Back Pain in Children and Adolescents

 

Am Fam Physician. 2020 Jul 1;102(1):19-28.

  Patient information: A related handout on this topic is available at https://familydoctor.org/backpack-safety.

Author disclosure: No relevant financial affiliations.

Back pain is a relatively common presenting symptom in children and adolescents. Typical causes include muscle strain or spasm, spinal deformities (e.g., Scheuermann kyphosis, adolescent idiopathic scoliosis), spondylolysis, bulging or herniated intervertebral disks, apophysitis of the iliac crest, and functional pain syndromes such as fibromyalgia. Spondyloarthropathies such as ankylosing spondylitis may present with low back pain and stiffness, which are often worse in the morning. Less common but more serious causes include malignancy and infections. The physical examination should include postural inspection, evaluation for tenderness, range of motion, strength testing, and testing for fractures and nerve impingement. Treatment for patients with muscle strain include relative rest, home-based exercises, physical therapy, and limited use of nonsteroidal anti-inflammatory drugs. If findings from the history and physical examination suggest underlying pathology, radiography and laboratory studies are indicated initially; magnetic resonance imaging, computed tomography, or a bone scan may be needed for further evaluation. It is generally accepted that the following factors warrant immediate evaluation: patient age younger than five years, symptoms persisting beyond four weeks, systemic symptoms, nighttime pain, bowel incontinence/urinary retention, or other neurologic symptoms.

Back pain is a relatively common condition in children. A 2011 Danish study found a prevalence of 28% to 48% in school-aged children, with increasing incidence in older adolescents.1 Care was sought in less than one-third of cases.1 One large cohort study found associations between back pain and age greater than 12 years, a family history of back pain, spending more than two hours per day studying or watching television, an uncomfortable school desk, widespread pain, and sleep problems.2 Evidence is mixed on the effect of heavy backpacks.3 Back pain in children should be assessed carefully because it can limit participation in sports, activities, and school. An estimated 10% to 15% of affected children will develop chronic low back pain later in life.4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Constant pain, bony tenderness, abnormal neurologic findings, or back pain that occurs at night may warrant further evaluation in children, including imaging and possibly laboratory testing.10,11,13,14

C

Expert opinion and consensus guideline in the absence of clinical trials

Radiography with anteroposterior and lateral views should be ordered for patients with suspected spondylolysis.14

B

Systematic review of imaging for spondylolysis

Most patients with spondylolysis respond to conservative treatment, including relative rest, quadriceps and hamstrings flexibility exercises, and core strengthening with a guided exercise program.23,24

B

Meta-analysis and prospective cohort study

Treatment of Scheuermann kyphosis is generally conservative, without bracing or orthopedic interventions unless the deformity is severe (more than 80 degrees), progressive, or restricts pulmonary function.30,31

C

Prospective comparative study of respiratory measures and clinical review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Constant pain, bony tenderness, abnormal neurologic findings, or back pain that occurs at night may warrant further evaluation in children, including imaging and possibly laboratory testing.10,11,13,14

C

Expert opinion and consensus guideline in the absence of clinical trials

Radiography with anteroposterior and lateral views should be ordered for patients with suspected spondylolysis.14

B

Systematic review of imaging for spondylolysis

Most patients with spondylolysis respond to conservative treatment, including relative rest, quadriceps and hamstrings flexibility exercises, and core strengthening with a guided exercise program.23,24

B

Meta-analysis and prospective cohort study

Treatment of Scheuermann kyphosis is generally conservative, without bracing or orthopedic interventions unless the deformity is severe (more than 80 degrees), progressive, or restricts pulmonary function.30,31

C

Prospective comparative study of respiratory measures and clinical review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

History

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The Authors

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SURAJ ACHAR, MD, CAQSM, FAAFP, is a faculty member at 360 Sports Medicine at Rady Children's Hospital and a professor of family medicine and public health at the University of California San Diego School of Medicine....

JARROD YAMANAKA, MD, CAQSM, is a sports medicine physician at Fairview Sports and Orthopedic Care, Blaine, Minn.

Address correspondence to Suraj Achar, MD, 9500 Gilman Dr., La Jolla, CA 92023 (email: sachar@health.ucsd.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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