Pediatric emergency medicine trisk 1061 1061
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Inspection of the back should assess for normal alignment (e.g., abnormal
kyphosis or lordosis), signs of local injury or rash. In spondylolysis, there is
excessive lumbar lordosis. With Scheuermann kyphosis there is a fixed thoracic
or lumbar kyphosis unaffected by patient position which is best observed from the
side during trunk flexion. It is noteworthy that idiopathic scoliosis typically does
not cause back pain, so scoliosis found on inspection of a child with back pain
may suggest a concomitant finding.
Palpation of the spine can isolate areas of tenderness. Fractures, vertebral
osteomyelitis, and discitis typically have tenderness over the affected areas, while
muscular back pain may have tenderness to the paraspinal muscles. Ranging the
back can elicit pain with certain maneuvers. Discitis will have pain with trunk
flexion, as may certain spinal cord tumors. Children with spondylolysis may have
pain with hyperextension of the back. A positive straight leg raise test suggests
radiculopathy, possibly secondary to disc herniation or spondylolisthesis. With
sacroiliitis, there is a positive FABER (Flexion, Abduction, External Rotation)
test. With this maneuver, the supine patient’s leg is flexed at the knee while the
ipsilateral hip is abducted and externally rotated so that the ankle rests over the
contralateral knee. Applying force on the flexed knee will produce pain at the
contralateral, inflamed sacroiliac (SI) joint.
The physical examination should not be limited to the back and spine. Flank
tenderness suggests lateral muscle strain, renal inflammation, or infection. A
careful abdominal examination may reveal an intra-abdominal infection or mass.
A pelvic examination may identify an imperforate hymen or cervical motion
tenderness. A broader examination may reveal signs concerning for pneumonia,
influenza, or other etiologies of back pain. Table 54.2 lists historical and physical
examination “red flags” for back pain that may suggest serious underlying
pathology. Figure 54.1 provides an algorithmic approach for diagnosis of
etiologies of back pain in children.
