Back pain in children is less common than in adults but is more common than previously thought. The younger the child and the more acute the history, the more likely that there is serious underlying pathology responsible for the symptoms.
Back pain may be due to abnormal posture or leg alignment so check the lower limbs for joint involvement, hypermobility or leg length discrepancy.
Neck pain may be postural. When associated with restricted movement, then consider inflammatory joint disease. However, isolated neck involvement in inflammatory joint disease is unusual, so be aware of red flags to suggest malignancy or infection.
Pain in the thoracic region or neck is more likely to suggest pathology than lumbar pain.
Scoliosis is usually not painful – the presence of painful scoliosis warrants urgent referral.
Red flags include young age, persistent or worsening pain, night pain or systemic features (such as fever or weight loss) and neurological signs. Always consider malignancy. Benign bone tumours (osteoid osteomas) may occur in vertebrae and can cause night pain.
Mechanical back pain is common particularly in adolescents and is often caused by factors such as poor posture and carrying heavy school bags on one shoulder. It tends to be worse in the evenings and localised to lower back. As a general rule, school bags should not exceed approximately 15% of the child's weight.
Consider spondylolysis and spondylolisthesis in physically active young people engaged in activity with hyperextension of the spine (e.g., cheerleaders, wrestlers, cricketers, gymnasts).
Consider ankylosing spondylitis in teenagers (especially boys) with inflammatory back pain and tenderness over the sacroiliitis joints.
Scheuermann’s disease’ can be a normal variant observed on a radiograph as a coincidence. Radiographs may show anterior wedging of the vertebrae, narrowing of disc spaces and Schmorl’s nodes. It can be associated with back pain in older children and adolescents but if there is severe pain then it is important to suspect another cause for the pain.
Please note: a pdf document of these Top Tips is also available here.
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