Low Back Pain in Adolescents: A 1-Year Analysis of Eventual Diagnoses

Management of low back pain accompanying sagittal plane pathologies in children: Spondylolysis/spondylolisthesis and Scheuermann's disease

Background

Low back pain in childhood was underappreciated for a long time, but recent studies report higher prevalences, up to 70%. Two of the common causes are spondylolyis/spondylolisthesis and Scheuermann's disease. These disorders are relevant in a way they both cause significant back pain, and may disrupt the sagittal spinal balance.

Purpose

To present the current evidence on the diagnosis, natural history and treatment of these disorders with a special focus on sagittal spinal alignment.

Methods

This study is conducted as a literature review.

Results and Conclusions

Spondylolysis and low-grade spondylolisthesis have a benign course and are typically treated conservatively. When pars repair is indicated, pedicle screw-based techniques achieve more than 90% fusion with acceptable complication rates. High-grade spondylolisthesis, however, is frequently progressive. Surgical treatment involves fusion, which can be done in situ or after reduction. Reduction is useful for "unbalanced" patients to acquire sagittal spinopelvic balance, and it is important to distinguish these patients. Despite lowering the risk for pseudoarthrosis, reduction brings a risk for neurologic complications. With re-operation rates as high as 40%, these patients definitely require careful preoperative planning. Scheuermann's disease generally causes back pain in addition to cosmetic discomfort during adolescence. If the kyphosis is lower than 60°, symptoms typically resolve into adulthood with conservative measures only. However, it must be kept in mind that these patients may experience problems with physical performance and have a lower quality of life even when the problem seems to have "resolved". Severe kyphosis and intractable back pain are the most frequently referred surgical indications, and surgery typically involves fusion. Proper utilization of osteotomies and proper selection of the upper and lower fusion levels are of utmost importance to prevent complications in these patients.

How back pain influences daily activities and quality of life: Incidence of back pain related to age

Low back pain is a prevalent global musculoskeletal issue, with a lifetime prevalence ranging from 49% to 70% in adults. Traditionally associated with adults, recent field surveys indicate comparable prevalence rates in children and adolescents, challenging earlier assumptions. Non-specific low back pain, where the source cannot be identified through diagnostic imaging, accounts for about 80%-90% of cases. Studies have shown that over 80% of adolescents with low back pain exhibit no underlying pathology. The prevalence of low back pain in younger populations varies widely, influenced by study methodology, age, and pain types. Research suggests that back pain prevalence in adolescents increases with age, with a shift in attitudes considering it is not necessarily indicative of specific issues. Level of evidence: level V.

Update on Pediatric Spine Imaging

The spine is often difficult to evaluate clinically in children, increasing the importance of diagnostic imaging to detect a wide variety of spinal disorders ranging from congenital abnormalities to severe infections. Clinical history and physical examination can help determine whether imaging is needed and which imaging technique would be best. The most common cause for back pain, even in children, is muscular strain/spasm that does not require any imaging. However, red flags such as pain at age < 5 years, constant pain, night pain, radicular pain, pain lasting > 4 weeks, or an abnormal neurologic examination may require further investigation. Imaging can be of great value for diagnosis but must be interpreted along with the clinical history, physical examination, and laboratory findings to achieve an accurate diagnosis. We discuss imaging for the most common and/or important spine pathologies in children: congenital and developmental pathologies, trauma, infectious processes, inflammatory causes, and tumors.

Investigation of Vitamin D Levels and the Effects of Being an Agricultural Worker on Etiology and Night Pain in Children and Adolescents With Chronic Low Back Pain

Objective: Chronic low back pain in children is a condition that should be investigated. In this study, we examined the effects of agricultural work on imaging results, risk factors, night pain, and vitamin D levels in children and adolescents with chronic low back pain.

Material and methods: The study included 133 patients who presented to the Physical Medicine and Rehabilitation and Neurosurgery outpatient clinics with low back pain that had lasted more than three months. The patients were evaluated based on the duration of their low back pain, the presence of night pain, a family history of low back pain, their employment status, local or radicular pain, and their body mass index (BMI). A physical examination was carried out to look into the etiologies of low back pain. Appropriate imaging, such as x-ray radiography, magnetic resonance imaging (MRI), and computed tomography (CT), was performed for the patients. Blood samples were collected from patients to assess inflammatory pathologies and vitamin D levels.

Results: The 133 patients in the study ranged in age from seven to 16 years, with a mean age of 14.3 + 1.9 years. Further, 60.2% (n = 80) of the cases were male, while 39.8% (n = 53) were female. Imaging revealed findings in 59.4% of the patients. In 97.7% of the participants, D hypovitaminosis was detected. There was no significant relationship between the patients’ imaging findings and vitamin D deficiency, family history, BMI, and employment status (p = 0.441, 0.147, 0.082, 0.605). The relationship between family history, employment status, and night pain was statistically significant (p < 0.001). There was no statistically significant relationship between night pain and vitamin D deficiency (p = 0.667).

Conclusion: Mechanical strain due to agricultural work and family history was found to be associated with night pain in patients with chronic low back pain in our study. The most important finding of this study is that night pain, which is considered a red flag, can occur in both inflammatory pathologies and situations causing mechanical low back pain, and risk factors should be thoroughly investigated. Studies with patients who have sufficient vitamin D will help to clarify the relationship between chronic low back pain and vitamin D.

Back Pain without Disease or Substantial Injury in Children and Adolescents: A Twin Family Study Investigating Genetic Influence and Associations

This twin family study first aimed to investigate the evidence for genetic factors predicting the risk of lifetime prevalence of non-specific low back pain of at least three months duration (LBP (life)) and one-month current prevalence of thoracolumbar back pain (TLBP (current)) using a study of children, adolescents, and their first-degree relatives. Secondly, the study aimed to identify associations between pain in the back with pain in other regions and also with other conditions of interest. Randomly selected families (n = 2479) with child or adolescent twin pairs and their biological parents and first siblings were approached by Twins Research Australia. There were 651 complete twin pairs aged 6-20 years (response 26%). Casewise concordance, correlation, and odds ratios were compared for monozygous (MZ) and dizygous (DZ) pairs to enable inference about the potential existence of genetic vulnerability. Multivariable random effects logistic regression was used to estimate associations between LBP (life) or TLBP (current) as an outcome with the potentially relevant condition as predictors. The MZ pairs were more similar than the DZ pairs for each of the back pain conditions (all p values < 0.02). Both back pain conditions were associated with pain in multiple sites and with primary pain and other conditions using the combined twin and sibling sample (n = 1382). Data were consistent with the existence of genetic influences on the pain measures under the equal environments assumption of the classic twin model and associations with both categories of back pain were consistent with primary pain conditions and syndromes of childhood and adolescence which has research and clinical implications.

No associations between C-reactive protein and spinal pain trajectories in children and adolescents (CHAMPS study-DK)

Preliminary evidence points to a link between C-reactive protein (CRP) and spinal pain in adults. However, there is a paucity of research in younger populations. Therefore, we aimed to determine associations between CRP and spinal pain in childhood and adolescence. We identified trajectories of spinal pain from childhood to adolescence and investigated the associations between CRP and trajectory subgroups. Six- to 11-year-old children from 13 primary schools, were followed from October 2008 and until 2014. High-sensitivity CRP collected at baseline (2008) was measured using serum samples. The outcome was the number of weeks with non-traumatic spinal pain between November 2008 and June 2014. We constructed a trajectory model to identify different spinal pain trajectory subgroups. The associations between CRP and spinal pain trajectory subgroups were modelled using mixed-effects multinominal logistic regression. Data from 1556 participants (52% female), with a mean age of 8.4 years at baseline, identified five spinal pain trajectory subgroups: "no pain" (55.3%), "rare" (23.7%), "rare, increasing" (13.6%), "moderate, increasing" (6.1%), and "early onset, decreasing" (1.3%). There were no differences in baseline high-sensitivity CRP levels between spinal pain trajectory subgroups. Thus, the heterogeneous courses of spinal pain experienced were not defined by differences in CRP at baseline.

Investigation of Spinal Magnetic Resonance Imaging Results of Pediatric Patients Presenting with Low Back Pain

Objective: Low back pain in pediatric patients can be severe in terms of its consequences and should be investigated. In this study, the etiology of pediatric low back pain was examined, and it was evaluated whether there was a relationship between age and gender. Material and Methods: In this study, 228 patients under 18 who applied to Şanlıurfa Training and Research Hospital Physical Medicine and Rehabilitation and Brain and Nerve Surgery polyclinics complained of low back pain and underwent spinal Magnetic Resonance Imaging (MRI) in 2021 were analyzed retrospectively. Results: The ages of 228 patients included in our study ranged from 4 to 18 years, with a mean age of 12.8±2.5. 54.8% of the cases were male (n=125), 45.2% (n=103) were female. While MRI findings were not observed in 92 cases, MRI findings were found in 136 cases. Disc pathology was detected in 44.7% (n=102) of the cases, and structural pathology was found in 14.9% (n=36). The most common disc pathology was bulging, constituting 32.9% (n=75) of the cases. There was no significant difference between the genders of the cases according to the incidence of disc pathology (p=0.434). When age and incidence of disc pathology were evaluated, the age of the group with disc pathology was significantly higher than the group without disc pathology (p

Balance and Posture in Children and Adolescents: A Cross-Sectional Study

Balance and posture are two topics that have been extensively studied, although with some conflicting findings. Therefore, the aim of this work is to analyze the relationship between the postural angles of the spine in the sagittal plane and the stable static balance. A cross-sectional study was conducted with children and adolescents from schools in northern Portugal in 2019. An online questionnaire was used to characterize the sample and analyze back pain. Spinal postural angle assessment (pelvic, lumbar, and thoracic) was performed using the Spinal Mouse^®, while stabilometry assessment was performed using Namrol^® Podoprint^®. Statistical significance was set as α = 0.05. The results showed that girls have better balance variables. There is a weak correlation between the anthropometric variables with stabilometry variables and the postural angles. This correlation is mostly negative, except for the thoracic spine with anthropometric variables and the lumbar spine with BMI. The results showed that postural angles of the spine are poor predictors of the stabilometric variables. Concerning back pain, increasing the postural angle of the thoracic spine increases the odds ratio of manifestation of back pain by 3%.

Magnetic resonance imaging findings among young adults with low back pain at Nsambya hospital

Background

Studies on MRI findings among patients with LBP have been conducted; especially among adolescents and young adult population in developed countries. However, MRI lumbar spine evaluation findings in young adult patients with low back pain in Uganda is not known. The purpose of this study was to determine the MRI findings and their correlation to clinical features in young adult patients with low back pain in Nsambya hospital.

Methods

This was a descriptive cross sectional study. One hundred and fifty-seven patients with low back pain in the 18–39 year age group underwent MRI lumbar spine evaluation. The MRI changes in the lumbar spine and correlation to clinical features were determined. Correlation was assessed by Pearson chi square tests (Fisher’s exact test) and p values reported at 0.05 level of significance.

Results

Of the 157 patients 129 (82.2%) had severe pain, whereas ninety (57.3%) had pain that had lasted more than 10 weeks. Sixty-five (41.4%) patients were found to have MRI evidence of disc desiccation, majority (61%) of whom had multiple level disease, mostly involving the lowest 2 disc levels. Facet joint arthropathy (47.8%), marginal osteophyte (31.8%) and disc contour irregularity [disc bulge] (31.2%) were other common MRI features seen. There was an association between duration of pain and limb weakness, and development of marginal osteophytes. There was also association between clinical presentation and disc bulge.

Conclusions

The MRI finding of disc degeneration among young adult patients with LBP is higher than reported. Age and pain distribution are predictors of developing disc desiccation.

Association Between Family History of Surgically Treated Low Back Pain and Adolescent Low Back Pain

STUDY DESIGN

Cross-sectional.

OBJECTIVE

To study the associations between a family history of surgically treated low back pain (LBP) and adolescent LBP.

SUMMARY OF BACKGROUND DATA

A family history of LBP is related to adolescent LBP, but whether a family history of back surgery is relevant to adolescent LBP is not known.

METHODS

A subpopulation of the Northern Finland Birth Cohort 1986 was contacted when they were aged between 18 and 19years. The postal questionnaire asked the participants to report their LBP and a relative's (mother, father, sibling) LBP and back surgery, and to provide data on potential covariates. The association between a family history of LBP ("no family history of LBP," "family history of LBP but no surgery," and "family history of LBP and surgery") and adolescent LBP (no LBP, occasional LBP, and frequent LBP) were evaluated using logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for sex, smoking, and psychological distress.

RESULTS

Of the 1374 adolescents in the study, 33% reported occasional LBP and 9% frequent LBP. Both the "family history of LBP but no surgery" and "family history of LBP and surgery" categories were associated with frequent LBP (adjusted OR [aOR] 2.09, 95% CI 1.38-3.16; aOR 2.23, 95% CI 1.02-4.90, respectively). Occasional LBP was associated with the "family history of LBP and surgery" category. A subgroup analysis of adolescents with a family history of LBP found no statistically significant associations between family history of back surgery and adolescent LBP.

CONCLUSION

Our findings suggest that adolescents who report a family history of LBP have higher odds of frequent LBP irrespectively of a family history of back surgery.Level of evidence: 4.

Assessing a child or adolescent with low back pain is different to assessing an adult with low back pain

In contrast to an assessment of an adult presenting with low back pain (LBP), clinicians should utilise different approaches when assessing children and adolescents presenting with LBP. Children are not 'little adults'. There are some unique pathologies that only occur in this age group: (i) serious pathologies include infection, fracture, child abuse and malignancy; (ii) growth-related pathologies include scoliosis, Scheuermann's disease, pars fracture and spondylolysis; and (iii) rheumatological conditions include juvenile idiopathic arthritis and ankylosing spondylitis. With changes in each child occurring physically, emotionally and socially, a clinician's knowledge of typical developmental milestones is essential to identify regression or delayed development. When listening to a child discuss their pain experience, a flexible structure should be implemented that gives the capacity to actively listen to a child's narrative (and that of their guardian) and to conduct an effective physical examination. This viewpoint also summarises the relationship between potential clinical diagnoses and key elements of a physical examination. Deciding on the type and timing of paediatric-specific physical examination tests requires unique child-centred considerations. Paediatric-specific outcome measures should be used but implemented pragmatically, with consideration regarding the time, complexity and pathology suspected. Systematic and rigorous approaches to both treatment planning and re-assessment are then proposed for the assessment of children and adolescents presenting with LBP.

Treatment of Unspecific Back Pain in Children and Adolescents: Results of an Evidence-Based Interdisciplinary Guideline

Using a structured approach and expert consensus, we developed an evidence-based guideline on the treatment and prevention of non-specific back pain in children and adolescents. A comprehensive and systematic literature search identified relevant guidelines and studies. Based on the findings of this literature search, recommendations on treatment and prevention were formulated and voted on by experts in a structured consensus-building process. Physical therapy (particularly physical activity) and psychotherapy (particularly cognitive behavioral therapy) are recommended for treating pediatric non-specific back pain. Intensive interdisciplinary treatment programs should be provided for chronic and severe pain. Drug therapy should not be applied in children and adolescents. Further research on non-specific back pain in childhood and adolescence is strongly needed to reduce the imbalance between the high burden of non-specific back pain in childhood and adolescence and the low research activity in this field.

Pediatric back pain-Diagnostic algorithm

BACKGROUND

Back pain in the pediatric population is common. History and a thorough physical examination and a systematic work-up approach are key components to guide the physician in evaluating the possible causes of pain and providing appropriate treatment.

OBJECTIVE

The main aim of this review was to develop an algorithmic approach to assist physicians in the assessment of pediatric back pain. A comprehensive review of prevalence, differential diagnoses and proper management of pediatric back pain are also presented.

MATERIAL AND METHODS

An extensive literature search was performed in PubMed to gather articles on the prevalence, risk factors, diagnostic tools, differential diagnoses and appropriate management of pediatric back pain.

RESULTS

Available literature revealed that pediatric back pain is a common complaint. Although most cases are non-specific and self-limiting, there is a wide differential that should be considered including inflammatory, neoplastic, infectious and mechanical causes. Sedentary lifestyle, obesity and vigorous physical activity have been shown to increase the likelihood of developing back pain. We proposed an algorithm to guide the physician's decision about the next step in the diagnostic process.

CONCLUSION

A well-defined strategy in the diagnostic process is needed in approaching children/adolescents with back pain. This would have the benefit of minimizing costs, unnecessary tests and child/family anxiety as well as increasing the likelihood of early diagnosis and proper treatment.

Review of Pediatric Neurologic History and Age-Appropriate Neurologic Examination in the Office

The neurologic examination of an infant or child can be daunting, as they are unable to verbally communicate or follow directions. It starts with tailoring the pediatric neurologic history and examination to the child's specific age group. A good neurologic history obtained from the patient and parents is key to evaluating a pediatric patient. This article offers pearls on what information to ask the caregivers and patients, and salient aspects of a brief neurologic examination.

[Chronic pain in pediatric primary care : What do adolescents and parents expect and how do they perceive treatment?]

BACKGROUND AND OBJECTIVES

Recurrent pain in childhood and adolescence is a common health problem. Pediatricians are usually the patients' first contact person. The current study investigated patients' and parents' expectations when consulting a pediatrician and their rating of the treatment.

MATERIALS AND METHODS

In 36 pediatric practices, 224 patients with recurrent pain and 273 parents participated in this cross-sectional tablet survey. The collected data included the motivation for arranging a physician consultation, pain concept, treatment expectations, and assessment of treatment. Additionally, the patients' age was investigated as an influencing factor.

RESULTS

The patients' and parents' predominant motivation for arranging a consultation was the clarification of the cause of pain. Older patients were additionally motivated by frequent but ineffective drug use. Predominantly in older patients, a biopsychosocial pain explanation was identified. Approximately half of all patients and parents indicated biological and psychological influencing factors. The most frequent expectation of the consultation was obtaining information on pain management. Overall, consultations were rated very positively, especially when patients and parents felt understood and taken seriously.

CONCLUSIONS

Information about the cause of pain and pain management are essential for patients and parents. Besides good communication, sufficient time resources of the practitioner are required.

Low Back Pain in Adolescent and Geriatric Populations

Spinal pain is the most common form of musculoskeletal pain. Chronic low back pain may contain nociceptive, neuropathic, and central components. Children are at risk of developing spinal pain. An increasing proportion of children develop low back pain as they become adolescents. In most adolescents, no specific diagnosis is identified. Psychological factors play a role in adolescents with back pain. Lumbar spinal stenosis causes neurogenic claudication in older patients. Magnetic resonance imaging is the best radiographic technique to detect nerve compression. Surgical decompression with or without fusion may offer greater short-term benefit but may not be significantly better than medical therapy.

Back Pain in Children and Adolescents

Back pain has long been considered an uncommon complaint in the pediatric population. When present, teaching had been that pediatric back pain almost always has a diagnosable cause, many of which are progressive and potentially debilitating. Recent evidence has suggested that pediatric back pain is not only more common than once thought but also, within certain populations, benign and idiopathic. This, in turn, places an increasing amount of pressure on pediatricians to accurately assess and manage their patients presenting with complaints of back pain. The aim of this article is to serve as a review of the current literature on pediatric back pain. The article reviews the epidemiology, basic anatomy, and important elements of a history and examination, which should be considered when a child presents complaining of back pain. Last, a common differential diagnosis with evaluation and management is also given to help guide pediatricians through their medical decision making.

Evaluating low back pain in adolescents

Low back pain in adolescents is a common complaint in primary care. With an average prevalence rate of 40%, adolescent low back pain correlates with greater healthcare use, higher incidences of adult back pain, and negative effects on overall well-being. A thorough history and physical examination can increase early detection and accurate diagnosis while ensuring the judicious use of diagnostic modalities. Although underlying serious pathology is rare in adolescents with low back pain, clinicians should recognize specific signs and symptoms that necessitate urgent evaluation and intervention. This article emphasizes the value of using a thorough history and physical examination to guide the initial diagnostic workup and to enhance the early detection and accurate diagnosis of adolescents who present with low back pain.

Posterior Vertebral Endplate Fractures: A Retrospective Study on a Rare Etiology of Back Pain in Youth and Young Adults

BACKGROUND

Posterior lumbar vertebral endplate fracture occurs with avulsion of the ring apophysis from the posterior vertebral body. Although this has been described in adolescents and young adults, proper diagnosis is often delayed or missed entirely. Surgery may be curative.

OBJECTIVE

To determine the common clinical features and treatment outcomes in youth and young adults with posterior lumbar vertebral endplate fractures.

DESIGN

Retrospective case series.

SETTING

Academic medical institution.

PATIENTS

Patients 10 to 25 years old from 2000 through 2012 with posterior vertebral endplate fracture diagnosis.

MAIN OUTCOME MEASUREMENTS

Demographic characteristics, diagnostic studies, interventions, and change in symptoms postoperatively.

RESULTS

A total of 16 patients had posterior vertebral endplate fractures (8 male patients; mean age, 15.2 years)-8.3% of 192 patients with inclusion age range undergoing spinal surgery for causes unrelated to trauma, scoliosis, or malignancy. The most common signs and symptoms were low back and radiating leg pain, positive straight leg raise, hamstring contracture, and abnormal gait. Cause was sports related for 12 patients (75%). Mean (range) time to diagnosis was 13.0 (3.0-63.0) months. Diagnosis was most commonly made with lumbar magnetic resonance imaging (n = 6). Most fractures occurred at L5 (n = 8, 50%) and L4 (n = 5, 31.3%). Conservative measures were trialed before surgery. Nine patients had "complete relief" following surgery and seven "improved."

CONCLUSIONS

Posterior vertebral endplate fracture should be considered in differential diagnosis of a youth or young adult with back pain, radiating leg pain, and limited knee extension, regardless of symptom onset. For patients in whom conservative management fails, consultation with an experienced physician whose practice specializes in spine medicine is recommended.

LEVEL OF EVIDENCE

IV.

Pediatric Pain Syndromes and Noninflammatory Musculoskeletal Pain

Chronic musculoskeletal pain (CMP) is one of the main reasons for referral to a pediatric rheumatologist and is the third most common cause of chronic pain in children and adolescents. Causes of CMP include amplified musculoskeletal pain, benign limb pain of childhood, hypermobility, overuse syndromes, and back pain. CMP can negatively affect physical, social, academic, and psychological function so it is essential that clinicians know how to diagnose and treat these conditions. This article provides an overview of the epidemiology and impact of CMP, the steps in a comprehensive pain assessment, and the management of the most common CMPs.

Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review

Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy.