Back pain in children is frequently mechanical with contributory factors such as poor posture, physical inactivity, obesity or abnormal loading (such as carrying heavy school bags on one shoulder). The causes of back pain are varied.
Certain sporting activities such as cricket, bowling or gymnastics pose increased risk of back pain, with possible consequences such as spondylolysis and spondylolisthesis which present as acute, or acute on chronic pain, with pain on spine extension ('Stork's test - see pREMS spine) and also with localised tenderness (see pREMS).
Scheuermann’s 'disease' results from vertebral wedging due to an osteochondrosis of the thoracic spine. This is often asymptomatic (and may be a coincidental finding on radiograph); it can result in thoracic kyphosis, 'slouching appearance', in which case referral to physiotherapy or paediatric orthopaedics is warranted.
Infections such as vertebral osteomyelitis and Tuberculosis (TB) may present with backache and need to be excluded in endemic regions. Pott's spine is a complication of TB spine.
Scoliosis (lateral curve of the spine) is often asymptomatic, may be more obvious on forward bending and can result from a spectrum of causes.
Inflammatory back pain (often with morning stiffness) and with tender sacroiliac joints can be a feature of Juvenile Idiopathic Arthritis (especially Enthesitis Related Arthritis, Psoriatic Arthritis) and also arthritis in association with inflammatory bowel disease.
A detailed history and examination identifying red flag symptoms and signs prompts urgent referral and helps identify the cause.
Red flags for urgent referral of patients with back pain include:
- painful scoliosis.
- night waking.
- neurological symptoms suggestive of nerve root entrapment or cord compression.
- systemic findings to suggest malignancy or sepsis.
- very young children (<5 years).
- suggestion of inflammatory back pain.
The photograph below shows a thoracolumbar scoliosis
The radiograph below shows a collapsed vertebra (arrow) and scoliosis due to TB infection (this appearance is called Pott's spine)