Pediatric emergency medicine trisk 1055 1055
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CHAPTER 54 ■ PAIN: BACK
DANIEL M. FEIN
INTRODUCTION
Back pain is a relatively uncommon presenting complaint in children. In
pediatrics, the prevalence of back pain is extremely low in toddlers and increases
with age, peaking at the end of adolescence where it approaches rates reported in
adults. The differential diagnosis is broad and warrants careful attention,
especially in younger children, as it can be a sign of significant pathology.
DIFFERENTIAL DIAGNOSIS
Trauma is a common cause of back pain. The trauma may be an isolated direct
force to the back or a more complex mechanism leading to multiple trauma (see
Chapters 111 Musculoskeletal Trauma and 112 Neck Trauma ). Vertebral fracture
and spinal epidural hematoma are significant injuries due to acute trauma.
Repetitive microtraumas due to certain movements (especially in competitive
athletes) may lead to spondylolysis—a stress fracture of the vertebral pars
interarticularis—typically in the lumbar region. Bilateral spondylolysis may lead
to spondylolisthesis—forward slippage of cephalic vertebrae relative to the
caudal vertebrae. High-grade slippage can lead to neurologic symptoms.
Intervertebral disk herniation is less common in children than in adults, and the
diagnosis is often delayed. Scheuermann kyphosis, anterior wedging of ≥5
degrees in three consecutive vertebrae, typically occurs in the lower thoracic
region. Muscle strains are also a common cause of back pain in adolescents.
A high index of suspicion for infectious etiologies of back pain in children is
crucial as they may present without classic signs of infection such as fever or
elevated markers of inflammation. Discitis is more common in children younger
than five, has an insidious onset, and often presents with nonspecific symptoms
such as irritability, crying at night, and refusing to sit. Vertebral osteomyelitis is
more common in adolescents and can be due to bacteria (e.g., Staphylococcus
aureus ) or Mycobacterium tuberculosis (Pott disease). The classic presentation of
a spinal epidural abscess is a triad of fever, spinal pain, and neurologic deficits.
This infectious emergency requires prompt diagnosis with magnetic resonance
imaging (MRI), treatment with intravenous antibiotics, and potentially surgery.
Many other nonspinal infections cause back pain including local infections (e.g.,
pyomyositis of the back muscles, pyelonephritis), systemic infections (e.g.,
