When to Worry About Back Pain in Kids

Every parent whose child is complaining of back pain worries that a more serious problem may be occurring. While there are certainly serious causes of back pain, the vast majority of kids with back pain have symptoms that result from muscle or ligament injury, without any structural abnormality.

Some of the warning signs to look out for more serious problems include:

• Night pain (especially pain that awakens your child from sleep)
• Constant symptoms of pain
• Symptoms of generalized illness (fever, chills, malaise, weight loss)
• Symptoms persisting beyond several weeks
• Symptoms in very young children
• Leg pain, numbness, or weakness

These warning signs don't necessarily mean there is a more serious problem, however, they are a good screening test to determine if more evaluation should be pursued. For example, muscular back pain can persist for months, however, if the symptoms have been going on for several weeks, it's best to ensure the diagnosis is clear.

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As stated, muscular back pain is by far the most common cause of back pain in children and adolescents, with about two thirds of all kids complaining of back pain ultimately being diagnosed with this type of injury.

Injuries include muscle strains and ligament strains, overuse injuries, problems with posture, and poor conditioning of the muscles of the back. Most often imaging, including x-rays, CT scans, and MRIs are not helpful at making this diagnosis, and these tests are generally not needed unless there are the aforementioned warning signs. As with any test, there are downsides to excessive testing (exposure to radiation, and tests may lead to other unnecessary testing or procedures), so you should discuss with your doctor the value of obtaining any specific imaging study.

Most often muscular back pain will respond to rest and modifications in activities. Many treatments may provide transient relief, and while long-term effects of treatments is debatable, they are generally safe. These treatments might include physical therapy, chiropractic treatment, stretching programs (yoga), or massage treatment.

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Stress fractures can occur in the spine. Most often these stress fractures occur in adolescents, and these adolescents may never know an injury has occurred. Over time, signs of the stress fracture may show up.

The most common type of spinal stress fracture is called a spondylolysis, an injury to the bone in the back of the spinal column. This injury occurs most often in adolescents who do sports involving repetitive hyperextension (bending backwards) of the spine, such as gymnasts and divers. If the stress fracture occurs on both sides of the spinal column, this can cause instability of the spinal column, or a condition called spondylolisthesis. This condition, also called a spinal "slip," can lead to the vertebral column alignment to shift.

Stress fractures often make kids and parents nervous, because these injuries typically don't heal, and they can cause symptoms into adolescence and young adulthood. However, most children and adolescents diagnosed with spondylolysis are treated nonsurgically, and actually do better with less-invasive treatments. Surgery is typically reserved for those who have persistent pain even after many months of nonsurgical treatment, or those patients with severe slips leading to loss of spinal alignment.

Long term studies show that the chance of having back pain in adulthood is unchanged by the presence of a childhood stress fracture. While this can be a source of problems, the chance of developing back pain in adulthood is little changed by having spondylolysis as a child.

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Disc herniations are much less common in children than adults, but they can occur, and they can cause serious symptoms. When a disc herniation of the spine occurs, the soft cushion between two vertebrae is ruptured. This disc material is forced out of its normal space, and can push against the nerves and spinal cord.

Symptoms of a disc herniation can include leg pain, numbness and tingling in the legs, weakness of the lower extremities, and difficulty bending or straightening the spine. MRI tests can be helpful to diagnose a disc herniation, as x-rays will typically be normal.

In children, normal disc material is pliable and elastic--it has a much better ability to withstand unusual forces on the spine. As we age, the disc loses its elasticity and pliability, and can become prone to rupture. However, even in the younger population, discs can rupture due to excessive forces (traumatic injuries) or abnormal disc structure, and cause these symptoms of a herniation.

Most often, disc herniations can be managed without a surgery, but children and adolescents with severe pain or signs of significant nerve injury may benefit from a surgical procedure to relieve pressure on the nerve.

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Infections of the spinal bone or discs can be a challenging diagnosis to make. Often occurring in young toddlers or in adolescents, spinal infections may cause vague symptoms of malaise, low-grade fevers, and generalized back pain.

The diagnosis of spinal infection is often made because of abnormal laboratory studies showing signs of infection (elevated white blood cell count) or inflammation (elevated ESR or CRP). When suspected, typically imaging tests are performed to confirm the location of the infection.

Treatment of infection usually can be accomplished with antibiotics (most often given intravenously, at least until the infection has started to improve), although occasionally a surgery can be considered. Surgery is generally only considered if the infection has caused damage to the spinal structure or if the infection cannot be adequately controlled with the use of antibiotics.

Problems with the alignment of the spine can cause a noticeable deformity, and may be associated with the occurrence of back pain. It should be noted, however, that more subtle deformities, that while noticeable, seldom causes issues of pain. The two most common spinal deformities in children are scoliosis and Scheuermann's kyphosis. Scoliosis is a deformity that causes an S-shaped curve to the spine when seen from the back. Scheuermann's kyphosis causes a sharp bend in the spine when seen from the side.

These two conditions are vary different, but the treatment principles are similar. In less severe deformities, observation is the most appropriate treatment. Once the deformity has progressed to a more significant level (determined my measurement of angles seen on x-ray images) a brace may be considered. Only in the most severe deformities is surgery considered as an option for treatment of these conditions. Even when surgery is considered, a deformity of the spine may persist, as full correction of the deformity may cause more problems than just a partial correction.

Several different benign and malignant bone tumors can occur in the spinal column. Sometimes these cause significant pain, other times they can be found without causing symptoms. While spinal tumors are a very unusual cause of back pain in children and adolescents, they should be considered as a possible, albeit unusual, diagnosis.

Some of the warning signs mentioned previously can be associated with tumors, specifically the complaint of night pain, or the complaint of generalized illness or weight loss. Back pain in association with these symptoms may raise the concern for possible tumors, and imaging tests can help to determine if that is a possible diagnosis.

Treatment of spinal tumors is variable depending on the specific type of tumor. Even benign (noncancerous) tumors may require surgery as sometimes untreated tumors can lead to deformities of the spine. Cancerous tumors in the spine of require a combination of treatments that may include medications, radiation, and surgery.

_Sources:

_{Shah SA, Saller J. Evaluation and Diagnosis of Back Pain in Children and Adolescents" J Am Acad Orthop Surg. 2016 Jan;24(1):37-45.}