigue
 Allodynia - pain disproportionate to stimulus
Pain amplification syndromes
Treatment
 Physical therapy:
– Aerobic exercise daily
– Desensitization with toweling
– Range of motion exercises
 Cognitive
behavioral therapy
– Progressive muscle relaxation
– Guided imagery
– Self-hypnosis
 Pharmacotherapy
– Low dose amitriptyline or SSRI

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