Pediatric orthopaedic surgeon Paul Sponseller discusses the causes and treatments of back pain in children.
I'm paul spong cellar from pediatric orthopedics at johns Hopkins and I'd like to talk about an area that I have a lot of experience with determining the causes and treatment of Children with back pain. I call it, why does this child have back pain? Because kids can come in with all different backgrounds, athletic or not ages and juvenile or adolescents and we have to sort out the causes and the differential and then finally arrive at the treatment. Back pain is common in Children. About 30% of adolescents experience it. But most cases of benign and self limiting, it's important to try to triage it by functional impairment and severity. Kids who have back pain but it's not limiting them and it's not increasing often don't have a serious underlying cause. And we can really treat them according to how much impairment it provides. The most common causes of back pain in Children. In the order of decreasing frequency include Spagnolo license, which is a stress fracture of L. five disk problem such as protrusion or less common degeneration, inflammation of the sacred iliac joints or S. I. Joints infosys scoliosis infection are tumor. Let's start with Pandelis is again, this is the one you can do the most about. It's a unique problem in Children and adolescents because they are so active. It's a stress fracture of the powers inter articular terrorists, which is the part between the vertebral body and the back joints of the spine. It happens most often where the curvature is sharpest at that lumbar lord doses at the very bottom of your spine because there is impingement from one point above to another facet joint below, especially due to hyperextension. It's actually surprisingly common. About 5% of the population has it and many of them develop it by elementary school like first grade. Others don't have it that early but they develop it as they go into the adolescent period of high athletic activity, about a third of those will slip a bit during adulthood. In other words develop a list thesis but most of these don't slip much and they're symptomatic in most cases The most common age group for presenting responded license is aged 10-16. Again the period of increasing activity when the bone density may not be quite adult level. The diagnosis is made by the nature of pain. It's axel not leg pain but lower back pain and it's worse with extension. So when the child bends backward they'll say oh that hurts the most when they bend forward, they can often touch the floor without much discomfort at all. It's also often seen on the lateral X ray if you have a good quality lateral. But if there is some obl equipe, it may be hard to see an M. R. I. Or a C. T. Scan. Usually clinches the diagnosis because that's where you can see either the reactive edema is shown here or the bony break, which is shown best on a cat scan. The treatment is largely conservative usually with rest assisted by non steroidals, they can be made asymptomatic. We try to enforce rest by using a brace for 2-3 months. So the child remembers not to get involved in sports and not to horse around with their friends after that period of rest and hopefully healing. They can rehab their core, their abdominals and they're back extensive muscles to get strong again, be able to move, minimizing the stress on the powers. This is about 95% successful and I define success as minimal pain. The bone doesn't always heal well, but they usually stop hurting and that's the end point you want. It's a rare patient that needs anything more done, such as injection or surgery. But surgery for those who need it is actually very successful. It's not a spine fusion, but it's just a repair of the cracked bone with a pair of screws and some bone graft. As shown here and out of about 100 patients I see with bond analysis only about one Or at most 2% ever need to have surgery. The vast majority have minimized their symptoms and can get back to their desired lifestyle. A more severe consequence of spandau laces is the more rare slippage or spanned over a thesis which is forward slipping of the vertebra above on the one below usually L five S. One and this is the level because that's where the disk is most highly slanted downward and the slipping vector is more pronounced in this level. Only about one out of 10 spinal license patients will develop any less thesis and they tend to slip if at all during adolescence and growth not much after maturity. The symptoms are fairly similar lower back pain, rarely pain in the buttocks and thighs. It typically does not produce leg pain or radiating pain. The treatment is same as panda license, which is rest followed by physical therapy when they're asymptomatic. Of course, there's no way to get that large gap to hell with bone again. But the disk is such an important and effective stabilizer that they tend to stay in that same degree of slip So most do not slip much after maturity and they remain asymptomatic. There is a very low to nearly no risk of nerve damage and patients with up to 50% slip. That is grade two can play sports. So this off road cyclists actually belong to this X ray and he's had a slip for over five years And it looks like it's slipped a fair bit but it actually hasn't changed at all over the years. And now he's up to 10 years since I've seen him last. He's still able to compete in off road cycling and his pain is manageable and minimal moving on to more adult like problems. You can have back pain from disc problems and this can be either wear and tear. In other words degeneration or protrusion or so called herniation of the nucleus. This is the second most common cause of actual back pain. It's important to realize that an M. R. I. Reading does not correlate with the clinical state of the patient. The radiologist will often read the M. R. I. Report and the lumbar spine to show degeneration. Whereas in fact it's just a change in the hydration of the nucleus propose sis. About 50% of people who get a lumbar cat scan will have some disc changes, some disc degeneration or wear and tear. In this case the symptoms are worse with flexion or with straight leg raising, which is another form of flexion at the hip. People who sit for a long period of time are more prone to get this kind of symptom of the disk and disk bulging and disc protrusion. But treatment is still conservative consisting of rest, non steroidals. Physical therapy, occasionally bracing and occasionally epidural steroid injections as you may have heard others of your friends get from time to time. The natural history is that the vast majority of disc bulges. Disc protrusions. Disc herniation are time limited. They get better with time, although it may take several months. They tend to get better as the the bulge recedes or the herniation shrinks just enough to allow the nerve root to pass freely. Another common cause of low back pain is a sacred iliac joint issue. This is more common in teenagers, not juveniles. More common in those with infosys um along the ankle opening spondylitis spectrum. These patients often have other areas of angulo sis. So their chest expansion may be limited because the ribs are getting stuff. It's also seen in other immune disorders such as inflammatory bowel disorder or psoriasis and other inflammatory skin disorders. H. L. A. B. 27 can be positive but it also has a high false positive and false negative rate. So it's not definitive in these cases. I will usually refer the patient to rheumatology for some corroboration on the bottom is an S. I. Joint information. A young preteen who actually had low back pain but it turned out to be due to the side joints. And you can see how irregular and eroded the secretly joints are especially on the left side but also on the right, shown an M. C. T. And an M. R. I. Another cause of unilateral secretly. Joint problems can be a disc infection secretly a joint infection or pathogenic S. I. Joint problems. In these cases, patients are often very symptomatic, federal and acute pain, but only on one side. Sherman hypnosis is another cause of back pain. In both the thoracic and lumbar spines. It's defined as wedging or growth disturbance of the vertebrae with narrowing of the disc space irregularity the in place as you can see here with these indentations and undulations called s'mores nodes. It also can occur in the lumbar lumbar spine even without the presence of fibrosis, although the ideology is unknown. I like to think of it as an osteoporosis which is a disorder behavior of cartilage in response to load in the spine, kind of analogous to Perthes in the hip or Blount's disease in the knee or seaver's disease in the hell. It's a disorder of cartilage as it's trying to grow but getting so much low that it affects its function, its integrity and causes symptoms. Sherman's typically has a young adolescent onset. It causes a focal infosys that's best seen when you bend forward. There often is tight hamstrings and a mild scoliosis. And back pain can be either in the thoracic or lumbar regions at the apex of the curve. It can also cause appearance problems and these are the least talked about. There's some taboo associated with talking about that but it's important to dig into with these teenagers. Asus conservative treatment is the main state exercises may release, relieve the pain such as hamstring strengthening, extensive strengthening but they don't straighten out the deformity of the hostess Bracing actually does improve it for me as well as the pain and can produce 10-15 to even 20° of correction if war until maturity. The indications were bracing our pain occurred between 20 and 45 and 70 growth remaining and flexibility. Here's an example of what poses brace result, showing 20° of permanent correction from 65 all the way down to 40 for now that he is done with a brace and skeletal immature scoliosis can cause back pain but it's very common and most patients don't have too much back pain. Scoliosis is defined as a lateral or sideways curve with rotation and it can occur early in adolescence or even in adulthood It is quite prevalent. About 2-3% of the population has a very mild scoliosis, but only 1/10 of 1% is in the range that could be considered for surgery. The ideology here is also unknown. It seems to be a connected tissue growth in matrix problem. There are many different genes that have been found linked to scoliosis but absent a true focal, concise radiologic idea. We can at least say that it's auto so more dominant with incomplete penetrates back pain. Is president about a quarter of patients that initial evaluation but other identifiable causes rarely found, such as the spinal ISIS, a Sherman's or anything else. So, an extensive work up is not needed unless the pain is severe and functionally impairing the treatment is to localize it to the curve apex to prove that it's from the scoliosis brace it. If the curve meets criteria and also add therapy such as strengthening and stretching. The role of physical therapy and scoliosis has many advocates, especially in europe for correcting scoliosis in my opinion. I haven't seen that it is most effective in correcting pain. My take is that it's good for engaging the patient and getting them to understand and be aware of and manage their back as well as to improve their self image in an interested patient. Dietary factors such as vitamin D. Um which is shown to be low in scoliosis can be supplemented and this may improve their chance of not progressing infectious spinal problems can also cause back pain. Often called inflammatory or infectious disc itis or pie, a genic spondylitis. This is a spectrum of bone disc and bone involvement. The findings are very great stiffness and guarding abdominal pain, sometimes elevated said rate and even occasionally, a positive blood culture early on the X rays can be negative. So you need either a bone scan or an M. R. I. To pick it up. The plain films begin to show the erosions at 2- four weeks. Aspiration can be done. But empirical treatment for staff usually works and so it's not always needed. The treatment involves anti staff antibiotics for six weeks supporting the patient with the use of a rest period, cast or brace and eventually many of them will fuse, which gives them auto stabilization. As shown here in this station here, you can see this 15 year old girl who has increased T. Two signal in the T. 12 body and actually around the end plate as well narrowing of the disc compared to the one above and below and after diagnosis with positive blood cultures, she was treated and you can see her two levels or auto and collapsing and eventually auto fusing tumors are very rare but serious cause of back pain. They tend to cause pain at night, when the child is not so active, may affect the sleep, It's less related to activity. And you can take the form with either a cord tumor like uh glioblastoma, um or it may take the form of a bone tumor such as as Roma or uh leukemia. Lymphoma. Infiltrates neuroblastoma is another tumor seen in young kids, but it produces more leg symptoms and not quite as much back. So in summary back pain is common in Children. It's usually mild not limiting function, so you don't have to go to an extreme work up. In most cases, conservative treatment is appropriate for most serious causes, such as tumor infection are rare, but this is all the more reason to know what to watch for and how to do a good systemic and thorough exam to pick up the diagnosis for your patient.