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Back Pain

Sam is an 8 year old boy who is referred by his paediatrician to paediatric rheumatology with a 12 month history of pains in his neck and upper back. He is fine when he wakes up in the mornings and has no sleep disturbance at night. His pain tends to get progressively worse through the course of the day, especially at school if sitting for long periods of time. The worse time for his pain is end of the day and he sometimes has difficulty getting to sleep as he cannot get comfortable. He is otherwise well, with no loss of appetite or weight loss and feels well. He has no other joint pains. He is able to take part in PE at school but does not do any sports outside of school. There are no pins and needles in his legs and no pain in his back on coughing or straining.

There is a family history of back pain although there are no clinical details available other than his father having backache from an early age. 

On examination, he looks well and is not pale or thin. pGALS demonstrates hypermobility in his hands and he has mobile flat feet. There is no tenderness of his spine but he has got reduced forward flexion of his lumbar spine but can just reach his knees. He has tight hamstrings. He has a normal straight leg raise and normal reflexes. 

What is the likely diagnosis?

This is likely to be mechanical back pain.

There are no red flags in the history (suggestive of infection, malignancy or nerve / root compression). The family history of back pain in his father and starting at an early age is interesting and raises possibility of inflammatory back pain. However neither the history nor the examination are typical of inflammatory back pain in Sam. 

What investigations may be considered any why?

Investigation is warranted if there is clinical concern, or symptoms are worsening or interfering with function.

Blood tests and radiographs will be normal with mechanical back pain.

HLA-B27 has an association with inflammatory back pain but is present in many healthy individuals and is therefore not diagnostic.

MRI scan of the spine to include sacroiliac joints and using Gadolinium may be indicated to exclude pathology and is more useful in adolescents as radiographs may be normal.

Radiographs including oblique views may be indicated to exclude spondylolysis / listhesis although further imaging may be needed. Radiographs are not helpful to exclude sacroiliitis and may be normal. 

Management of mechanical back pain is physiotherapy, advice on posture and carrying heavy loads (e.g., school bags) and encouraging activity (swimming is ideal) and weight loss if appropriate. Hamstring stretches and advice on foot wear may be helpful.