Back pain in children

Asiya Khan Shakir MD (Dr. Shakir of Georgia Regents University has no relevant financial relationships to disclose.)
Basheer Shakir MD (Dr. Shakir of the Medical College of Georgia at Georgia Regents University has no relevant financial relationships to disclose.)
Ian Heger MD (Dr. Heger is Chief of the Section of Pediatric Neurosurgery of Georgia Regents University and Children's Hospital of Georgia and has no relevant financial relationships to disclose.)
Bernard Maria MD, editor. (Dr. Maria of Icahn School of Medicine at Mount Sinai and Director of Pediatric Neurology and Developmental Medicine at Goryeb Children)
Originally released January 22, 2007; last updated July 3, 2014; expires July 3, 2017

This article includes discussion of back pain in children, dolor en la espalda, dorsalgia, dorsodynia, lumbago, lumbalgia, and spondylalgia. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

The authors explore current concepts related to back pain in the pediatric population. This article highlights the multifactorial nature of back pain in children and adolescents, with a systematic discussion on the history, varied clinical manifestations, pathophysiology, prognoses, treatments, and diagnostic modalities for each of the etiologies. Additionally, the authors address prenatal trunk development, cutting edge genetic research, and updated epidemiological data.

Key points

 

• Prevalence of back pain at the age of 15 is about 53%, which means back pain is much more common in the pediatric population than previously thought.

 

• History and physical examination are imperative in guiding the correct diagnosis of back pain. Diagnostic modalities like x-rays, SPECT, and MRI scans can help investigators further pinpoint the diagnosis.

 

• Back pain in children presents in a bimodal age distribution, which correlates with prepubertal and pubertal growth spurts.

 

• Physical therapy, rehabilitation, education, steroid therapy as well as other medications, and surgery are treatment options for back pain.

Historical note and terminology

Back pain and spinal injury have been documented in texts dating as far back as 1550 BC. The Edwin Smith papyrus findings of Ancient Egypt include the earliest description and treatment of fractured vertebrae. Priests treated the sick by initiating a rest cure and applying bandages on any visible wounds (Knoeller and Seifried 2000). Studies of dinosaur remains, Neanderthals, crocodile autopsies, and Egyptian mummies reveal simple spinal degenerative changes as well as ankylosing spondylitis in these species (Blumberg and Sokoloff 1961; Allan and Waddell 1989). Before the Dark Ages, Hippocrates and Galen included brief discussions of fleeting back and joint pain and consequent symptomatic treatment with warm baths and rest in their writings in 400 BC and 150 AD, respectively. However, when medical discovery became limited during the Dark Ages, back pain was given mythological etiology like “witch's shot” and was treated by maneuvers that gave special powers to the feet of a mother who had carried a breech child (Keele 1957; Black 1883). The Renaissance brought with it the rebirth of modern medicine as anatomy and circulation were correlated with disease signs and symptoms. In 1642, Biallou used the Greek term rheuma to offer an explanation for back pain. Until the nineteenth century, the term rheuma, thought to be brought on by cold and damp, referred to an evil humor or watery discharge that flowed from the brain to cause pain in joints and muscles (Allan and Waddell 1989). Trauma and spinal irritation were introduced as a possible cause of back pain in the 1800s. Although Paulus of Aegina was removing bone fragments from the spinal column in order to treat back pain as early as the seventh century AD, it was not until 1886 that Mac Ewen published a detailed description of a laminectomy (Knoeller and Seifried 2000). The “Dynasty of the Disc,” which refers to the few decades when all back pain was attributed to disc prolapse, was birthed at Massachusetts General Hospital in 1932 (Parisien and Ball 1998). Neurosurgeon William J Mixter and orthopedist Joseph S Barr collaborated and consequently popularized discectomies when they diagnosed and operated on a spinal tumor in a patient with a history of spinal trauma (Koebbe et al 2002).

Spina bifida, a pediatric back pathology, was mentioned in the writings of Hippocrates around 400 BC. In the Hippocratic Corpus, Hippocrates writes of a fluid sac that “makes violence in the sacral bone” (Smith 2001). Spondylitis was first mentioned as a cause of paraplegia in the late 1800s, independently by Strumpell, Marie, and von Bechterew (Brain et al 1952). Spondylitis, spondylosis, and spondylolisthesis originate from the Greek word spondylo, or “vertebrae.” Spondylosis, also known as spondylosis deformans, refers to a generalized disc disease related to the degeneration of intervertebral discs (Morgan and Biery 1985). Spondylolisthesis, from the Greek –olisthesis, or “to slip,” refers to displacement of the vertebral body (Wiltse and Winter 1983). Sciatica, thought to be first coined by Hippocrates in 400 AD, arises from the Greek word ischios, or “hip,” and can cause radiating leg pain (Pearce 2007). Sciatica is sometimes referred to as lumbosacral radicular syndrome, ischia, and nerve root pain (Koes et al 2007). Radiculopathy refers to diseases of the nerve root, from the Greek –radix, or “root” (Knauff 2009).

Scheuermann kyphosis was first described by the Danish surgeon Holger Werfel Scheuermann in 1920 as a “round back” deformity radiographically distinguished from postural kyphosis (Scheuermann 1977). This condition, sometimes referred to as juvenile osteochondrosis of the spine, is characterized by anterior wedging of 3 adjacent vertebral bodies by 5 degrees or more. Additionally, this disease process presents with kyphosis greater than 45 degrees between T5-T12 (Stoddard and Osborn 1979; Hart et al 2010). There are 2 major types of Scheuermann kyphosis: type I, classic, and type II, thoracolumbar (Tomé-Bermejo and Tsirikos 2012). An atypical lumbar form, with an unknown prevalence, is also reported in literature (Lucas-Garcia et al 2013).

Back pain has been consistently documented in very early historical texts. It is only in recent times that specific structural causes and treatment have been attributed to this ailment.

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