• RECENT STUDIES- >50% children experience some back pain by 15yrs of age

HISTORYNATURE OF PAIN• ACUTE- #S,LIGAMENTOUS SPRAIN, DISC HERNIATIONS,SLIPPED VERTEBRAL APOPHYSIS.

WITHIN 24HRS• SLOW-ONSET-TUMORS,SCHEUERMANN’S KYPHOSIS• MILD PAIN FOLLOWING ACTIVITY-MUSCLE STRAIN• RECURRENT PAIN

SPONDYLOLYSIS,SPONDYLOLISTHESIS,HERNIATED DISC

• PERSISTENT,NIGHT PAIN-TUMOURS, INFECTIONS

• LOCALISED PAIN- SPONDYLOLYSIS/NEOPLASMS

• GENERALISED,DIFFUSE PAIN- INFLAMMATORY PROCESSES

• PAIN RADIATING TO LOWER LIMB- VERTEBRAL APOPHYSIS #,EPIDURAL ABSCESS,HERNIATED LUMBAR DISC, INTRASPINAL TUMOUR

CONSTITUTIONAL SYMPTOMS

• MALIGNANCY-fever, chills, malaise, anorexia, weight loss

• DISCITIS- antecedent bacterial or viral infections

Neurological symptoms-numbness,weakness, gait abnormalities

AGGRAVATING AND ALLEVIATING FACTORS

-Sport activities-increase risk of spondylolysis, spondylolisthesis

-Pain –worse at night maybe due to malignancy-Back pain due to osteoid osteoma-relieved by

NSAIDs-Rest usually alleviates pain in most cases

AGE-RELATED CONDITIONS

<4yrs –infection,neoplasms<10yrs- discitis , vertebral osteomyelitis>10yrs-spondylolysis,spondylolisthesis, disc

herniation• Teenagers-Scheuermann’s kyphosis• Tumors such as osteoid osteoma and

aneurysmal bone cysts

PSYCHOSOMATIC PAIN

• Maybe seen in Preadolescents or adolescents• diagnosis by exclusion

ASSESSMENT OF GENERAL SYMPTOMS

• GENERAL INSPECTION Neurocutaneous markers assoc with

intraspinal defects-midline skin defects Can communicate with underlying deeper

structures- indicate spinal cord abnormality or dysraphism

ASSESSMENT OF THE SPINE

• POSTURE, ALIGNMENT• SCOLIOSIS• SPINAL FLEXIBILITY ASSESSED- stiffness,

listing,dysrhythmia indicates pathological cause• STRAIGHT LEG RAISING TEST-r/o herniated

discs, apophyseal #• Hyper extending the spine while child stands on

one leg- spondyolysis, spondylolosthesis

NEUROLOGIC ASSESSMENT

Spinal cord anomaly- clonus or abnormal Babinski sign or abnormal abdominal reflex

DIAGNOSTIC STUDIES• RADIOGRAPHY VERTICAL ALIGNMENT

DISC SPACE NARROWING VERTEBRAL SCALLOPING

LYTIC OR BLASTIC LESIONS

LATERAL VIEW- PARS INTERARTICULARIS DEFECT

• BONE SCAN sensitive in infections, stress #, benign and

malignant neoplasms

• COMPUTED TOMOGRAPHY bone tumours, and fractures to assess

spondylitic lesions in lumbar spine

• SINGLE-PHOTON EMISSION CT-localizing spinal lesions, diagnosing spondylosis,stress #

• MAGNETIC RESONANCE IMAGING- evalute spinal cord and neural elements

LABORATORY TESTS

• COMPLETE BLOOD COUNT• ESR• C-REACTIVE PROTEIN• URINALYSIS

MECHANICAL DISORDERS

• MUSCLE STRAIN- adolescent athelete, no radiation on pain, neurologic findings normal

Treatment-modification of activity, application of ice first then cold, NSAIDs

• APOPHYSEAL RING FRACTURE/SLIPPED VERTEBRAL APOPHYSIS-

-posteroinferior apophysis avulses from vertebral body,displaced into spinal cord-Presents with sudden onset back pain-Treatment-surgical removal of bony fragment

with attached cartilage and disc

DEVELOPMENT DISORDERS

• SPONDYLOLYSIS –defect in pars interarticularis, caused by repetitive microtrauma

• SPONDYLOLISTHESIS-pars defect b/l at same level,fwd slippage or subluxation of upper vertebral segment on the one below.

•Caused by repititive hyperextension•Mild to mod severity-radiates to lower limb•Postural defects,shuffling,stiff legged gait

• Xray-lytic lesions pars interarticularis Scotty dog sign

• MRI detects early spondylolysis

• Treatment-modify patients activities, If a/c # TLSO can relieve pain-Surgery is indicated for slips >50% translation

SCHEUERMANN’S KYPHOSIS

• Anterior wedging of 3consecutive vertebrae →kyphotic deformity

• Intravertebral herniation of disc material (Schmorl’s nodules) seen

• Localised pain, more on sitting and standing• O/E- thoracic kyphosis ,hamstring tightness• Xray-thoracic kyphosis >50degrees• Treatment-extension exercise,Milwaukee brace surgical intervention-spinal fusion

LUMBAR SCHEUERMANN’S DISEASE

• Similar to Scheuermann’s kyphosis• Involves thoracolumbar spine• Xray –end plate irregularities,disc space

changes,Schmorl’s nodules• Orthosis- decreases pain

IDIOPATHIC SCOLIOSIS

• Painful left thoracic curves – indicate pathology

SYRINGOMYELIACavitation of spinal cord. c/o headache,neckpain,cavus foot, abnl

gait,painful thoracic scoliosis

TETHERED SPINAL CORD• Low back pain, recent onset scoliosis, ↓motor function• Bladder dysfunction, Babinski’s sign• MRI• Treatment-cord release

IDIOPATHIC JUVENILE OSTEOPOROSISLong bone pain due tocompression #s,difficulty walking

VERTEBRAL OSTEOMYELITIS• Osteomyelitis a continuation of discitis• Two disorders converge- infectious spondylitis• More significant bony change

ANKYLOSING SPONDYLITISMales, AdolescenceLoss of spinal flexibility, abnl kyphosis,limited chest expansion during sleep

inspirationMRI-inflamed sacro-iliac joint

• EOSINOPHILIC GRANULOMASeen in 10-15%Xray -lytic lesionsD/D leukemia,infectious processes

• ANEURYSMAL BONE CYST15-20%Treated by-curettage, bone grafting

MALIGNANCIES

• A/C LYMPHOCYTIC LEUKEMIACommon malignancy producing back painX ray-osteopenia,vertebral body compression,

metaphyseal leukemic linesLab investigations- ↑WBC count, ↓platelet

count ,anemia, ↑ESR

• SPINAL TUMOURS-Ewings sarcoma, osteogenic sarcoma, chondroma

CT/MRI-staging tumour

• SPINAL METASTASES- neuroblastoma

• SPINAL CORD TUMORS- astrocytomas, ependymomas

INTRAABDOMINAL AND INTRATHORACIC CAUSES OF

BACK PAIN• Inflammatory bowel d/s, hydronephrosis, UTI,ovarian cysts• More constant pain,worse at night• Pneumonia-thoracic back pain

PSYCHOSOMATIC BACK PAIN(CONVERSION REACTION)

• Diagnosis is one of exclusion, • Made only after all other possibilities ruled

out• Detailed history to be take

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