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Chapter 25 Back Pain in Children and Adolescents 423
sleep, and does not radiate. It is exacerbated by vigorous activity and prolonged sitting. e severity of the back pain is
variable, with some patients denying signicant symptoms
and instead presenting for evaluation of poor posture. Neurologic symptoms are highly unusual.
Physical examination of the patient with Scheuermann
disease shows increased thoracic kyphosis, which is most
notable on forward bending, in which the apex appears to
protrude posteriorly. e deformity is usually fairly rigid, and
does not disappear with hyperextension. ere may be concomitant hamstring tightness, with inability to touch the oor
with the ngertips.
e diagnosis is made radiographically (Fig. 25.5). Criteria
for the diagnosis of Scheuermann disease have been outlined
by Sorenson as:
1. three contiguous vertebral bodies with greater than 5
degrees of anterior wedging
2. abnormal disc narrowing
3. endplate irregularities
4. Schmorl nodes, dened as disc herniations into the verte-
bral bodies
e vast majority of patients with Scheuermann disease can
be managed nonoperatively.63 Physical therapy exercises and
nonsteroidal medication can be helpful in relieving symptoms.
e role of bracing is controversial. Patients with signicant
remaining spinal growth may benet from orthotic treatment
because it has been proposed that correction of deformity
may be achieved in compliant patients.64 e Milwaukee brace
is the orthosis of choice for the treatment of Scheuermann
disease.65 Surgical correction of deformity and fusion is
reserved for patients with severe kyphosis measuring greater
than 75 degrees, those whose symptoms are refractory to conservative measures, and those who have signicant cosmetic
concerns.
66
Lumbar Scheuermann Disease
Lumbar Scheuermann disease is a less common variant in
which increased kyphosis and endplate changes are seen in the
lumbar spine.67 It also occurs most frequently in adolescence,
with overuse believed to be the cause. Microfractures occur
in the vertebral endplates, resulting in low back pain. Radiographs reveal endplate irregularities and disc space narrowing, anterior Schmorl nodes, and possible anterior wedging
of the aected vertebrae, leading to loss of lumbar lordosis.
Radiographs may also show associated spondylolysis or sco-
27,68
liosis.
e radiographic appearance of vertebral changes
and disc space narrowing may resemble infection or tumor.
Scintigraphy may reveal mildly increased uptake at one or two
vertebral levels.27 MRI shows signal change and dehydration
in the lumbar discs, with further disc deterioration occurring
over time.69 Treatment is symptomatic, and pain is usually
ameliorated with modication of activity or use of an orthosis.
Idiopathic Scoliosis
e majority of patients who have idiopathic scoliosis do not
complain of back pain, but symptoms are not as uncommon
as previously thought. In a study by Ramirez and coworkers,23
32% of 2442 children believed to have idiopathic curves
complained of some degree of back pain. e most common
factor associated with a positive diagnosis on further evaluation were le-sided thoracic curves, which were associated
with spinal cord abnormalities. Plain radiographs were found
to be sucient in the evaluation of typical curves if the neurologic examination was normal. Careful inspection of the
apex of the deformity and at the lumbosacral junction (for
spondylolysis and spondylolisthesis) will occasionally yield a
cause for both the pain and the scoliosis (see Fig. 25.4). In the
absence of neurologic ndings on physical examination, MRI
was not helpful. A recent study did show that MRI was useful
in identifying neural axis abnormalities in 6% of 104 patients.
Back pain and early age of onset of scoliosis were present in
those with MRI abnormalities.
70
SECTION
IV
FIG. 25.5 Anterior wedging of the thoracic spine in a 15-year-old male
with Scheuermann kyphosis.
Syringomyelia
Syringomyelia is dened as cystic dilation of the central canal
of the spinal cord. e dilation of the cord leads to abnormali-
ties in the neurologic pathways that transmit pain and temperature. While not always symptomatic, patients may
complain of pain. ere is a predisposition toward le thoracic
scoliosis in patients with syringomyelia.71 Physical ndings
include scoliosis, foot deformities such as cavus, decreased
sensation, and asymmetric abdominal reexes. e syrinx is
clearly imaged on MRI. Treatment is neurosurgical decompression, although controversy exists regarding the size of
syrinx that requires surgery.
424 PEDIATRICS
Tethered Spinal Cord
Low back pain may be the presenting complaint in children
with tethered spinal cords. e cord normally terminates at
the L1–L2 level. Persistence of the cord more distally implies
tethering. Physical ndings may include foot deformity, spas-
ticity, or weakness. Oen, radiographs will show coexistent
congenital vertebral abnormalities. e diagnosis is made on
MRI, in which the lum may appear thickened or the conus
visualized at L3 or distal. Treatment of the symptomatic
tethered cord is surgical release, which is typically performed
by a neurosurgeon.
Idiopathic Juvenile Osteoporosis
Idiopathic juvenile osteoporosis is a rare disease that usually
aects children in the rst 2 decades of life. Presenting symp-
toms include back and leg pain due to compression fractures
and pain during weight bearing.
include vertebral wedging due to compression fractures with
mildly increased kyphosis. Bone mineral density is decreased,
but metabolic laboratory values are normal. e dierential
diagnosis includes leukemia. Orthotic management of back
pain is usually sucient. Medical management should be
under the supervision of a pediatric rheumatologist. e
disease is self-limiting, and symptoms resolve during puberty.
72,73
Radiographic ndings
74
FIG. 25.6 Disc space narrowing (arrow) and endplate irregularities in a
child with T11–T12 discitis.
Infectious and Inammatory Etiologies
Discitis
Discitis is dened as a presumed bacterial infection of the
intervertebral disc space. It is the most common cause of back
pain in the young child. e incidence of discitis is greatest
in children aged 5 years and younger, though it can occur in
older children.75 e etiology is believed to be infectious. In
the immature child, blood vessels traverse the vertebral endplates and terminate in the nucleus pulposus. erefore, in
young children the disc is vascular, which allows for seeding
of bacteria into the disc space.
but include back pain, refusal to walk, limping, and abdominal
pain. e child usually is systemically ill; therefore, the patient
oen presents to the emergency department. Approximately
half will have fever on presentation.
Physical examination reveals spinal stiness, and oen the
spine is held in a exed position. If asked to retrieve a toy from
the oor, the child with discitis will squat by bending the knees
rather than bend the spine. Young children may exhibit
Gower’s sign when rising from the oor, using their upper
extremities to push up on the legs as a strategy to minimize
lumbar motion. Tenderness in palpation of the aected area
can be present.
Radiographic ndings are usually minimal at the time of
presentation. Subtle disc space narrowing and paraspinal so
tissue swelling on the lateral view are the rst radiographic
changes (Fig. 25.6). Over time, endplate irregularities are seen.
Because plain radiographs are usually normal at the time of
presentation, further imaging is required. Technetium bone
76–78
Presenting complaints vary,
scans show increased uptake on both sides of the aected disc
space (Fig. 25.7A). Bone scans are positive in 74% to 100% of
children with discitis
79,80
and can lead to earlier diagnosis and
treatment. MRI also localizes the infection and delineates the
extent of so tissue involvement (Fig. 25.7B). In patients who
are refractory to treatment, MRI is useful in assessing whether
a so tissue abscess is present.81 MRI shows decreased signal
on T1-weighted images and increased signal on T2 images. If
an abscess is present, there is peripheral enhancement with
the administration of gadolinium.
82
e evaluation of the child with possible discitis also
includes obtaining laboratory studies. Elevation of the sedimentation rate and C-reactive protein are seen in more than
90% of children with discitis.20 e white blood cell count may
be elevated but is less reliable.76 Blood cultures should be
obtained and are positive in more than 50% of children with
80
discitis.
In the past, the treatment of discitis was controversial, but
now there is agreement that discitis represents a bacterial
infection and should be treated with antibiotics.
76,81,83
Cultures
of the intervertebral disc are positive in 60% of children, with
Staphylococcus aureus the most common organism. A recent
study of disc space cultures showed that S. aureus was cultured
in 55% and Kingella kingae in 27% of children with discitis.84
Because of the preponderance of S. aureus, and the fact that
40% of cultures from the disc space remain negative, routine
aspiration of the aected disc is not recommended.83 If the
patient fails to improve quickly with antistaphylococcal antibiotics, then ne-needle aspiration under CT guidance can be
useful.85 Although administration of a second-generation
Chapter 25 Back Pain in Children and Adolescents 425
SECTION
IV
A
FIG. 25.7 (A) Bone scan in a child with discitis shows increased uptake. (B) Magnetic resonance image reveals
destruction of the disc space, erosion of endplates, and vertebral involvement.
B
cephalosporin for 3 weeks has been recommended,83 epidemiologic trends in antibiotic resistance may alter which antibiotic should be chosen. Surgical biopsy and debridement are
reserved for patients who do not respond to medical management, have a neurologic decit, have an abscess on MRI, or
whose diagnosis is in question.
e outcome of pediatric discitis is favorable. Ten-year
radiographic follow-up has shown narrowed disc space (60%
of children) or bony ankylosis (40%), but kyphosis is rare and
generally mild and patients are pain free.
86
Disc space infection in children younger than 1 year is
usually very aggressive and requires immediate diagnosis and
treatment. Infants are oen septic at presentation. Residual
kyphosis following eradication of the infection has been
described.
87
Vertebral Osteomyelitis
include fever, malaise, weight loss, and night sweats. Neurologic ndings occur more frequently in tuberculosis than in
discitis.89 Radiographic changes are more advanced in children
with tuberculous spondylitis, and consist of bony destruction
of the vertebral body, kyphosis, so tissue abscesses, and so
tissue calcications. CT scan ndings include erosions with
calcication, and intraspinous, paravertebral, and epidural
abscesses.
90,91
A chest radiograph shows evidence of tuberculosis in 67% of children with tuberculous infection of the
spine.90 e puried protein derivative test is usually positive,
except in the immunologically challenged child, in whom it
remains nonreactive. Pathologic examination of tissue from
ne-needle aspiration of the aected bone yields a positive
diagnosis in 83% of children and teens92 and shows epithelioid
giant cells and caseous necrosis or tubercle bacilli. Polymerase
chain reaction has been used for faster identication of the
organism.
e distinction between discitis and osteomyelitis in children
is blurred. It is believed that osteomyelitis is a continuation of
discitis,77 with the two entities representing a condition called
infectious spondylitis. Osteomyelitis produces more notable
vertebral body radiographic changes. Again, S. aureus is the
most common organism.
78
Opportunistic infections may also aect the vertebral
column, especially in immunocompromised patients such as
those with malignancies or who have had organ transplants.
Fungal infections such as coccidioidomycosis are rare but
must be kept in mind in endemic regions.
88
Tuberculosis is increasing in frequency and is seen most
commonly in children from endemic regions. Symptoms
Ankylosing Spondylitis and Rheumatologic Conditions
Ankylosing spondylitis is a rheumatologic condition characterized by loss of spinal mobility. It may present in adolescence
as back pain. It occurs more frequently in males than in
females. Physical ndings include loss of lumbar exibility so
that lordosis does not reverse on forward exion, increased
kyphosis, and limited chest expansion with inspiration. Plain
radiographs may reveal sclerosis, narrowing, or fusion of the
SI joints. MRI has been shown to be superior to bone scan in
identifying inammation of the SI joint.
ation of patients with ankylosing spondylitis shows a high
93,94
Laboratory evalu-
426 PEDIATRICS
A
FIG. 25.8 (A) Anteroposterior radiograph of the thoracic spine of a 16-year-old male with lower extremity
weakness and loss of bladder function shows absence of the spinous process at T2 (arrowheads). (B) Computed
tomographic scan delineates the extent of the aneurysmal bone cyst of the posterior elements of T2
(arrowheads).
B
incidence of HLA-B27. Onset of ankylosing spondylitis prior
to the age of 16 years has been linked to worse functional
outcomes than in adult-onset patients.95 Other rheumatologic
conditions linked with back pain include polymyositis, dermatomyositis, and inammatory bowel disease.
Hematologic Conditions
Sickle Cell Anemia
In a recent study of pediatric patients presenting to a Canadian
emergency department for the evaluation of back pain, 13%
were found to have sickle cell anemia.22 e spine has been
reported as the second most common site for pain crisis in
these patients, second only to the knee. Anemia is present in
86%.96 Physical examination reveals tenderness to palpation.
Treatment is pain management and admission to the hematology service.
β-alassemia may also produce pain crises that aect the
spine. Up to 25% of patients with thalassemia complained of
low back pain in a recent study.
97
Neoplasms
Aneurysmal Bone Cysts
Aneurysmal bone cysts (ABCs) are nonmalignant expansile
lytic lesions of bone characterized by their vascularity.
Although not malignant tumors, they can be locally aggressive. eir etiology remains unclear, and a few familial cases
have been identied.98 Approximately 15% of ABCs aect the
spinal column, with a predilection for the posterior elements.
If of sucient size, the lesion may extend into the anterior
column.
bone cysts documented that 30% were located in the cervical spine, 30% in the thoracic spine, and 40% in the lumbar
spine.
lesion itself, or from an associated pathologic fracture. Neurologic compromise is unusual.
99,100
A large multicenter series of spinal aneurysmal
101
Symptoms consist of back pain that can result from the
Radiographs show an expansile lytic lesion with a “bubbly”
appearance. ere is expansion of the cortex. CT scans best
dene the extent of the lesion, and reveal the thin rim of
surrounding bone (Fig. 25.8). On occasion, sacral lesions have
been shown to aect more than one vertebral level.
102
Treatment of ABCs is surgical curettage with bone gra-
103
ing.
Due to the vascularity of the cysts, preoperative embolization is very helpful in reducing intraoperative blood loss
and therefore improving visualization.
104–106
Spinal cord monitoring during embolization has been advocated to avoid vascular injury to the spinal cord.
107
Scheduling the surgical
resection shortly following embolization is necessary to
prevent revascularization of the lesion prior to curettage.
When resection of the lesion leads to mechanical instability,
simultaneous fusion is recommended.
108
ere is a 10% to 14%
recurrence rate following curettage and graing for spinal
ABCs. A four-step surgical program—consisting of curettage,
use of a high-speed burr, electrocautery, and bone graing,
with stabilization via short posterior fusion with instrumentation as needed—has been recently proposed, with all patients
free from disease at follow-up.
109
Repeat embolizations as well as radionuclide ablation have
been used to denitively treat spinal ABCs in limited cases.
106
Repeat embolization has been advocated in patients who do
not have neurologic ndings or pathologic fracture, for whom
the diagnosis is certain, or in patients whose lesions have
recurred.
110
Osteoid Osteoma
Osteoid osteomas are the most common benign spinal tumor
occurring in children, with presentation occurring in the
second decade of life. ey typically are located in the poste-
rior elements of the spine. Osteoid osteomas produce back
pain that is worse at night, and ameliorated by aspirin or
nonsteroidal medication.
Physical examination reveals decreased spinal exibility.
Oen, the patient will stand with a list. e neurologic examination is generally normal.
Chapter 25 Back Pain in Children and Adolescents 427
Plain radiographs are usually insucient to make the
diagnosis, but an olisthetic scoliosis might be apparent. When
scoliosis is present, the lesion is usually located in the concavity of the apex of the curve.
111
Bone scan is positive, with
distinct increased uptake seen (Fig. 25.9). CT scans provide
the best imaging of osteoid osteomas, with a small radiolucent
nidus and surrounding sclerosis and new bone apparent (Fig.
25.10). MRI shows increased signal intensity in the muscles
FIG. 25.9 Bone scan of a 15-year-old male with a 2-year history of back
pain shows increased uptake at T10 (arrow).
and surrounding bone.
112
e MRI appearance, as well as the
tendency for enhancement in the so tissues near the lesion,
may lead the physician to suspect a malignant tumor.
113
Long-term administration of NSAIDs can provide pain
relief in a small group of patients with spinal osteoid osteomas;
thus, a trial of nonsurgical treatment is warranted. Usually,
symptoms are sucient to merit surgical removal of the nidus,
which typically results in immediate relief of pain. Intraoperative CT imaging has been used to better target the nidus and
therefore minimize bony resection.
114
Newer treatments are
under investigation, including percutaneous CT-guided
burring of the nidus and thermocoagulation.
115,116
When
scoliosis has been long-standing, persistence of the deformity
is possible following successful removal of the osteoid osteoma.
Osteoblastoma
Although osteoblastoma is a less common benign lesion of the
spine, 40% of osteoblastomas are located in the vertebrae.
ey also are located in the posterior elements of the spine,
but because they are by denition larger than osteoid osteo-
mas, they oen extend anteriorly into the vertebral bodies.
e primary symptom of osteoblastoma is back pain, which is
usually less severe than in osteoid osteoma. Neurologic abnormalities may result based simply on the size of the lesion and
its encroachment on the spinal canal or neural foramina.
e lesion can be usually seen on plain radiographs, but
CT scans are invaluable in assessing the size and extent of the
osteoblastoma. As in osteoid osteoma, the MRI in osteoblastoma can overestimate the extent and aggressiveness of the
118
lesion.
mately 40% of aected patients.
Plain radiographs also reveal scoliosis in approxi-
111
Treatment is surgical removal of the lesion, with fusion as
needed to address instability based on the size of resection.
Recurrence occurs in 10% of osteoblastomas.
112
117
SECTION
IV
FIG. 25.10 Computed tomographic scan shows a radiolucent nidus with
surrounding bony sclerosis in an 11-year-old with back pain due to an
osteoid osteoma.
Eosinophilic Granuloma/Langerhans Cell Histiocytosis
Eosinophilic granuloma, also known as Langerhans cell histiocytosis (LCH) or histiocytosis X, is a peculiar condition of
childhood typied by the development of lytic lesions of bone.
e lesions may occur singly or aect multiple areas of the
skeleton, including the spine. When the condition is associated with systemic involvement, it is known as Hand-SchullerChristian disease or the more severe Letterer-Siwe disease.
LCH has a higher incidence in males. e average age at
diagnosis is 6 years, with the majority of patients in their rst
decade of life.
Vertebral lesions in LCH occur in 10% to 17% of aected
children. e patients may present with back pain or a limp.
On occasion, neurologic signs can be present.
Radiographs show lytic lesions within the vertebral body
or, more rarely, the posterior elements. Larger lesions lead to
collapse of the vertebral body, which can be either symmetric
or asymmetric (Fig. 25.11). Although vertebra plana (also
known as coin-on-end appearance) is the classically described
spinal lesion in LCH, it has been reported that only 40% of
119
428 PEDIATRICS
children with LCH and vertebral lesions have vertebra plana.
120
Skeletal surveys oen result in the identication of other sites
of involvement, which supports the diagnosis. Typical sites of
involvement include the skull, the pelvis, and the diaphysis
of the long bones. Bone scan is positive in 90% of children
with LCH.
121
e dierential diagnosis includes leukemia, infection,
and other malignant tumors, such as Ewing sarcoma.
122
If
the radiographic appearance is atypical and other peripheral
skeletal lesions are not identied, a surgical biopsy of the
spinal lesion is warranted. Pathologic specimens show clonal
proliferation of Langerhans-type histiocytes, eosinophils, and
giant cells.
123
Most patients with LCH experience spontaneous resolution of their disease. Because the condition appears to be
self-limiting, the indications for treatment are few. Back pain
due to a unifocal spinal lesion can usually be relieved by
rest and the use of orthoses.
119,123
Patients with neurologic
compromise may be treated with low-dose radiation therapy
or surgical debridement of the lesion and stabilization.
121,124
Radiation therapy has fallen out of favor as treatment for LCH
of the spine due to the potential for secondary malignancies.
Multifocal disease, particularly when associated with systemic
involvement, is treated with chemotherapy.
125
e long-term outcome of LCH in the absence of systemic
disease is very good. Recurrence of disease is not seen in chil-
125,126
dren.
seen, although complete restoration to normal is unusual.
Over time, improvement in vertebral body height is
127,128
Malignant Tumors
Leukemia
Leukemia is the most common pediatric malignancy that produces back pain. Many children rst present to the orthopaedic
surgeon; reports indicate that 6% to 25% of children with acute
leukemia present initially with back pain.
children are initially misdiagnosed; thus, the orthopaedic
surgeon must have a high level of suspicion to properly evaluate
this population.
131
e history may reveal symptoms of pallor,
fatigue, loss of appetite, or fever. e parent should be questioned about a history of bruising or abnormal bleeding.
Radiographic ndings are not always initially present but
include generalized osteopenia, vertebral compression fractures, and metaphyseal leukemic lines. Of children with acute
lymphoblastic leukemia, 7% have vertebral compression
fractures
130,132
(Fig. 25.12).
e diagnosis can usually be made on laboratory examination, with abnormalities seen in any or all of the three cell
lines, that is, anemia, thrombocytopenia, and leukopenia. e
sedimentation rate is usually elevated. Of children with leukemia, 10% or more will initially have normal automated
132,133
counts.
Inspection of the peripheral smear will reveal the
diagnosis in some of these children.
Chemotherapy under the direction of pediatric oncology is
the treatment of choice. Spinal bracing can be prescribed to
relieve back pain and prevent further compression fractures.
129,130
Many of these
FIG. 25.11 Lateral radiograph of a 12-year-old male with vertebra plana of
T11 consistent with eosinophilic granuloma (arrowheads). Back pain
resolved with conservative treatment.
FIG. 25.12 Osteopenia and multiple compression fractures in a child
presenting with back pain due to leukemia.
Chapter 25 Back Pain in Children and Adolescents 429
Vertebral Malignant Tumors
Malignant tumors of the spine cause signicant back pain in
over 50% of children at the time of diagnosis.
they must remain in the dierential diagnosis of pediatric
back pain. Pain may radiate into the legs, resembling the
symptoms of a herniated disc. While patients with disc herniation are in their second decade of life, children with spinal or
spinal cord tumors may be younger. Neurologic decits and
reex changes are uncommon in disc herniation but frequent
in tumors.
135
Vertebral tumors include Ewing sarcoma and osteosar-
136
coma.
Osteosarcoma rarely aects the spine.
are variable, with osteolytic, osteoblastic, and mixed appearances possible. CT and MRI are used to stage the tumor.
Treatment is dicult.
Up to 10% of Ewing sarcomas occur in the spine, with the
sacrum the most frequent site.
tion is 13.3 years.
139
Symptoms consist of relentless back pain.
138
e average age at presenta-
Neurologic decits are present in 58% of patients with spinal
Ewing tumors.
140
Radiographs may show an expansile lytic
lesion with variable vertebral collapse. Cases of Ewing sarcoma
that radiographically resemble vertebra plana have been
reported, leading to the misdiagnosis of eosinophilic granu-
140
loma.
MRI delineates the extent of the lesion and its accom-
panying so tissue mass.
134
Although rare,
137
Radiographs
Spinal Metastasis
Nonorthopaedic Causes of Pain
Intraabdominal processes such as inammatory bowel disease,
hydronephrosis, ovarian cysts, endometriosis, and urinary
tract infections can produce back pain. Pain due to these
conditions is not exacerbated by activity and tends to be
more intense at night. Pediatric referral should be made when
nonmusculoskeletal causes are suspected.
Psychosomatic Pain (Conversion Reaction)
As discussed in the beginning of this chapter, there are children
in whom an organic etiology for back pain cannot be found
despite thorough evaluation. Back pain can be inuenced by
psychosocial factors that alter the patient’s perception of pain
and the eect of pain on everyday life. Psychosomatic pain
remains a diagnosis of exclusion. It is more prevalent in adolescence, particularly in those teens whose family members
have a history of similar back pain. A detailed social history
oen reveals problems at home or school, oen resulting in
anxiety and depression. Treatment is dicult but includes
intervention by a psychologist and physical therapy. Recent
studies show that up to 71% of children and adolescents who
have negative diagnostic evaluations for back pain continue
to have pain at an average of 4.4 years of follow-up.19 Even
8 years aer initial evaluation, 62% of 58 patients were still
symptomatic.
146
SECTION
IV
Neuroblastoma is the most frequent tumor to metastasize to
the spine in children.
tumors, neuroblastoma represented one-third of all cases.
141
In a recent study of 29 malignant spine
134
Radiographs usually show diuse vertebral involvement. e
thoracic spine is most frequently involved. An elevation of
urinary normetanephrine may help diagnosis.
138
Other tumors
that involve the spine include rhabdomyosarcoma, Wilms
tumor, and primary neuroectodermal tumors.
142
Spinal Cord Tumors
Common spinal cord tumors in children are astrocytomas and
ependymomas. e onset of symptoms is indolent. Neurologic
signs such as deterioration of gait, delay in motor skills, and
loss of bladder control raise suspicion.
usually present, leading to initial referral to the orthopaedic
surgeon in 31% to 58% of patients who are eventually diagnosed with spinal cord tumors.
143,144
reveals motor decits, clonus, and possibly scoliosis. ere
may be limitation of spinal exibility. Radiographs can show
changes due to pressure or expansion of the tumor, including
absence or thinning of the pedicle or widening of the intervertebral foramina. Spinal cord tumors are best seen on MRI.
Although uncommon, neurobromas in children and
adolescents with neurobromatosis can undergo malignant
degeneration into neurobrosarcoma. Back pain in a patient
with neurobromatosis should be evaluated.
143–145
Back pain is
Physical examination
KEY POINTS
Use of Diagnostic Tests
Radiograph: History of signicant trauma; night pain, fever or
inability to walk; age 8 years or younger; duration of pain
greater than 2 months
Bone scan: Negative plain radiograph with normal neurologic
examination, persistent pain, history of athletic overuse
CT scan: Positive plain radiograph or bone scan
MRI: Abnormal neurologic examination, painful scoliosis in
patient younger than 8 years, painful le thoracic scoliosis
Laboratory tests: Night pain, fever, age younger than 8 years,
constant pain
Likely Diagnoses Based on Age
Younger than 5 years: Tumor, discitis
Age 5 to 10 years: LCH, discitis, tumor/leukemia
Age 10 to 18 years: Musculoskeletal back pain, lumbar
Scheuermann disease, herniated disc or apophysis, spondylolysis, osteoid osteoma, tumor/leukemia
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