Orthopaedic Surgery - Back Pain in Children

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Basics

Pediatric back pain is less common than back pain in adults but becomes increasingly frequent with age.

The estimated prevalence is approximately 6% among children aged 7–10 years and approximately 18% among adolescents aged 14–16 years.

Participation in competitive sports has been associated with a higher risk of pediatric back pain. Behavioral, emotional, and psychological difficulties may also be associated with a greater frequency of symptoms.

Although most pediatric back pain is musculoskeletal and self-limiting, persistent or severe symptoms require careful evaluation because infection, tumor, structural abnormalities, and neurologic disorders may also present with back pain.

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Etiology

The differential diagnosis of pediatric back pain is broad.

Important causes include spondylolysis, spondylolisthesis, tethered cord syndrome, neoplasms, spondyloarthropathies, Bertolotti syndrome, discitis, pyogenic sacroiliitis, Scheuermann disease, lumbar disc herniation, and musculoskeletal strain.

Age, pain characteristics, neurologic findings, systemic symptoms, and activity history help distinguish among these conditions.

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Spondylolysis

Spondylolysis is a defect or stress fracture involving the pars interarticularis, the portion of the vertebral arch located between the superior and inferior facet joints.

It usually develops as a fatigue injury caused by repeated lumbar extension and rotational movements.

Sports involving repetitive hyperextension, such as gymnastics and certain throwing or kicking activities, can increase mechanical stress on the pars.

The estimated prevalence in children is approximately 4.4%.

The fifth lumbar vertebra (L5) is affected most commonly.

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Spondylolisthesis

Spondylolisthesis refers to anterior displacement of one vertebral body relative to the vertebra beneath it.

In children and adolescents, it frequently occurs in association with a pars defect or spondylolysis.

Its estimated prevalence is approximately 0.9%.

Low back pain is the most common clinical manifestation, although some patients may also develop radicular pain or neurologic symptoms if neural structures are affected.

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Primary Tethered Cord Syndrome

Primary tethered cord syndrome is caused by abnormal fixation of the lower spinal cord to surrounding tissues.

This abnormal attachment restricts normal movement of the cord during growth and may progressively impair the lumbosacral nerve roots.

The estimated prevalence is approximately 0.1%.

Tethered cord syndrome may occur together with other congenital spinal abnormalities, including spina bifida.

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Clinical Features of Tethered Cord Syndrome

Symptoms may include low back pain, lower-extremity muscle wasting, clubfoot deformity, leg-length discrepancy, scoliosis, weakness, and sensory loss.

Bladder or bowel dysfunction may also occur in clinically significant cases.

Progressive neurologic abnormalities should prompt further spinal cord evaluation.

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Neoplastic Causes

Tumors are a rare cause of pediatric back pain, accounting for approximately 0.1% of cases.

Both benign and malignant bone or spinal cord tumors may present with back pain.

Pain that is persistent, occurs at night, is associated with systemic symptoms, or is accompanied by neurologic abnormalities warrants further investigation.

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Osteoid Osteoma

An osteoid osteoma is a benign primary bone tumor that may involve the spine.

Up to approximately 20% of osteoid osteomas can occur in spinal locations.

A characteristic clinical feature is back or neck pain that is worse at night and responds markedly to NSAIDs.

The lesion may also cause painful scoliosis when located asymmetrically in the posterior spinal elements.

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Ewing Sarcoma

Ewing sarcoma is an important malignant bone tumor occurring in children and adolescents.

It may present with localized pain together with systemic or constitutional symptoms such as fever, fatigue, and weight loss.

Persistent unexplained back pain associated with constitutional symptoms should therefore raise concern for malignancy.

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Spinal Cord Tumors

Spinal cord tumors may be benign or malignant.

Clinical manifestations depend on the location and extent of the lesion.

Children may develop back pain, progressive motor weakness, sensory abnormalities, gait disturbance, or bowel and bladder dysfunction.

Neurologic deterioration requires prompt imaging.

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Spondyloarthropathies

Pediatric spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, enthesitis-related arthritis, reactive arthritis, and arthritis associated with inflammatory bowel disease.

Their estimated prevalence is approximately 0.2%.

Common manifestations include inflammatory back pain, sacroiliitis, enthesitis, and dactylitis.

Many affected children are HLA-B27 positive, although HLA-B27 positivity alone does not establish the diagnosis.

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Associated Features of Spondyloarthropathies

Reactive arthritis may occur in association with urethritis and conjunctivitis.

Psoriatic arthritis may be associated with cutaneous or nail manifestations of psoriasis.

Enteropathic arthritis occurs in association with inflammatory bowel disease.

Recognition of these associated features can help identify an inflammatory cause of back pain.

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Bertolotti Syndrome

Bertolotti syndrome occurs when a lumbosacral transitional vertebra becomes symptomatic.

A lumbosacral transitional vertebra is an anatomical variant in which the lowest lumbar vertebra has an enlarged transverse process that partially or completely articulates or fuses with the sacrum.

The estimated prevalence of this anatomical variant is approximately 4–10%.

When the abnormal articulation is responsible for low back pain, the condition is termed Bertolotti syndrome.

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Clinical Features of Bertolotti Syndrome

Pain is commonly mechanical and may worsen during lumbar extension.

Some patients also develop radicular symptoms caused by altered lumbosacral mechanics or nerve compression.

Radiographs may demonstrate an enlarged transverse process articulating with the sacrum.

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Discitis

Discitis is an inflammatory or infectious disorder of the intervertebral disc space and is seen most commonly in children younger than approximately 5 years.

Young children may present with back pain, irritability, refusal to walk, or reluctance to sit or bend.

Many affected children remain afebrile, and the peripheral white blood cell count may be normal.

The erythrocyte sedimentation rate (ESR) is elevated in many cases and can support the diagnosis.

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Pyogenic Sacroiliitis

Pyogenic sacroiliitis is a bacterial infection involving the sacroiliac joint.

Patients may complain of pain in the lower back, buttock, hip, or abdomen.

The ESR is often elevated, although the white blood cell count may remain normal.

Because symptoms may be poorly localized, diagnosis can be delayed without a high index of suspicion.

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Scheuermann Disease

Scheuermann disease is a developmental disorder involving the thoracic or thoracolumbar vertebrae.

Its estimated prevalence is approximately 0.2%.

The classic radiographic criterion is anterior wedging greater than 5° in at least three consecutive vertebral bodies.

The precise cause is uncertain, although a hereditary component with autosomal dominant inheritance and incomplete penetrance has been proposed.

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Clinical Features of Scheuermann Disease

Patients commonly present during adolescence with back pain and a rigid focal kyphotic deformity.

Pain may worsen with prolonged sitting, standing, or activity.

Unlike postural kyphosis, the deformity is relatively rigid and does not fully correct with voluntary posture.

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Herniated Nucleus Pulposus

Lumbar disc herniation is uncommon in younger children but may occur in adolescents, sometimes after trauma.

The lumbar spine is affected most frequently.

Symptoms often include low back pain radiating into one or both lower extremities, depending on the nerve root involved.

Neurologic deficits may develop when compression is substantial.

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Musculoskeletal Back Pain

Muscular strain and ligamentous sprain are the most common causes of pediatric back pain.

Symptoms are generally related to activity and improve with rest.

Musculoskeletal back pain is typically self-limiting.

When the history and examination are reassuring and no red-flag features are present, additional imaging may not be necessary.

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Diagnosis

History

History should focus on defining the location, quality, severity, duration, and pattern of pain.

The clinician should ask about trauma, sports participation, repetitive activities, aggravating movements, and previous episodes.

Particular attention should be paid to features that suggest more serious pathology.

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Concerning Symptoms

Red-flag symptoms include motor or sensory deficits, persistent nocturnal pain, bowel or bladder dysfunction, progressive weakness, and gait disturbance.

Constitutional symptoms such as fever, unexplained weight loss, and fatigue may suggest infectious, inflammatory, or neoplastic disease.

These findings usually warrant further investigation.

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Psychological Assessment

Mental and emotional well-being should also be considered.

Anxiety, depression, behavioral problems, and emotional distress have been associated with a higher prevalence of pediatric back pain.

These factors should be evaluated without assuming that the pain is purely psychological.

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Physical Examination

A complete examination should include inspection, palpation, provocative maneuvers, lumbar range of motion, gait assessment, and a detailed neurologic examination.

The findings should be interpreted together with the history.

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Inspection

The child’s posture should be evaluated in both the coronal and sagittal planes.

The examiner should look for scoliosis, excessive kyphosis, abnormal lordosis, pelvic asymmetry, or other deformity.

Skin findings such as dimples, hairy patches, masses, or other congenital markers over the spine may suggest occult spinal dysraphism.

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Gait Assessment

Gait should be observed for abnormalities such as Trendelenburg gait, limping, weakness, or ataxia.

An abnormal gait may indicate hip pathology, neurologic dysfunction, pain, or muscular weakness.

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Palpation

The spinal column, paraspinal muscles, and sacroiliac joints should be palpated.

Midline spinal tenderness raises concern for fracture, infection, or other structural pathology.

Paraspinal tenderness is more commonly associated with muscular strain.

The examiner should also assess for swelling, edema, or a palpable mass.

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Straight Leg Raise Test

The straight leg raise test helps assess possible lumbar disc herniation with nerve root irritation.

With the patient lying supine, the examiner passively raises the leg while maintaining the knee in extension.

Reproduction of radicular pain when the hip is flexed approximately 30–70° supports irritation of the lumbosacral nerve roots and raises suspicion for disc herniation.

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FABER Test

The FABER test evaluates pathology involving the sacroiliac joint or hip.

With the patient supine, the tested hip is flexed, abducted, and externally rotated so that the ankle rests over the opposite thigh.

Downward pressure is then applied to the flexed knee while the contralateral pelvis is stabilized.

Pain around the sacroiliac region may suggest SI joint pathology, including sacroiliitis.

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Lumbar Range of Motion

Lumbar range of motion does not always identify the specific cause of pain, but it can help assess functional limitation and disease progression.

Average pediatric lumbar flexion is approximately 52°, with extension around 19°.

Average axial rotation is approximately 33° to the left and 32° to the right.

Average lateral flexion is approximately 30° to the left and 31° to the right.

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Neurologic Examination

A detailed bilateral neurologic examination should assess motor strength, sensation, and reflexes.

Neurologic abnormalities may help localize a disc herniation or identify spinal cord or nerve root pathology.

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Disc Herniation Findings

An L4–L5 disc herniation may cause weakness involving ankle or great-toe dorsiflexion, depending on the affected nerve root.

An L5–S1 disc herniation may produce a diminished or absent Achilles tendon reflex.

Sensory changes should also be mapped according to the involved dermatome.

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Neurologic Red Flags

Progressive weakness, abnormal reflexes, sensory loss, gait disturbance, or bowel and bladder dysfunction should raise concern for significant neurologic compression or a spinal cord lesion.

Neoplastic and congenital neurologic disorders must also be considered.

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Imaging

The three principal imaging modalities are plain radiographs, CT, and MRI.

The decision to image should be based on the patient’s symptoms and examination while considering radiation exposure and the possible need for sedation in younger children.

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When Imaging Is Not Required

When the neurologic examination is normal and there are no concerning features such as fever, weight loss, persistent night pain, or neurologic changes, immediate imaging is often unnecessary.

Children with uncomplicated musculoskeletal pain may be managed initially with observation and conservative care.

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Plain Radiographs

Plain radiographs are often the initial imaging study when structural pathology is suspected.

They are useful for evaluating vertebral alignment, deformity, spondylolysis, spondylolisthesis, transitional vertebrae, Scheuermann disease, and some tumors.

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CT

CT provides excellent visualization of bone detail.

It can help define pars defects, fractures, congenital abnormalities, and other osseous lesions.

Three-dimensional reconstructions can be useful when detailed anatomical assessment is required.

Because CT exposes children to ionizing radiation, its use should be selective.

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MRI

MRI provides detailed visualization of the spinal cord, nerve roots, intervertebral discs, bone marrow, ligaments, and soft tissues.

It is particularly useful for evaluating infection, tumors, tethered cord, disc herniation, sacroiliitis, and neurologic abnormalities.

MRI avoids ionizing radiation but may require sedation in some young children.

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Imaging in Spondylolysis

Plain radiographs may demonstrate a radiolucent defect through the pars interarticularis.

When radiographs are normal but clinical suspicion remains high, advanced imaging may be considered.

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Imaging in Spondylolisthesis

Radiographs demonstrate anterior displacement of one vertebral body relative to the vertebra below.

Standing lateral radiographs are particularly useful for assessing the degree of slip.

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Imaging in Tethered Cord Syndrome

MRI is the preferred study.

Findings may include abnormalities of the filum terminale, a low-lying cord, or dorsal adherence of the spinal cord.

Associated congenital abnormalities may also be identified.

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Imaging in Osteoid Osteoma

Radiographs or CT may demonstrate a small focal lesion, often with surrounding sclerosis.

CT is particularly useful for identifying the central nidus when osteoid osteoma is suspected.

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Imaging in Ewing Sarcoma

Radiographs may show a destructive bone lesion with a mixture of lytic and sclerotic features.

MRI is useful for defining marrow involvement and soft-tissue extension.

Further oncologic imaging is required if malignancy is suspected.

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Imaging of Spinal Cord Tumors

MRI is the investigation of choice for suspected spinal cord tumors.

Lesions may demonstrate abnormal signal intensity, often appearing hyperintense on T2-weighted imaging, depending on tumor type.

MRI also demonstrates the degree of cord or nerve compression.

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Imaging in Bertolotti Syndrome

Radiographs may reveal an enlarged transverse process of the lowest lumbar vertebra contacting or articulating with the sacrum.

The imaging abnormality must correlate with the patient’s symptoms before it is considered the source of pain.

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Imaging in Discitis

Plain radiographs may eventually demonstrate narrowing of the intervertebral disc space, although early studies can be normal.

MRI is more sensitive for early infection and for evaluating adjacent vertebral and soft-tissue involvement.

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Imaging in Pyogenic Sacroiliitis

MRI may demonstrate inflammation, edema, or fluid around the sacroiliac joint.

It is useful for identifying associated abscess formation or surrounding bone involvement.

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Imaging in Scheuermann Disease

The radiographic diagnosis requires anterior wedging of more than 5° in at least three consecutive vertebrae.

Other findings may include irregular endplates and Schmorl nodes.

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Imaging in Disc Herniation

MRI may demonstrate disc bulging, protrusion, extrusion, reduced disc height, or nerve root compression.

It is the preferred imaging modality when neurologic symptoms suggest clinically important disc disease.

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Imaging in Musculoskeletal Pain

Imaging is usually normal in uncomplicated muscular or ligamentous back pain.

When the history and examination are reassuring, normal imaging is not required to establish a clinical diagnosis of musculoskeletal strain.

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Treatment

Treatment depends on identifying the underlying cause.

Management options include activity modification, rest, physical therapy, medication, and surgery.

Most uncomplicated musculoskeletal causes can be treated conservatively.

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Rest and Activity Modification

Rest from the provoking activity is often the first step in treating spondylolysis and low-grade spondylolisthesis.

Repetitive extension, rotation, and impact activities may need to be temporarily avoided.

Activity is gradually resumed after pain improves and strength and flexibility have been restored.

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Physical Therapy

Physical therapy is beneficial for many causes of pediatric back pain.

Treatment may focus on core strengthening, flexibility, hamstring stretching, posture, spinal stabilization, and correction of biomechanical abnormalities.

The program should be tailored to the child’s diagnosis and activity demands.

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Medication

NSAIDs and acetaminophen can be used for symptomatic treatment of many conditions, including musculoskeletal pain, Bertolotti syndrome, and disc herniation.

Medication should be combined with treatment of the underlying cause rather than used as the sole therapy.

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Spondyloarthropathy Treatment

NSAIDs are commonly used as initial treatment for inflammatory spondyloarthropathies.

Patients with persistent active inflammatory disease may require biologic therapy, including tumor necrosis factor inhibitors, under specialist rheumatologic care.

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Osteoid Osteoma Treatment

Pain from osteoid osteoma often responds markedly to NSAIDs.

Definitive treatment may be considered when symptoms persist or medication is undesirable for long-term use.

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Treatment of Discitis

Discitis is generally treated with appropriate antimicrobial therapy when bacterial infection is suspected or confirmed.

Empiric therapy commonly includes coverage against Staphylococcus aureus, with subsequent adjustment according to cultures and clinical response.

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Treatment of Pyogenic Sacroiliitis

Pyogenic sacroiliitis also requires antibiotic therapy directed toward the causative organism.

Staphylococcus aureus is an important pathogen to cover initially when bacterial infection is suspected.

Drainage may be required if an abscess or persistent collection is present.

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Treatment of Neoplasms

Tumors require treatment according to their histologic diagnosis and stage.

Malignant conditions such as Ewing sarcoma may require systemic chemotherapy together with local control by surgery and/or radiotherapy.

Spinal cord tumors require specialist oncologic and neurosurgical evaluation.

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Surgical Management of Spondylolysis

Most cases of spondylolysis are treated nonoperatively.

Persistent symptomatic lesions that fail conservative treatment may occasionally require direct repair of the pars defect using internal fixation and bone grafting.

Fusion may be considered in selected patients with associated instability or advanced spondylolisthesis.

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Surgery for Spondylolisthesis

Progressive or high-grade spondylolisthesis may require spinal fusion, particularly when there is persistent pain, progression of the slip, deformity, or neurologic compromise.

The exact procedure depends on the severity and level of the deformity.

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Surgery for Bertolotti Syndrome

Most patients with Bertolotti syndrome are initially treated conservatively.

Persistent symptoms attributable to the transitional articulation may occasionally require resection or fusion, depending on the anatomical abnormality and pain generator.

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Surgery for Tethered Cord Syndrome

Symptomatic tethered cord syndrome may require surgical detethering.

The goal is to release abnormal attachments and prevent further neurologic deterioration.

Surgery is particularly considered when progressive weakness, sensory loss, deformity, or bladder dysfunction is present.

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Surgery for Disc Herniation

Most pediatric disc herniations are initially managed nonoperatively when neurologic function is preserved.

Persistent radicular pain, progressive neurologic deficit, or significant neural compression may require discectomy, sometimes combined with limited decompression such as laminotomy or laminectomy.

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Follow-Up

Follow-up should be individualized according to the underlying diagnosis.

Children with uncomplicated musculoskeletal pain should demonstrate progressive improvement with activity modification and rehabilitation.

Persistent pain, worsening deformity, new neurologic abnormalities, or constitutional symptoms require reassessment.

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Prognosis

The prognosis is generally favorable for uncomplicated musculoskeletal causes of pediatric back pain.

Many stress-related and mechanical conditions improve with appropriate activity modification and physical therapy.

Prognosis for infection, tumors, neurologic disorders, and structural deformities depends on the underlying condition and how early treatment is initiated.

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Red Flags Requiring Further Evaluation

Features that should prompt more urgent investigation include night pain, persistent or progressive pain, fever, weight loss, fatigue, neurologic deficit, gait disturbance, bowel or bladder dysfunction, and significant spinal tenderness.

Back pain in very young children also deserves a lower threshold for further investigation.

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Patient Monitoring

Children should be monitored for improvement in pain, spinal motion, posture, gait, muscle strength, and neurologic function.

Return to sport should occur gradually after pain has resolved and normal strength, flexibility, and movement have been restored.

Failure to improve as expected should prompt reconsideration of the diagnosis and possible further imaging or specialist referral.