Back pain in children

Ava Yun Lin MD PhD

General Child Neurology

Updated 04.24.2025
Released 01.22.2007
Expires For CME 04.24.2028

Back pain in children

Author: Ava Yun Lin MD PhD

See Contributor Disclosures

Editor: Bernard L Maria MD

Cite this article

Back pain in children

In This Article

Quick Link

Introduction

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 of 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

	• The complaint of back pain in the pediatric population is becoming more common and continues to remain a challenge, with various rates of definitive diagnosis.
	• By utilizing a systematic approach to diagnose back pain in the pediatric population, the most common causative factors for back pain can be found and include the following: structural deformities, trauma, inflammatory diseases, malignancy, or infection.
	• History and physical examination are imperative in guiding the correct diagnosis of back pain. Diagnostic modalities include x-rays, SPECT, MRI scans, and NCS/EMG, all of which 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

The evaluation of pediatric back pain spans across multiple medical disciplines, including primary care, emergency department, physical medicine and rehabilitation, orthopedics, rheumatology, oncology, infectious disease, neurosurgery, and neurology, among others. Pediatric neurologists can determine if there is a neurologic cause for the back pain, and, if not, appropriately redirect the patient to other specialties. They can identify patients who have red flags indicative of a non-benign, pathological cause of back pain to guide patients to appropriate specialists and perform a thorough neurologic examination that is critical in identifying at-risk patients.

The history and physical examination are crucial in assessing back pain and should be performed in the context of age (134). Attention must be paid to symptom onset, incidence of potential trauma around the time of onset, characterization and radiation of pain, and exacerbating and alleviating factors.

Some proposed red flags in the history and examination include the following (27; 157; 98):

(1) Pain in children younger than 10 years of age
(2) Night pain
(3) Persistent pain for more than 4 weeks
(4) History of trauma, fever, weight loss; B-symptoms

In reviewing the past literature, emphasis has been placed on the neurologic examination; however, the definition of what this entails remains vague. Most publications regarding pediatric back pain are centered in the disciplines of orthopedics and radiology, which can lead to different interpretations of what the examination should entail. This is reflected in the history of how evaluation guidelines were designed over the years.

In addition to the red flags proposed in the literature, it is essential to rule out any potential spinal symptoms: urinary and fecal incontinence, urinary retention, saddle anesthesia, and sensory level on the trunk.

Clinical manifestations

Incidence and severity

The reported incidence of back pain in children varies considerably between studies, ranging from 7% to 72% (142; 200; 73). This heterogeneous outcome can be attributed to higher variability in study parameters, an increased popularity of organized sports over the decades with increased awareness of the benefits of regular physical activity (100), and the fact that the pediatric population undergoes significant musculoskeletal growth, especially during puberty.

The U.S. Department of Health and Human Services published an estimate that 54.1% of children aged 6 to 17 years participated in regular sports (19). There is a growing recognition of the benefits of regular physical activity established at a young age, including better overall mental health (193; 67), higher bone mineral density when girls become adult women (53), decreased cardiovascular risk (74), and reduced obesity and associated metabolic disorders in school-aged children (49). The benefits of regular physical activity also translate to children with underlying conditions that lead to long-term disability (165; 48), congenital or acquired spinal conditions (141; 123), congenital or acquired conditions of the limb (40; 169; 128), and congenital heart conditions (11).

Both over- and under-regular activities contribute to the development of back pain, independent of age (89; 168; 91; 118; 181). There is a greater risk for overuse injuries in children with levels of activity higher than their degree of physical conditioning (60). Sports that require repetitive axial loading, extending, or twisting carry an inherently higher risk of developing exercise-induced back pain (89; 73). There is also evidence suggesting that female athletes experience higher incidents of pain related to the facet and sacroiliac joints (196). Sedentary lifestyles in children lead to obesity and psychosocial difficulties, and the combination of these factors is known to increase risk for developing back pain (90; 117; 143). The American Academy of Pediatrics recommends 60 minutes of activity daily to promote baseline physical health, even for children with mental or physical disabilities (29; 48). Although accommodations are needed for children with disabilities, the opportunity to experience the can-do attitude empowered by participation with acceptable risks is priceless for these children.

Incidents of back pain correlate with the timing of adolescent growth spurts, with a sharp increase in prevalence between the ages of 12 and 18. This reflects the change in mechanical load on the spine during linear growth and pubertal development (86; 118; 75). Combined with the escalation of organized sports intensity during this period (junior high and high school), this age group is at higher risk of developing symptoms of back pain. The lifetime prevalence of back pain is considered to be similar to that of adults once the child reaches the age of 18 (89; 88; 26).

Most pediatric back pain cases are fortunately benign in etiology but can be quite debilitating (210; 22). Chronic back pain in patients aged 8 to 16 years has led to reduced quality of life and increased missed school days (81). However, pediatric back pain was heralded as a rare entity with a high risk for series pathology in the early 2000s (190; 142; 182; 42; 200; 89; 88; 78; 181), which unfortunately led to increased radiation exposure, medical costs, and patient and family anxiety due to the multitudes of diagnostic tests. At least 50% of patients with pediatric back pain have a benign or nonspecific musculoskeletal strain without concern for other organic pathology, even after thorough work-up (27).

In a retrospective study that reviewed 232 patients from birth to 18 years of age who presented to a pediatric emergency department with a chief complaint of back pain, a nonpathologic diagnosis was found in 76.8% of the visits (22). In comparison, benign or nonspecific musculoskeletal strain in adults is estimated to be up to 85%, much higher than the pediatric population (43). Although the majority of pediatric back pain is from benign or nonspecific musculoskeletal causes, this population warrants higher attention to avoid overlooking serious pathologies. Healthcare providers play a critical role in ensuring the back pain is indeed of simple musculoskeletal origin without concerning pathology, and additionally guiding appropriate rehabilitative exercises to reverse this injury and prevent chronic suffering. An estimated 10% to 15% of affected children will develop chronic low back pain later in life (90).

Neurologic examination

For a source of back pain or neck pain to be neurologic in origin implies injury to one or more of the cervical or lumbosacral nerve roots. The official term is “radiculopathy” and is most likely to cause associated motor and sensory deficits.

Comprehensive manual muscle testing is essential. The caveat is to truly gauge whether the patient is unable to move due to pain or if it is truly weakness.

Light touch would be sufficient sensory testing for the purposes of this evaluation.

Reflexes should include (at minimum) biceps, triceps, patellar, and ankle. Perineal and anal evaluation would be determined by whether there were spinal symptoms present on history.

The combined presence of dermatomal pain or numbness with segmental reflex loss and myotomal weakness approaches specificities of 78% (lumbosacral disease) and 99% (cervical disease). In all cases, myotomal weakness is the most accurate predictor of root disease (72).

Table 1. Neurologic Examination Findings

Root	Primary location of weakness	Primary location of sensory deficit	Reflex loss
C4	Mildly impact the trapezius	Cap distribution along the shoulders
C5/6	Shoulder abduction Shoulder external rotation Elbow flexion Wrist extension	C5: Lateral arm C6: Lateral forearm	Biceps and brachioradialis
C7	Elbow extension Wrist flexion Finger extension	Posterior forearm extending down the third digit	Triceps
C8/T1	Intrinsic hand muscles	C8: Medial forearm T1: Medial arm	--
L1	--	Inguinal region	--
L2	Hip flexion	Proximal anteromedial thigh	--
L3/4	Hip adduction Knee extension	L3: distal anteromedial thigh + medial knee L4: anterior thigh, medial leg	Patellar
L5	Hip abduction Ankle dorsiflexion/eversion/inversion	Lateral thigh + anterolateral leg + dorsomedial foot + plantar surface of the foot
S1/2	Hip extension Knee flexion Ankle plantar flexion	Posterior leg + lateral foot/ankle	Achilles
S2-4	--	Medial buttock + perineal region + perianal region	Bulbocavernosus and anal wink
Adapted from (35).

In particular, patellar areflexia is noted to be six to seven times more common in L3 to L4 herniation compared to other levels (195).

Red flag symptoms can indicate a serious underlying problem like malignancy, neoplasm, or infection. Alerting symptoms include an acute onset of pain with no history of trauma, pain that occurs at rest, or pain that causes awakening from sleep. Early morning stiffness and pain are routinely associated with inflammatory etiologies. Back pain with fever, nocturnal pain, and bony tenderness may suggest infectious etiology, whereas recent weight loss and bruising might be indicative of malignancy (134). Red flag symptoms include patient age under 3 years, weight loss, fatigue, bladder or bowel incontinence, and radiculopathy (69). It is essential to perform a complete review of systems to rule out gastrointestinal or renal etiologies for back pain.

Special testing

The Spurling test. This test is designed to assess cervical radiculopathies and is one of the most studied physical examinations for this entity (187; 05; 172; 85). The test is performed by passive cervical extension with rotation to the affected side and axial compression. A positive test is determined if the maneuver elicits radicular pain ipsilateral to the direction of the head rotation.

In a cross-sectional study, the Spurling test was not very sensitive, but it was specific for cervical radiculopathy that was later confirmed with EMG. The cervical extension induces posterior bulging of the intervertebral disc. Rotation of the head leads to narrowing of the neuroforamina in the cervical spine. Axial compression is applied to mimic exaggerated preexisting nerve root compression.

With a positive Spurling test, the suspected diagnosis is a cervical nerve root compression commonly related to intervertebral disc pathology (eg, herniation).

Shoulder abduction (relief) sign. This test is designed to assess cervical radiculopathies. Active abduction of the symptomatic arm is achieved by the patient placing their ipsilateral hand on their head. A positive test results in relief (or reduction) of cervical radicular symptoms.

Neck distraction test. This test is designed to assess cervical radiculopathies. An active distractive force is applied by the examiner while grasping the patient’s head under the occiput and chin. A positive test results in relief (or reduction) of cervical radicular symptoms.

The straight leg raise test. This test is designed to assess lumbosacral radiculopathies, specifically at L5/S1, where the majority of the herniated discs occur due to anatomy (50; 103; 121; 191). The patient is supine, whereas the provider passively raises the affected lower extremity with the knee fully extended. This maneuver accentuates the underlying disc herniation. If pain is elicited in the back, it is most likely a central protrusion. Lateral protrusions elicit leg pain, and intermediate protrusions produce a combination of both pain patterns. The straight leg raise test is valuable in the diagnosis of herniated lumbar discs with apparently high specificity (greater than 90%).

The slump test. This test is designed to assess lumbosacral disc herniations but does not cause root compression as a result (121; 191). The patient is first seated upright, then instructed to “slump” forward, flexing the thoracic and lumbar spines while maintaining their gaze ahead. Once the patient is fully slumped forward, they flex the cervical spine and extend one knee with passive upward pressure applied by the provider. This will effectively apply increasing tension along the sciatic nerve and subsequently trigger radicular pain. If additional ankle dorsiflexion is applied, the test is renamed as the Lasegue test.

The FABER test (Flexion, Abduction and External Rotation). This test helps identify back pain mimics, including pain from hip pathology of the sacroiliac joint (10; 146; 188; 184). The patient is placed supine, with the provider passively flexing the knee and hip to 90 degrees while the foot of the examined extremity is placed on the opposite knee (figure 4 position). The test is positive if pain is elicited when the provider gradually pushes the knee downwards towards the examination table, leading to further high abduction and external rotation. Ipsilateral anterior pain would point towards a hip joint pathology, whereas posterior pain would suggest sacroiliac pathology.

Work-up

Imaging. Several guiding algorithms for pediatric low back pain have been proposed over the years; however, these publications focus on the use of imaging modalities rather than considering electrodiagnostic testing. This may be due to the availability of appropriate NCS/EMG for pediatric patients historically, but this modality is now becoming more available.

The majority of the present imaging guidelines base their information on hallmark studies done by Feldman and colleagues in 2000 and 2006 (54; 55). Key findings included the following:

(1) Radiographs led to a diagnosis of pathological pediatric low back pain in 22%, with low sensitivity and specificity.

(2) The use of MRI can increase diagnostic sensitivity to 36% [also noted in subsequent studies (162; 156)].

(3) Radicular type pain, night pain, and abnormal neurologic exams were found to be most predictive. However, the authors did not specify what features of the neurologic examination were the most pertinent.

A prospective study of patients between the ages of 4 and 18 identified the following three factors, with a positive likelihood ratio greater than 1 or close to 1: (1) constant pain; (2) night pain; and (3) abnormal neurologic examination (157). In this study, elements of the neurologic examination included sensory or motor abnormalities, back pain on straight leg raise test, hamstring tightness, and asymmetric abdominal or extremity reflexes. The study showed a 100% predicted probability of achieving a specific diagnosis on imaging work-up if all three predictors are present. However, the caveat is that only two out of the 388 patients evaluated fit these criteria. Approximately 40% predicted probability for specific diagnosis is estimated for those who have 0, 1, or 2 predictors. The authors felt that emphasis should be placed on the neurologic examination because it has the highest specificity in predicting pathology (0.95).

The American College of Radiology published a 2017 guideline regarding the yield of various imaging modalities for pediatric back pain (51). Red flags identified are (1) constant pain, (2) night pain, (3) radicular pain, and (4) pain lasting more than 4 weeks.

A secondary factor is if the neurologic examination is abnormal. An abnormal neurologic exam, even in the absence of the above red flags, should trigger serum testing for infectious, inflammatory, or neoplastic processes. XR is not indicated unless there is preceding trauma. If an MRI study is warranted, total spine with and without contrast is recommended (61; 07; 82; 51). Depending on the patient’s size, one may get a better definition of the spinal structures when ordering the C/T/L spine MRI studies separately as opposed to aiming for a total spine condensed into a single study.

Abnormal neurologic examination with one or more of the identified red flags would prompt both XR and serum testing for infectious, inflammatory, or neoplastic processes. If MRI study is warranted, noncontrast studies can suffice unless there is concern for infectious, inflammatory, or neoplastic processes on serum studies, for which with and without contrast modality is required (07; 156; 51; 138). CT, either with or without contrast, is not as beneficial as the MRI study and, therefore, not typically warranted. In situations where MRI is contraindicated or has limited diagnostic value due to known hardware implantation, CT myelogram is considered, although it carries the risk of invasiveness and a degree of radiation required for the study. Technetium-99m bone scan with SPECT can be considered if MRI was not diagnostic and when the neurologic examination is abnormal but nonlocalizable (51). Tc-99m whole body bone scan with SPECT improves detection of spondylosis, particularly active spondylosis (12; 51). It is only moderately sensitive in evaluating infection and tumor.

Electrodiagnostic. Similar to our adult counterparts, pediatric neurology clinics are also inundated with patients presenting with back pain with concern for a neurologic cause. For back pain to be of neurologic origin, the injury needs to be localized to the spinal cord or the nerve roots. In these cases, neurologic deficits are not subtle. Once inflammatory, infectious, or oncological causes are ruled out by blood test and imaging, the remaining question is whether the condition (either identified or not identified) led to nerve root compression, thus, the perpetual pain. The best evaluation methods are nerve conduction studies and electromyography (NCS/EMG).

The power of NCS/EMG is the ability to localize the neuropathy (mononeuropathy, radiculopathy, plexopathy), to determine the severity of neuropathy gauge the possibility for reinnervation better, and to determine the temporal course of the injury (acute vs. chronic, stable vs. unstable) (34; 44; 45).

Shea and colleagues first described how NCS/EMG could identify fibrillation potentials in a specific myotome, thereby supporting a diagnosis of compressive radiculopathy (173). NCS/EMG (particularly the EMG portion) is the most sensitive neurophysiological test for root lesions (21; 101). The utility of the study highly depends on how rigorously the needle EMG was performed. The needle examination has incomplete sensitivity because it requires motor axon loss for abnormalities to be detected (122). Studies place the sensitivity of electrodiagnostic testing for active radiculopathy at 43% to 79%, owing to a wide variation in EMG protocols, the definition of a positive study, and which gold standard was used. Reported specificities range widely from 40% to 100% (32; 36; 133). One study reported that abnormal electrophysiological findings were noted in 82% of the patients with confirmed lumbosacral radiculopathy. Furthermore, EMG can distinguish radiculopathy versus neuropathy, thus differentiating intrinsic versus peripheral nerve involvement, which requires completely different treatment paradigms (34).

A retrospective study demonstrated that concordant abnormalities are often seen when patients undergo both EMG and MRI testing. The concordance was highest in patients who had motor, sensory, or reflex abnormalities on physical examination (135).

Associated condition 1: spondylolysis

Pathophysiology. Spondylolysis is due to a unilateral or bilateral defect in the pars interarticularis, which may be either congenital or due to a pathological fracture (134; 131). This is most commonly seen in the L4/5 region and is noted to be the most common pathological cause of back pain in pediatrics, accounting for up to 50% of cases in athletic patients (17; 129). Congenital causes of spondylolysis tend to have a gradual onset in pain compared to acquired cases (59). Acquired cases are most often seen in those with repetitive microtrauma due to excessive lumbar extension in activities or sports that involve repeated, explosive truncal rotation, such as in baseball, softball, tennis, football, dance, and gymnastics (62; 39; 105). Spondylolysis is usually asymptomatic until the onset of puberty, which coincides with the experience of rapid linear growth (69). Single-sport athletes tend to have more upper-level spinal stress injuries and a lower incidence of active spondylolysis on MRI at the time of diagnosis than multi-sport athletes (105).

Spondylolysis can evolve into spondylolisthesis, which occurs when a defect in the pars interarticularis leads to forward translation of one vertebra about the next vertebra, often seen in bilateral pars interarticularis defects (15; 183; 189).

Clinical presentation. Patients with spondylolysis complain of moderate pain in the lumbar region, which is worsened by physical activity and alleviated by rest. The described pain can sometimes radiate to the posterior thigh or buttocks, or both (14), even in the absence of associated nerve root irritation. Advanced spondylolisthesis can present with hamstring tightness and a “crab-like” gait with knee and hip flexion. When individuals with advanced spondylolisthesis are observed from the side, they may show flattening of the lumbar lordosis as well as a vertically oriented sacrum. Additionally, in very serious cases, a “stair step” can be palpated at the level of slippage (76).

Paravertebral spasm, hyper lumbar lordosis, loss of normal lordosis, limited lumbar extension and flexion, and localized tenderness can sometimes be observed on physical examination (39).

Early identification and appropriate treatment of spondylolysis can prevent progression to spondylolisthesis, particularly in young athletes.

There is a known genetic component with spondylolysis and spondylolisthesis. It is five times more likely to occur in patients with first-degree relatives carrying this diagnosis. There also appears to be a correlation with incidences of spinal bifida as well (02; 189).

Work-up. XR, MRI, and SPECT are recommended.

Treatment. The majority of cases improve with conservative treatment, which includes use of NSAIDs and physical therapy. Bracing can be used to reduce axial strain but does not seem to influence outcome. The bony defect may persist despite the resolution of clinical symptoms (102). It is beneficial for patients to have at least a one-time consultation with an orthopedic specialist.

Associated condition 2: discitis

Pathophysiology. Discitis is described as the infection of the vertebral disc. If allowed to progress, the infection can spread to the vertebral bodies themselves, leading to osteomyelitis. Discitis often presents in the lumbosacral area, whereas osteomyelitis can affect any region of the spine. Delayed treatment can result in death, spinal deformities, chronic pain, or segmental instabilities. To reduce negative outcomes, early diagnosis and treatment are essential. It can be challenging to diagnose in young toddlers and children, who tend to present with vague symptoms of back pain, difficulty walking, and irritability. A recent infection is routinely present, leading to hematogenous spread to the intervertebral disc (56).

Clinical presentation. Children usually report back pain that is worse with movement, frequently presenting with abnormal gait (175). They will often refuse to bend forward because this will compress a swollen and infected intervertebral disc. Pain is often challenging to localize but persistent. Fever is not always present. Osteomyelitis is more likely to present with a history of fever; however, the absence of fever does not rule out osteomyelitis (56).

Work-up. Serum studies include CBC, CRP, ESR, and blood cultures.

MRI of the spine with and without contrast is the most ideal imaging modality. AP and lateral spine radiographs can show loss of disc height and sclerosis, but not until 3 to 4 weeks of disease progression (56; 93).

Treatment. Treatment includes prolonged broad-spectrum antibiotic therapy for several weeks. The length of antibiotic therapy is based on repeat imaging and response to antibiotics. MRI remains the gold standard for diagnosis and efficacy of treatment (18).

Associated condition 3: Scheuermann kyphosis

Pathophysiology. Scheuermann kyphosis is a rigid progressive kyphosis of the thoracic spine due to anterior wedging greater than or equal to 5 degrees involving multiple thoracic vertebrae and occurs during adolescence. Some patients may not begin to experience back pain due to this condition until much later in adulthood (209). It typically presents at the onset of the pubertal growth spurt, between 13 and 17 years of age, and is diagnosed based on classic lateral radiograph findings (115). Concurrent spondylosis was found in up to a third of the patients (140).

The incidence of disease ranges from 0.4% to 8.3%. Previously, it was thought that the male-to-female ratio was 2:1 (37), but it is now believed to be closer to 1. Between 30% and 60% of the patients complain of pain in the midthoracic interscapular area between T7 and T9, which corresponds with the apex of the deformity (71).

The etiology of this condition is currently unclear. Several theories were debunked, including osteonecrosis of the ring apophysis in the vertebral body, leading to arrest of anterior growth and osteoporosis. It is known that the condition is caused by defective growth of the vertebral body end plate, the weakest component of the disc-vertebra interface, susceptible to excessive mechanical stress and a key conduit for vascular and nutritional supply to the intervertebral disc. Disorganized end plate ossification and reduced collagen production are seen on histological studies (84; 171; 95).

Clinical presentation. Scheuermann kyphosis typically manifests at between 12 and 15 years of age but may not come to clinical attention until later in life. When the patient is viewed from the side, the Adam forward-bend test shows the gibbus deformity – an abrupt posterior angulation of the thoracic spine. The resultant anteriorly rounded shoulders can lead to contractures and limited shoulder flexion with time (16). There is compensatory increased cervical lordosis forming a “gooseneck” deformity. Similarly, increased lumbar lordosis can lead to strain on the pars interarticularis, placing these patients at risk of developing spondylolysis. The exaggerated lordosis can also lead to hamstring and hip flexor tightness and muscle strain (57). Scoliosis can also be seen concurrently (160).

It is imperative to conduct a thorough physical and neurologic examination. Although uncommon, severe cases can have concurrent syrinx, intradural cysts, disc herniations, or cord injury. Acute angulation of the thoracic spine leads to the spinal cord draping directly over the vertebral bodies and, therefore, interrupts typical cerebrospinal fluid flow, leading to syrinx and cysts. Severe curvature (higher than 100 degrees) can cause restricted cardiopulmonary function (132; 113).

Work-up. XR is recommended. If surgery is considered or if the patient has an abnormal neurologic examination, MRI without contrast may be done to assess for potential neural axis anomalies.

Treatment. The progression of this condition is less predictable, unlike scoliosis. Conservative management includes reducing sports with repetitive spinal strain, such as weightlifting. Physical therapy should focus on core strength to improve sagittal posture, but its utility in slowing disease progression remains unclear (201). It is important to work on stretching to prevent shoulder contractures and overtly tight hamstrings.

Bracing is indicated in pediatric patients with an immature skeleton with kyphosis measuring 45 to 65 degrees (201). Braces are discontinued once a patient reaches skeletal maturity; unfortunately, a loss in correction gained during treatment occurs in 30% of compliant patients (20). Surgery is reserved for patients with rigid or fixed curves greater than 70 degrees, severe cosmetic concerns, and any neurologic deficits (113).

Associated condition 4: scoliosis

Adolescent idiopathic scoliosis remains the most common type, affecting 1% to 4% of adolescents, particularly young women (31). Pediatric patients with immature skeletons are at the highest risk of curve progression, particularly during growth spurts, where there is the highest risk of mismatch between skeletal growth and muscle maturation. Bracing is recommended once curvature reaches 20 degrees in hopes of preventing progression to a surgical threshold, which is defined as greater than 50 degrees (99; 46).

Associated condition 5: disc herniation

Pathophysiology. Disc herniation is typically the result of degenerative changes and is, therefore, uncommon in pediatrics (124; 68; 166). It can still present in the setting of (1) trauma, (2) sports-related injuries with subsequent axial load, such as weightlifting, wrestling, and gymnastics, and (3) obesity. Due to anatomy, L4/5 and L5/S1 are the most frequently involved segments.

Clinical presentation. Patients typically present with radicular pain that appears to be worse in the lower extremities compared to the back. Pain is worse with lumbar flexion and improves with rest. The straight leg raise and slump tests may also be positive (106).

Work-up. Radiographs are typically normal, with MRI without contrast as the best option. However, there is a high false-positive rate on MRI (155).

Treatment. Conservative measures are preferred. Surgical correction was not as successful in pediatrics as in adults but can potentially provide some symptom relief (41; 38; 94; 154).

Disc herniation is likely to present with pain only if it is associated with structural deformities like disc prolapse or Scheuermann disease, which may delay the diagnosis of this process. Patients may present with localized pain and sciatica--a sign of nerve root compression or irritation. One distinctive feature present in the pediatric population with disc herniation is that 90% of patients have a positive straight leg raise test elicited on physical examination. Plain films are not useful in evaluating disc herniation. The gold standard for diagnostics of a herniated disc is followed up with MRI (134).

Associated condition 6: apophyseal ring fracture

Apophyseal ring fractures result in avulsion of the posterior arch, leading to bony fragments being displaced in the spinal canal (03). They can be found in all ages and are highly associated with degenerative changes in the elderly and rigorous activity that constantly applies a heavy axial load (weightlifting, wrestling, gymnastics, etc.). Apophyseal ring fractures are surprisingly common in cases of pediatric lumbar disc herniation (30; 83).

Clinical findings and work-up are similar to those of disc herniation.

Associated condition 7: axial spondylarthritis

Pathophysiology. “Ankylosing spondylitis” is a term used since the 1970s to describe HLA-B27-associated inflammatory disease that predominantly impacts the sacroiliac joints based on radiography. The advent of MRI methods has enabled providers to detect early inflammatory changes before the definite arthritic deformation captured on XR (185). As a result, “axial spondylarthritis” is now accepted as more accurate terminology to describe this category.

Nomenclature and classification have also evolved in pediatric-onset situations. The primary overarching term used for pediatric-onset inflammatory arthritis is “juvenile idiopathic arthritis.” This is further divided into several subcategories, with the description of enthesitis-related arthritis befitting the pediatric equivalent of adult-onset axial spondylarthritis (114). Enthesitis-related arthritis is present in approximately 17% of all patients in two large juvenile idiopathic arthritis registries (179). It is important to know that not all enthesitis-related arthritides will have axial manifestations. Juvenile spondyloarthritis has also been used as an umbrella term for patients with onset of disease before the age of 16 and considered to be on a continuum with adult-onset spondylarthritis (177). Early-onset disease occurs in those less than 5 years of age, with a higher female prevalence, association with dactylitis, ANA positivity, and uveitis. Later-onset conditions tend to have a male prevalence with enthesitis, sacroiliitis, and psoriasis (79; 161). HLA-B21 is positive in up to 12% of juvenile cases, with a similar incidence in both the late- and early-onset groups, and it does not correlate with risk of axial disease; thus, it is less informative in this population (79; 94).

Gastrointestinal inflammation is strongly correlated with juvenile spondylarthritis, with up to two thirds of patients experiencing concurrent subclinical gut inflammation (127; 64). Although calprotectin can be elevated, the levels vary tremendously and are inaccurate as a marker for inactive or active disease or to distinguish those with or without sacroiliitis on MRI (202).

Clinical presentation. Inflammatory back pain is often dull with insidious onset deep in the lower back or buttocks or is misinterpreted as chest pain. Patients often report morning stiffness that improves with activity but returns after a period of rest. Nighttime pain is not uncommon, particularly starting in the second half of the night (after a period of inactivity), waking the patient, but it improves once the patient moves around (185).

Work-up. XR remains reasonable, but the majority of patients will require MRI with and without contrast for better resolution evaluation, which includes sacroiliitis (145). Serum studies, including CBC, CRP, ESR, ANA, and HLA-B27, are all reasonable.

Treatment. Because there is no single laboratory test or imaging result sufficient to arrive at the diagnosis, it is important to obtain at least a one-time consultation from a pediatric rheumatologist if there are concerns for axial spondylarthritis. Treatments may include NSAIDs and TNF-alpha inhibitors.

Associated condition 8: neoplasm

Primary tumors of the spine are rare in childhood and usually present with vague symptoms of malaise and fatigue. Other commonly associated symptoms include weight loss, fever, and night sweats (106). It is important to note that urinary and stool dysfunction rarely occur before the onset of motor and sensory deficits at a truncal level. The presence of urinary and stool dysfunction indicates concern for more advanced disease (80).

The location of the tumor can include extradural, intradural, extramedullary, and intramedullary. Due to the tumor location, one third of intramedullary tumors can cause concurrent painful scoliosis.

Table 2. Primary Tumors of the Spine

Location	Type	Tumor
Extradural	Malignant	Leukemia and lymphoma
	Malignant	Metastatic
	Malignant	Ewing sarcoma
	Malignant	Osteosarcoma
	Benign	Osteoid osteoma
	Benign	Osteoblastoma
	Benign	Chondroma/chondrosarcoma
Intradural extramedullary	Benign	Meningioma
	Benign	Myxopapillary ependymoma
	Benign	Peripheral nerve sheath tumors
	Benign	Dermoid and epidermoid tumors
Intramedullary	Malignant/Benign	Astrocytoma
	Benign	Ependymoma
Adapted from (80)

Benign tumors. Osteoid osteoma, osteoblastoma, and aneurysmal bone cyst are the most common benign spine tumors of childhood and are all of bone-related origin. Benign tumors elicit inflammation due to osteoblastic activity, which can lead to painful scoliosis with mass effect (92).

Osteoid osteomas tend to be small in size (less than 1.5 cm), with pain that is worse towards the end of the day that responds to NSAIDs. The risk of malignant transformation is low. On the other hand, osteoblastomas are larger on average (more than 2 cm), and pain does not tend to resolve with NSAIDS and does have the potential for malignant transformation with local destruction. The larger osteoblastomas and varieties of aneurysmal bone cysts often respond well to surgical resection (98).

Because tumors are bone-originated, CT spine tends to be most informative. It is recommended that patients obtain an oncological and neurosurgical consultation.

Malignancies of the spine include Ewing sarcoma, osteosarcoma, lymphoma, leukemia, and metastatic lesions, among others. Malignant lesions typically (but not always) occur in the anterior portion of the vertebrae, causing symptoms of spinal cord impingement (159).

Due to the destructive nature of Ewing sarcoma and osteosarcoma, XR can be sufficient to demonstrate the lesion, but advanced imaging with CT/MRI/nuclear medicine is subsequently recommended for tumor staging and surgical planning. Treatments can include resection followed by chemoradiation (98).

Hematological malignancies, including lymphoma and leukemia, can present with very vague back pain. These patients may also demonstrate easy bruising with abnormal CBC. Serum testing of CBC, LDH, and uric acid is important. The preferred imaging modality is MRI spine with and without contrast (98). Patients are then referred to pediatric oncologists and neurosurgeons for assessment of treatment and possible tumor resection (39).

Associated condition 9: leg length discrepancy

Leg length discrepancy is a common orthopedic condition in the general population (90% prevalence rate) (63), but it may be overlooked when evaluating children. Many conditions can lead to leg length discrepancy, including:

Idiopathic or congenital leg discrepancy
	• Skeletal dysplasias
	• Congenital hemihypertrophy
	• Syndromes including Beckwith-Wiedemann, Proteus, Klippel-Trenaunay-Weber
	• Gigantism with neurofibromatosis
	• Connective tissue disorders leading to notable ligamentous laxity or axial malalignment
	• Contractures of the lower extremities due to primary CNS injury (eg, cerebral palsy)
History of tumor, radiation, infection, injury in the lower extremities
	• Including developmental dysplasia of the hip and Legg-Calve-Perthes
(06)

The degree of leg length discrepancy is a key factor in health implications. The original stratification of leg length discrepancy severity by Reid and Smith indicated:

Mild = difference of 0 to 30 mm
Moderate = difference of 30 to 60 mm
Severe = greater than 60 mm

(207)

We now recognize that a discrepancy of greater than 10 mm is clinically significant and causes symptoms, including alternate gait or posture, balance problems, low back pain from asymmetric strain of paraspinal muscles, scoliosis if leg length discrepancy occurs in the pediatric range, and subsequent degenerative spine changes later in life. Pelvic lateral tilt to accommodate the longer leg is highly correlated with the severity of leg length discrepancy, whereas attempts to lengthen the shorter leg by toe walking are comparably less common because it requires more muscle effort. As a result, leg length discrepancy tends to cause more strain in the paraspinal muscles and lower back due to overuse injuries (87). One can imagine the impact of leg length discrepancy on a growing child and its associated risk for future pain and disabilities.

Leg length discrepancy can be detected both clinically and radiographically, as summarized in the table below. Among the clinical assessments, the block test has the best reliability, sensitivity (55%), and specificity (89%), with the high caveat of possible high interobserver variance (09). Radiographic evaluations can be plagued by artifactual misinterpretations depending on the degree of magnification, which favors clinical assessments in some publications (70). In general, x-rays are preferred over CT scans due to their comparable measurements and reduced radiation exposure (1.6 to 3.8 times less) (164). The advent of machine learning and AI holds significant promise for higher reproducibility, specificity, and sensitivity in automated detection in x-ray assessments (167).

Table 3. Clinical Evaluation of Leg Length Discrepancy

Clinical evaluations
Method	Description	Pros and cons
Tape measurements	Three types of measurements: (1) Measured from the umbilicus to the medial malleolus with the lower extremities in line with the trunk (2) Anterior superior iliac spine to the malleolus (3) Anterior inferior iliac spine to the lateral malleolus	• Precision up to 5 mm, but taking the mean of at least two to three measurements is recommended • Comparable to gold standard CT measurements Reliability is highly dependent on patient cooperation, the ability of the patient to lie flat (lack of fixed contractures), examiner skill, and experience (04; 06).
Palpation of bony landmarks with the use of standing blocks	The patient stands with feet 10 cm apart and knees extended. The examiner places hands on the posterior superior iliac spine, the anterior superior iliac spine, or the left/right iliac crests to assess for horizontal symmetry. The patient is then asked to stand with the shorter leg on blocks, measuring increments of 0.5 cm, until horizontal symmetry of bony landmarks is achieved.	Reliability is highly dependent on the examiner’s skill and experience, the patient’s ability to stand (lack of fixed contractures) (04; 06).
Prone leg check	Two methods: (1) The patient lies prone on the examination table with knees flexed. The examiner measures the height difference in the posterior aspects of the soles. (2) The patient lies prone on the examination table with knees extended. The examiner applies pressure in the cranial direction through the long axis of the lower extremities using thumbs to determine if there are discrepancies.	There are mixed reports regarding reproducibility and accuracy in several studies. It is unclear if a valid conclusion can be drawn (04; 06).
Supine leg check	The patient lies supine on the examination table with knees extended. The examiner applies pressure in the cranial direction through the long axis of the lower extremities using thumbs to determine if there are discrepancies.	There are mixed reports regarding the reproducibility and accuracy in several studies. It is unclear if a valid conclusion can be drawn (04; 06).
Radiographic evaluation
Method	Description	Pros and cons
Standing radiograph EOS	Allows simultaneous biplanar imaging and 3D reconstruction of the spine and lower extremities at a relatively low radiation dose. Often used in the evaluation of scoliosis, leg length discrepancy, and malalignment of lower extremities.	Should be done in an experienced center to prevent unwanted transverse plan magnification and other motion or distortion artifacts. Bias due to artifactual error is high, and reliability is low. New machine learning methods enable more accurate automatic assessment with an absolute error of less than 2 cm (04; 87; 167).
Full-length standing anteroposterior radiograph		Extremity helpful for evaluating angular deformities in the lower extremities because the method is similar to using the gold standard CT scan, but with lower radiation (164; 04).
CT scan		Often hailed as the gold standard for radiographic evaluation of leg length discrepancy. The results were highly reproducible, but it is still recommended to perform repeat measurements under the guidance or supervision of a surgeon. Radiation exposure is high (164; 04).

Treatment tends to be conservative (rehabilitation, bracing, shoe inserts, physical therapy) if mild, but a difference of more than 20 mm would warrant surgical consideration. The most common surgical approach is to shorten the longer limb by percutaneous epiphysiodesis to arrest the growth plates. Severe cases of leg length discrepancy ranging from 60 to 150 mm would require external fixator lengthening of the shorter limb, and those greater than 150 mm would require a combined approach to lengthen the shorter limb and shorten the longer limb. A leg length discrepancy of more than 200 mm is typically outside the corrective capabilities of surgical interventions, and external prostheses are used (04).

Clinical vignette

A 12-year-old boy presented to the clinic with a 6-month history of low back pain with radiation to the left hip and right knee. He also had tightness in his hamstrings, left more than right, which was interfering with his gait. He was unable to extend his legs or touch the ground with his hands without bending his knees. His stiffness was worse in the morning and improved throughout the day. Advil^® and Motrin^® did not alleviate the pain, but heat pads did. He reported no bowel or bladder incontinence. His physical examination was normal for sensation, strength, and muscle bulk, but he had a positive straight leg raise test, which was worse on the left leg.

Initially, the patient was sent to an orthopedic surgeon by his pediatrician. He was treated with rehab for possible slipped capital femoral epiphysis, which did not help. An MRI pelvis did not support the diagnosis. He was later seen by neurology and referred to a neurosurgery clinic with an MRI of the lumbar spine that revealed a broad-based disc bulge at L5-S1. A microdiscectomy was offered, and the patient underwent the procedure with a minimally invasive approach. The thecal sac was satisfactorily decompressed.

Postoperatively, the patient’s left leg radiculopathy improved, though his hamstring tightness persisted. The hamstring tightness subsequently improved with a course of physical therapy.

Biological basis

Anatomic localization

A key aspect is the unique anatomy of the pediatric back and how it changes throughout childhood. The spinal column is comprised of stacked bony vertebral bodies that articulate with each other through intervertebral discs. The discs are made of fibrocartilaginous anulus fibrosus encased around the gel-like nucleus pulposus. The posterior arch extends posteriorly from the vertebral body, creating an open canal for the spinal cord to pass through. Each posterior arch contains superior and inferior facets to articulate with the facets of adjacent vertebral bodies. This area is also termed the pars interarticularis. As a result, two foramina, one on each side, are formed by facets of adjacent vertebral bodies, which allows nerve roots to exit from the spinal cord and spinal column to the distal extremities. Paraspinal muscles attach to laterally extending processes in the posterior aspect of the vertebral body and are known as the transverse processes (118).

In the pediatric population, the vertebral body is inherently weaker than the posterior bony aspects. There is a growth plate on the superior and inferior aspects of each vertebral body, which starts to ossify around the age of 4 and often stays open until the age of 18 (73).

The body’s natural thoracic kyphosis paired with lumbar lordosis is key to buffering the axial load, which changes as one ages. As a toddler, lumbar lordosis is more notable than the degree of thoracic kyphosis, but both will progress throughout childhood and adolescence. In contrast, the contour of the sacrum is set after the age of 3, which, in effect, produces an increased anterior load and stress on the sacroiliac joint as one grows (58; 119; 120). Muscular strength also evolves as bones mature, causing a constant change of biomechanical musculoskeletal strain driven by growth (31; 25).

Scoliosis is defined as the deviation from midline greater than 10 degrees and is measured radiographically as the Cobb angle (25). The spine is rarely straight, and a curvature less than 10 degrees is physiologically typical. Scoliosis can occur idiopathically or due to underlying abnormal truncal muscle tone and strength, congenital or acquired skeletal deformities, neuromuscular weakness, or other causes of truncal and extremity asymmetry (163; 192; 153; 33; 208). The resultant altered mechanical back strain can easily lead to various musculoskeletal causes of back pain.

Sources of back pain include bone, spinal cord, nerve root, and muscle. Etiologies include mechanical compression as well as inflammation and infection.

Pathophysiology

Sacroiliac joint pain is reported by young athletes with a history of trauma. Young females are susceptible to sacroiliac injury because of the laxity of their developing pelvic girdles. Sacroiliac pain can be differentiated from radiculopathy with electromyelography studies (178).

Spondylolysis, which usually presents in young athletes over the age of 10, is a defect in the pars interarticularis – the weakest part of the vertebral body. This abnormality can be congenital, can follow stress-related injuries, or may manifest in individuals with a genetic predisposition. Gymnastics, ballet, weightlifting, and football are among the activities that cause hyperextension and rotational loading of the spine, which leads to repetitive trauma and, consequently, stress-related fractures resulting in spondylolysis (39). Spondylolysis is usually asymptomatic until the onset of puberty, which coincides with the experience of rapid linear growth (69).

Spondylolysis can evolve into spondylolisthesis, which occurs when a defect in the pars interarticularis leads to forward translation of one vertebra in relation to the next vertebra. Oftentimes, the slippage takes place in the fifth vertebral body and is classified into 1 of 4 grades depending on a calculated slippage percentage (110).

Disc herniation in children often requires surgery because the epiphyseal cartilage in this population is not fused, and trauma can cause a mass on the herniated disc. Additionally, the nucleus pulposus in these children is well-hydrated, which leads to lower resorption, unlike a similar degenerative lesion in adults (194).

The exact pathophysiology of Scheuermann kyphosis is unclear and remains a topic of debate. Twin studies reveal a genetic component to disease heritability, as there is stronger association of Scheuermann kyphosis in monozygotic twins when compared to dizygotic ones (37). Scheuermann originally attributed the deformity to aseptic necrosis of the ring vertebral apophyses (170). However, histological evidence shows irregular mineralization, abnormal endplate vertebral cartilage, disordered vertebral ossification, as well as altered collagen-proteoglycan ratios (08). In a landmark study, 93% of bone specimens from suspected Scheuermann kyphosis cadavers had Schmorl nodes (171). Schmorl nodes are formed when intravertebral discs herniate into the end plate of a vertebral body (136). Associations with Legg-Calvé-Perthes, dural cysts, hypertonia, growth hormone hypersecretion, and infections are also reported in the literature (147). It is uncertain whether the abnormal histological findings are a result or a cause of the disease (71). Kyphosis may be the first occurring symptom, which leads to increased anterior force, which in turn causes anterior body wedging and, consequently, the radiologic and histologic changes discussed above (203). In a groundbreaking twin genetic study, Damborg and colleagues found the heritability of Scheuermann disease to be about 74% (37).

Young athletes who participate in sports like weightlifting, gymnastics, and wrestling expose their spines to repetitive microtrauma or single trauma, which can cause apophyseal ring fractures. These fractures occur in vertebral bodies before they have been completely fused. Apophyseal fractures take place at the junction of the vertebral body and cartilaginous ring apophysis (62).

Discitis affects young children because the blood supply to the intervertebral disc and the cartilaginous vertebral end plate is different than it is in adults. There are multiple anastomotic channels that communicate between the vertebral end plate and disc in children, providing a hematogenous route of delivery for bacteria to the disc. These channels involute by adolescence, leaving behind end arteries (204).

Spondylodiscitis can occur either by hematogenous or non-hematogenous spread, with hematogenous spread being the most frequent route. Hematogenous spread involves allowing bacteria from distant sites to contaminate the spine in the setting of bacteremia. Infection origin can include respiratory, skin, oral, urinary, gastrointestinal tract, or any implanted device (126).

Diagnostic workup

The history and physical examination are important in guiding the diagnostic workup for a child with back pain, as there is no standard laboratory workup. For example, signs of infection, like fever, malaise, and weight loss, must be investigated by blood culture, chest radiographs, and PPD testing, if indicated. Additionally, a complete blood count with differential acute phase reactants and lactate dehydrogenase is indicated if malignancy is suspected (39).

Although spinal radiography may be the first step to rule out bony tumors, magnetic resonance imaging (MRI) is quite often the gold standard for diagnosis. MRIs can have limitations in the pediatric population as they are expensive and may require the patient to be sedated, which often requires an anesthesia team at a tertiary pediatric hospital (39).

Sacroiliac joint pain can be diagnosed with a proper physical examination; 89% of patients with sacroiliac joint pain in a study had tenderness in the sacral sulcus. Although this physical finding has low specificity, it has the highest positive predictive value of any other physical examination test when combined with maximal pain below L-5 (47). However, the definitive diagnostic test for sacroiliac joint pain is sacroiliac joint block (178).

According to one study, spondylotic lesions are seen on x-ray 30% to 38% of the time (148). The diagnostic test of choice in a young athlete with back pain is a lumbar SPECT scan. If the SPECT scan is positive, a CT scan is performed to localize and identify the defect. If the SPECT scan is negative for spondylolysis, an MRI may be performed to look for other possible etiologies for back pain (199).

AP and lateral x-ray views are the initial diagnostic tests of choice for Scheuermann kyphosis. Schmorl nodes, disc space narrowing, loss of disc space height, kyphotic deformity, and increased anterior-posterior diameter of the apical thoracic vertebrae may be identified on radiographs (39).

Patients who present with discitis often have abnormal x-ray findings. X-ray images show decreased disc space height as well as erosion of adjacent vertebral endplates. Technetium-99m bone scans also show increased uptake in affected areas. Further MRI investigation can also show the precise nature of these abnormalities (39).

The synovial and inflammatory changes in juvenile idiopathic arthritis are best viewed by MRI scans with contrast. Plain radiographs have the lowest sensitivity for detecting early arthritic changes, and bone scintigraphy and CT scan can provide a diagnosis; however, they are associated with high radiation exposure (39).

Tumors of the spine and spinal cord can be visualized on plain radiographs; however, MRI and CT scans provide a better view of the lesions. MRIs are necessary to localize meningeal, cord, or nerve sheath tumors. Additionally, bone scintigraphy is required to stage malignant bone tumors (39).

A diagnostic algorithm for a child presenting with back pain exists and includes complete blood count, C-reactive protein, computed tomography (FX), erythrocyte sedimentation rate, magnetic resonance imaging, nonsteroidal anti-inﬂammatory drugs, and single-photon emission computed tomography (134).

The diagnostic workup for spondylodiscitis includes an MRI as the detection method of choice for evaluation and identification. In addition to radiologic imaging, laboratory studies such as complete blood count, ESR, CRP, blood cultures, and PCR are obtained. Biopsy may be considered if spondylodiscitis is suspected and blood cultures are negative (126).

Management

Conservative management is usually the first line of therapy for back pain in children; this includes NSAIDs, rest, and physical therapy (39). Combined yoga, physical therapy, and mental health support has been shown in randomized controlled trials to reduce chronic pain in adult opiate-dependent patients (65). Myofascial release has also shown promise for pain reduction (116). The high incidence of depression and anxiety in adolescents experiencing back pain warrants attention towards concomitant mental health support as a part of their management (28).

The benefits of spinal manipulation in addition to traditional physical therapy are unclear, with the potential risk for injury depending on the experience of the provider (211). Many of the studies that suggest a benefit of spinal manipulation were, in fact, nonrandomized. International consensus statements from physical therapists recommend against cervical and lumbar spine manipulation in infants and children and caution its use in adolescents (130; 66). No evidence with high certainty is available to guide spinal mobilization or manipulation in the pediatric population in general.

Interventions including epidural or intramuscular injections of local anesthetics with or without steroids in adults show no difference in pain relief compared with sham, which would further support optimizing conservative management over pharmacological interventions in the pediatric population (198).

Targeted treatment for associated conditions related to back pain is described in more detail above. Some of the key aspects are highlighted below.

The most effective management of spinal cord tumors in children is gross total resection by decompressive laminectomy, followed by radiation (144).

There are multiple ways to manage spondylolisthesis, which range from no treatment and observation to bracin, and finally to surgical management. Wiltse and Jackson created a system to help decide which therapy is most effective (205). Asymptomatic children under 10 years of age with a slippage of 25% or less should be monitored with radiographs every 4 to 6 months. Limitation of activity, thoracolumbar orthosis, and Williams flexion exercises are the most effective options in managing slippages less than 50% (151). Frequency of radiographs can be reduced as the patient ages and eliminated once the patient’s growth spurt has ended. The treatment for a child with slippage greater than 50% is oftentimes surgery, regardless of the presence of symptoms (205). The amount of slippage and the degree of lumbar lordosis are the two main factors that are considered when deciding to operate (206). The most common and effective procedure is bilateral posterolateral fusion, whereby an autologous iliac bone graft is also utilized (112). Slippages less than 50% only require single-level fusion at L5-S1; however, more severe slippages require L4-S1 fusion (152). Studies show that patients who had reduction casts a few days after surgical correction of severe disc slippage and kyphosis had greater outcomes in terms of sagittal translation and kyphosis than those patients who did not have reduction casts (24).

Conservative therapy for disc herniation includes NSAIDs, rest, and physical therapy. However, conservative management is not as effective in managing disc herniation in children as it is in adults (174). Surgery is the recommended treatment for a herniated disc when the pain is refractory to 4 to 6 weeks of conservative management, pain affects a patient’s daily activities, if there is cauda equina syndrome or other neurologic deficits, or if spinal deformities are present. Posterior laminectomy with subtotal hemilaminectomy is oftentimes the procedure of choice (149). Percutaneous endoscopic discectomy is also routinely performed and is advantageous because it reduces postoperative soft tissue swelling and pain (125; 38). However, there is limited evidence in the literature discussing whether or not minimally invasive decompression is superior to open discectomies.

Discitis is usually treated with a variable range of antimicrobial therapy; however, some authors believe that discitis in children is a self-limiting condition that does not require antibiotics (176; 96). Recommended therapy can include 10 to 14 days of intravenous antibiotics followed by 4 weeks of oral antibiotic medication (23). The key to successful rehabilitation is spinal immobilization, which can vary from weeks to months (96).

Juvenile idiopathic arthritis is initially managed with nonsteroidal anti-inflammatory (NSAID) therapy. Children are often given ibuprofen, indomethacin, or naproxen. In monoarticular juvenile idiopathic arthritis, NSAID therapy can be replaced or added to intraarticular steroid injections of triamcinolone hexacetonide. If a patient’s pain and stiffness are refractory to the therapies mentioned above, low-dose corticosteroids and possibly low-dose methotrexate are used in treatment (197; 158).

In patients with spondylodiscitis, treatment goals are to eradicate infection or neurologic deficits, preserve spinal structure, and relieve pain. Broad-spectrum antibiotics, in addition to immobilization and physical therapy, are the most effective treatment options in most cases. Surgical treatment is only indicated in those patients with spinal cord compression or cauda equina, progressive neurologic deficits, or failure to respond to conservative treatment options (126).

Outcomes

Conservative management of spondylolysis and spondylolisthesis includes cessation of sporting activities and using a spinal brace with lumbar orthosis for at least 3 to 6 months. Previous research suggests bracing has positive effects on healing; however, newer studies suggest bracing has limited effects on healing and approximately 80% of patients heal within a year with rest and physical therapy with emphasis on core training (186). With physical therapy and rehabilitation that includes stretching and strengthening, most patients resume full activity within 6 months of intervention (108). Patients with high-grade slippage who are unresponsive to 6 months of conservative management, or those who have neurologic deficits, may undergo surgery for repair (39). These surgical patients also resume activity within 5 and a half to 6 months postintervention with adequate rehabilitation (150). A multicenter retrospective study of 50 adolescents determined that posterior spinal fusion of spondylolisthesis is associated with a 40% reoperation rate and high rate of postoperative radiculopathy (137). Patients with favorable factors of early detection, unilateral involvement, and location at the fourth lumbar vertebra had the highest likelihood of bony healing (13).

The majority of patients with Scheuermann kyphosis experience resolution of symptoms with over-the-counter NSAID therapy and spinal maturity (39). Most cases are treated with physical therapy and hamstring stretching. Additional interventions may include bracing, but no research supports significant long-term benefits (186). Indications for surgical intervention include severe progressive kyphosis over 70 degrees, back pain refractory to conservative therapy, progression of kyphosis despite bracing, and dissatisfaction with cosmetic deformity (111). Surgical intervention provides significant improvement in deformity. One large literature review on various surgical approaches in Scheuermann disease revealed an average improvement of 30 degrees in kyphosis in postoperative patients (115). Minor complications of surgery include hemothorax, pneumothorax, and wound infection. One of the major complications of surgery is junctional kyphosis, which consequently requires revision surgery (111).

Conservative management of lumbar disc herniation with no neurologic deficits includes NSAIDs, physical therapy, and limitation of activity. Although there is much room for debate on the efficacy of conservative versus surgical management, most authors in the literature state that surgical intervention is superior for children with herniated discs due to the unique nature of the pediatric spine. Additionally, trauma is the most common precipitating factor of disc herniation in the pediatric population. According to one literature review, positive short-term outcomes for surgical management were between 93% and 100%. Long-term positive outcomes were lower, ranging between 67% and 88%. Minor postoperative complications include wound hematoma and wound infection. Major complications include narrowing of disc space, foraminal stenosis, disc degeneration, and recurrent herniation of the disc at the same level as the initial operation (77; 107).

Discitis in children is a self-limiting condition. Management of discitis is often conservative and includes immobilization of the spine for the lesion to heal, as well as antibiotic therapy for 4 to 6 weeks. Sixty-five percent of children in a study by Kayser and colleagues had bony/fibrosis ankylosis of the affected segment in the spine. Interestingly, ankylosis was observed at a lower rate in younger patients. In addition, follow-up at least 10 years after discharge revealed that 80% of patients who returned had no symptoms, and 20% of patients reported back pain (96). All of the patients in the follow-up study had radiograph abnormalities consistent with kyphosis. Some patients also had high-grade intervertebral disc space narrowing as well as fusion of the vertebrae.

Treatment of spinal cord neoplasms requires surgical resection followed by radiation. In a long-term landmark study by O’Sullivan and colleagues, 20-year survival for patients with primary spinal cord tumors was 67% following resection and irradiation (144). However, this condition and treatment are associated with high neurogenic and spinal morbidity. Patients often experience progressive spinal deformities, recurrent tumors, and neurogenic disabilities either due to the primary tumor, the nature of resection, or the harmful effects of radiation (180). Radiation therapy is reserved for malignant tumors, postoperative regrowth or recurrence, or when there is substantial residual tumor that has been deemed unresectable (104).

Juvenile idiopathic arthritis is believed to have a good prognostic outcome, with 40% to 60% of patients in one study being in remission at the time of follow-up (139). Indicators of poor prognostic outcome include early radiographic involvement, early hip involvement, and the presence of rheumatoid factor. Chronic arthritis can affect bone and joint development, which can lead to leg-length inequality and developmental problems with the hip (109). NSAIDs are used to reduce structural damage, and biologics, including antitumor necrosis factor agents, are used to improve symptoms of early morning stiffness and function. Disease-modifying antirheumatic drugs such as methotrexate are used when NSAIDs alone do not relieve joint pain and swelling (186).

References

01: Achar S, Yamanaka J. Back pain in children and adolescents. Am Fam Physician 2020;102(1):19-28. PMID 32603067
02: Albanese M, Pizzutillo PD. Family study of spondylolysis and spondylolisthesis. J Pediatr Orthop 1982;2(5):496-9. PMID 6761366
03: Altaf F, Heran MK, Wilson LF. Back pain in children and adolescents. Bone Joint J 2014;96-B(6):717-23. PMID 24891569
04: Alfuth M, Fichter P, Knicker A. Leg length discrepancy: a systematic review on the validity and reliability of clinical assessments and imaging diagnostics used in clinical practice. PLoS One 2021;16(12):e0261457. PMID 34928991
05: Anekstein Y, Blecher R, Smorgick Y, Mirovsky Y. What is the best way to apply the Spurling test for cervical radiculopathy? Clin Orthop Relat Res 2012;470(9):2566-72. PMID 22806265
06: Applebaum A, Nessim A, Cho W. Overview and spinal implications of leg length discrepancy: narrative review. Clin Orthop Surg 2021;13(2):127-34. PMID 34094002
07: Auerbach JD, Ahn J, Zgonis MH, Reddy SC, Ecker ML, Flynn JM. Streamlining the evaluation of low back pain in children. Clin Orthop Relat Res 2008;466(8):1971-7. PMID 18553213
08: Aufdermaur M. Juvenile kyphosis (Scheuermann's disease): radiography, histology, and pathogenesis. Clin Orthop Relat Res 1981;(154):166-74. PMID 7471550
09: Badii M, Wade AN, Collins DR, Nicolaou S, Kobza BJ, Kopec JA. Comparison of lifts versus tape measure in determining leg length discrepancy. J Rheumatol 2014;41(8):1689-94. PMID 25028369
10: Bagwell JJ, Bauer L, Gradoz M, Grindstaff TL. The reliability of FABER test hip range of motion measurements. Int J Sports Phys Ther 2016;11(7):1101-5. PMID 27999724
11: Baleilevuka-Hart ME, Khader A, Gonzalez De Alba CE, Holmes KW, Huang JH. Sports participation, activity, and obesity in children who have undergone the Fontan procedure. Cardiol Young 2022;32(7):1027-31. PMID 34474695
12: Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology 1991;180(2):509-12. PMID 1829845
13: Berger RG, Doyle SM. Spondylolysis 2019 update. Curr Opin Pediatr 2019;31(1):61-8. PMID 30531225
14: Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. Am Fam Physician 2007;76(11):1669-76. PMID 18092709
15: Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, Grant WD, Baker D. The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine (Phila Pa 1976) 2003;28(10):1027-35. PMID 12768144
16: Bezalel T, Carmeli E, Kalichman L. Scheuermann's disease: radiographic pathomorphology and association with clinical features. Asian Spine J 2019;13(1):86-95. PMID 30326689
17: Bhatia NN, Chow G, Timon SJ, Watts HG. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop 2008;28(2):230-3. PMID 18388720
18: Bianchini S, Esponsito A, Principi N, Esposito S. Spondylodiscitis in paediatric patients: the importance of early diagnosis and prolonged therapy. Int J Environ Res Public Health 2018;15(6):1195. PMID 29875345
19: Black LI, Terlizzi EP, Vahratian A. Organized sports participation among children aged 6-17 years: United States, 2020. NCHS Data Brief 2022;(441):1-8. PMID 35969661
20: Bradford DS, Moe JH, Montalvo FJ, Winter RB. Scheuermann's kyphosis and roundback deformity. Results of Milwaukee brace treatment. J Bone Joint Surg Am 1974;56(4):740-58. PMID 4835819
21: Braune HJ, Wunderlich MT. Diagnostic value of different neurophysiological methods in the assessment of lumbar nerve root lesions. Arch Phys Med Rehabil 1997;78(5):518-20. PMID 9161372
22: Brooks T, Friedman L, Silvis R, Lerer T, Milewski M. Back pain in a pediatric emergency department: etiology and evaluation. Pediatr Emerg Care 2018;34(1):e1-6. PMID 29293477
23: Brown R, Hussain M, McHugh K, Novelli V, Jones D. Discitis in young children. J Bone Joint Surg Br 2001;83(1):106-111. PMID 11245515
24: Burkus JK, Lonstein JE, Winter RB, Denis F. Long-term evaluation of adolescents treated operatively for spondylolisthesis: A comparison of in situ arthrodesis only with in situ arthrodesis and reduction followed by immobilization in a cast. J Bone Joint Surg Am 1992;74(5):693-704. PMID 1624485
25: Calloni SF, Huisman TA, Poretti A, Soares BP. Back pain and scoliosis in children: when to image, what to consider. Neuroradiol J 2017;30(5):393-404. PMID 28786774
26: Calvo-Munoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr 2013;13:14. PMID 23351394
27: Calvo-Munoz I, Kovacs FM, Roqué M, Gago Fernández I, Seco Calvo J. Risk factors for low back pain in childhood and adolescence: a systematic review. Clin J Pain 2018;34(5):468-84. PMID 28915154
28: Campello CP, Gominho M, Arruda GA, et al. Associations between mental health and cervical, thoracic, and lumbar back pain in adolescents: a cross-sectional study. J Affect Disord 2025;375:366-72. PMID 39889927
29: Carbone PS, Smith PJ, Lewis C, LeBlanc C. Promoting the participation of children and adolescents with disabilities in sports, recreation, and physical activity. Pediatrics 2021;148(6):e2021054664. PMID 34851421
30: Chang CH, Lee ZL, Chen WJ, Tan CF, Chen LH. Clinical significance of ring apophysis fracture in adolescent lumbar disc herniation. Spine (Phila Pa 1976) 2008;33(16):1750-4. PMID 18628708
31: Cheng JC, Castelein RM, Chu WC, et al. Adolescent idiopathic scoliosis. Nat Rev Dis Primers 2015;1:15030. PMID 27188385
32: Cho SC, Ferrante MA, Levin KH, Harmon RL, So YT. Utility of electrodiagnostic testing in evaluating patients with lumbosacral radiculopathy: an evidence-based review. Muscle Nerve 2010;42(2):276-82. PMID 20658602
33: Chu WC, Lam WM, Ng BK, et al. Relative shortening and functional tethering of spinal cord in adolescent scoliosis - result of asynchronous neuro-osseous growth, summary of an electronic focus group debate of the IBSE. Scoliosis 2008;3:8. PMID 18588673
34: Chung T, Prasad K, Lloyd TE. Peripheral neuropathy: clinical and electrophysiological considerations. Neuroimaging Clin N Am 2014;24(1):49-65. PMID 24210312
35: Coker C, Park J, Jacobson RD. Neurologic approach to radiculopathy, back pain, and neck pain. Prim Care 2024;51(2):345-58. PMID 38692779
36: Coster S, de Bruijn SF, Tavy DL. Diagnostic value of history, physical examination and needle electromyography in diagnosing lumbosacral radiculopathy. J Neurol 2010;257(3):332-7. PMID 19763381
37: Damborg F, Engell V, Andersen M, Kyvik KO, Thomsen K. Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. J Bone Joint Surg Am 2006;88(10):2133-6. PMID 17015588
38: Dang L, Liu Z. A review of current treatment for lumbar disc herniation in children and adolescents. Eur Spine J 2010;19(2):205-14. PMID 19890666
39: Davis PJ, Williams HJ. The investigation and management of back pain in children. Arch Dis Child Educ Pract Ed 2008;93(3):73-83. PMID 18495896
40: Deans SA, McFadyen AK, Rowe PJ. Physical activity and quality of life: a study of a lower-limb amputee population. Prosthet Orthot Int 2008;32(2):186-200. PMID 18569887
41: DeLuca PF, Mason DE, Weiand R, Howard R, Bassett GS. Excision of herniated nucleus pulposus in children and adolescents. J Pediatr Orthop 1994;14(3):318-22. PMID 8006161
42: DeWolfe C. Back pain. Pediatr Rev 2002;23(6):221. PMID 12042598
43: Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344(5):363-70. PMID 11172169
44: Dillingham TR, Annaswamy TM, Plastaras CT. Evaluation of persons with suspected lumbosacral and cervical radiculopathy: electrodiagnostic assessment and implications for treatment and outcomes (Part I). Muscle Nerve 2020a;62(4):462-73. PMID 32557709
45: Dillingham TR, Annaswamy TM, Plastaras CT. Evaluation of persons with suspected lumbosacral and cervical radiculopathy: electrodiagnostic assessment and implications for treatment and outcomes (Part II). Muscle Nerve 2020b;62(4):474-84. PMID 32564381
46: Dolan LA, Weinstein SL, Dobbs MB, et al. BrAIST-Calc: prediction of individualized benefit from bracing for adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2024;49(3):147-56. PMID 37994691
47: Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Boqduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976) 1996;219(22):2594-602. PMID 8961447
48: Dubon ME, Tow S, Rabatin AE. Physical activity and sports participation among children and adolescents with disabilities. Pediatr Clin North Am 2023;70(3):603-14. PMID 37121645
49: Dunton G, McConnell R, Jerrett M, et al. Organized physical activity in young school children and subsequent 4-year change in body mass index. Arch Pediatr Adolesc Med 2012;166(8):713-8. PMID 22869403
50: Edgar MA, Park WM. Induced pain patterns on passive straight-leg raising in lower lumbar disc protrusion. A prospective clinical, myelographic and operative study in fifty patients. J Bone Joint Surg Br 1974;56-B(4):658-67. PMID 4281427
51: Expert Panel on Pediatric Imaging. ACR Appropriateness Criteria® back pain-child. J Am Coll Radiol 2017;14(5S):S13-24. PMID 28473069
52: Fabricant PD, Heath MR, Schachne JM, Doyle SM, Green DW, Widmann RF. The epidemiology of back pain in American children and adolescents. Spine (Phila Pa 1976) 2020;45(16):1135-42. PMID 32097269
53: Fehily AM, Coles RJ, Evans WD, Elwood PC. Factors affecting bone density in young adults. Am J Clin Nutr 1992;56(3):579-86. PMID 1503072
54: Feldman DS, Hedden DM, Wright JG. The use of bone scan to investigate back pain in children and adolescents. J Pediatr Orthop 2000;20(6):790-5. PMID 11097256
55: Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop 2006;26(3):353-7. PMID 16670548
56: Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics 2000;105(6):1299-304. PMID 10835072
57: Fisk JW, Baigent ML. Hamstring tightness and Scheuermann's disease a pilot study. Am J Phys Med 1981;60(3):122-5. PMID 6454348
58: Fon GT, Pitt MJ, Thies AC Jr. Thoracic kyphosis: range in normal subjects. AJR Am J Roentgenol 1980;134(5):979-83. PMID 6768276
59: Foreman P, Griessenauer CJ, Watanabe K, et al. L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus. Childs Nerv Syst 2013;29(2):209-16. PMID 23089935
60: Franz C, Møller NC, Korsholm L, Jespersen E, Hebert JJ, Wedderkopp N. Physical activity is prospectively associated with spinal pain in children (CHAMPS Study-DK). Sci Rep 2017;7(1):11598. PMID 28912463
61: Garg S, Dormans JP. Tumors and tumor-like conditions of the spine in children. J Am Acad Orthop Surg 2005;13(6):372-81. PMID 16224110
62: Ginsburg GM, Bassett GS. Back pain in children and adolescents: evaluation and differential diagnosis. J Am Acad Orthop Surg 1997;5(2)67-78. PMID 10797209
63: Gordon JE, Davis LE. Leg length discrepancy: the natural history (and what do we really know). J Pediatr Orthop 2019;39(Issue 6, Supplement 1 Suppl 1):S10-13. PMID 31169640
64: Gracey E, Vereecke L, McGovern D, et al. Revisiting the gut-joint axis: links between gut inflammation and spondyloarthritis. Nat Rev Rheumatol 2020;16(8):415-33. PMID 32661321
65: Groeger JL, Perez HR, Moonaz S, et al. Yoga and physical therapy for chronic pain and opioid use disorder onsite in an opioid treatment program: a randomized controlled trial. Subst Use Addctn J 2025;46(1):175-83. PMID 39087486
66: Gross AR, Olson KA, Pool J, et al. Spinal manipulation and mobilisation in paediatrics - an international evidence-based position statement for physiotherapists. J Man Manip Ther 2024;32(3):211-33. PMID 38855972
67: Guddal MH, Stensland SØ, Småstuen MC, Johnsen MB, Zwart JA, Storheim K. Physical activity and sport participation among adolescents: associations with mental health in different age groups. Results from the Young-HUNT study: a cross-sectional survey. BMJ Open 2019;9(9):e028555. PMID 31488476
68: Haidar R, Ghanem I, Saad S, Uthman I. Lumbar disc herniation in young children. Acta Paediatr 2010;99(1):19-23. PMID 19659503
69: Haidar R, Saad S, Khoury NJ, Musharrafieh U. Practical approach to the child presenting with back pain. Eur J Pediatr 2011;170(2):149-56. PMID 20495823
70: Harris I, Hatfield A, Walton J. Assessing leg length discrepancy after femoral fracture: clinical examination or computed tomography? ANZ J Surg 2005;75(5):319-21. PMID 15932444
71: Hart ES, Merlin G, Harisiades J, Grottkau BE. Scheuermann's thoracic kyphosis in the adolescent patient. Orthop Nurs 2010;29(6):365-71. PMID 21099641
72: Hassan A, Hameed B, Islam M, Khealani B, Khan M, Shafqat S. Clinical predictors of EMG-confirmed cervical and lumbosacral radiculopathy. Can J Neurol Sci 2013;40(2):219-24. PMID 23419571
73: Haus BM, Micheli LJ. Back pain in the pediatric and adolescent athlete. Clin Sports Med 2012;31(3):423-40. PMID 22657993
74: Hebert JJ, Klakk H, Møller NC, Grøntved A, Andersen LB, Wedderkopp N. The prospective association of organized sports participation with cardiovascular disease risk in children (the CHAMPS Study-DK). Mayo Clin Proc 2017;92(1):57-65. PMID 27865444
75: Hebert JJ, Leboeuf-Yde C, Franz C, et al. Pubertal development and growth are prospectively associated with spinal pain in young people (CHAMPS study-DK). Eur Spine J 2019;28(7):1565-71. PMID 30740638
76: Herman MJ, Pizzutillo PD. Spondylolysis and spondylolisthesis in the child and adolescent: a new classification. Clin Orthop Relat Res 2005;(434):46-54. PMID 15864031
77: Herring JA, Asher MA. Intervertebral disc herniation in a teenager. J Pediatr Orthop 1989:615-7. PMID 2794040
78: Hill JJ, Keating JL. A systematic review of the incidence and prevalence of low back pain in children. Physical Therapy Reviews 2009;14:272-84.
79: Hinks A, Martin P, Flynn E, et al. Subtype specific genetic associations for juvenile idiopathic arthritis: ERAP1 with the enthesitis related arthritis subtype and IL23R with juvenile psoriatic arthritis. Arthritis Res Ther 2011;13(1):R12. PMID 21281511
80: Hsu W, Jallo GI. Pediatric spinal tumors. Handb Clin Neurol 2013;112:959-65. PMID 23622304
81: Huguet A, Miro J. The severity of chronic pediatric pain: an epidemiological study. J Pain 2008;9(3):226-36. PMID 18088558
82: Huisman TA. Pediatric tumors of the spine. Cancer Imaging 2009;9 Spec No A (Special issue A):S45-8. PMID 19965293
83: Inoue T, Inokuchi A, Izumi T, et al. Co-existence of lumbar disc herniation and posterior ring apophyseal fracture: it is not rare and computed tomography is useful. Cureus 2023;15(2):e35475. PMID 36999108
84: Ippolito E, Bellocci M, Montanaro A, Ascani E, Ponseti IV. Juvenile kyphosis: an ultrastructural study. J Pediatr Orthop 1985;5(3):315-22. PMID 3998134
85: Iyer S, Kim HJ. Cervical radiculopathy. Curr Rev Musculoskelet Med 2016;9(3):272-80. PMID 27250042
86: Janssens KA, Rosmalen JG, Ormel J, et al. Pubertal status predicts back pain, overtiredness, and dizziness in American and Dutch adolescents. Pediatrics 2011;128(3):553-9. PMID 21807699
87: Jarrett DY, Ecklund K. EOS imaging of scoliosis, leg length discrepancy and alignment. Semin Roentgenol 2021;56(3):228-44. PMID 34281677
88: Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine (Phila Pa 1976) 2007;32(23):2630-7. PMID 17978666
89: Jones GT, Macfarlane GJ. Epidemiology of low back pain in children and adolescents. Arch Dis Child 2005;90(3):312-6. PMID 15723927
90: Jones GT, Watson KD, Silman AJ, Symmons DP, Macfarlane GJ. Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatrics 2003;111(4 Pt 1):822-8. PMID 12671119
91: Kamada M, Abe T, Kitayuguchi J, et al. Dose-response relationship between sports activity and musculoskeletal pain in adolescents. Pain 2016;157(6):1339-45. PMID 26894915
92: Kan P, Schmidt MH. Osteoid osteoma and osteoblastoma of the spine. Neurosurg Clin N Am 2008;19(1):65-70. PMID 18156049
93: Karabouta Z, Bisbinas I, Davidson A, Goldsworthy LL. Discitis in toddlers: a case series and review. Acta Paediatr 2005;94(10):1516-8. PMID 16263635
94: Karademir M, Eser O, Karavelioglu E. Adolescent lumbar disc herniation: impact, diagnosis, and treatment. J Back Musculoskelet Rehabil 2017;30(2):347-52. PMID 27858699
95: Kaur S, Lalam R. Scheuermann's disease. Semin Musculoskelet Radiol 2023;27(5):522-8. PMID 37816360
96: Kayser R, Mahlfeld K, Greulich M, Grasshoff H. Spondylodiscitis in childhood: results of a long-term study. Spine (Phila Pa 1976) 2005;30(3):318-23. PMID 15682013
97: Kedra A, Plandowska M, Kędra P, Czaprowski D. Physical activity and low back pain in children and adolescents: a systematic review. Eur Spine J 2021;30(4):946-56. PMID 32845380
98: Kentar Y, Schwarze M, Pepke W, Schiltenwolf M, Akbar M. Pediatric back pain-diagnostic algorithm. Orthopade 2022;51(1):36-43. PMID 34767043
99: Kesling KL, Reinker KA. Scoliosis in twins. A meta-analysis of the literature and report of six cases. Spine (Phila Pa 1976) 1997;22(17):2009-14. PMID 9306532
100: Kim HJ, Green DW. Adolescent back pain. Curr Opin Pediatr 2008;20(1):37-45. PMID 18197037
101: Kimura J. Electrodiagnosis in diseases of nerve and muscle: principles and practice. Oxford University Press, 2013.
102: Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop 2009;29(2):146-56. PMID 19352240
103: Kosteljanetz M, Bang F, Schmidt-Olsen S. The clinical significance of straight-leg raising (Lasègue's sign) in the diagnosis of prolapsed lumbar disc. Interobserver variation and correlation with surgical finding. Spine (Phila Pa 1976) 1988;13(4):393-5. PMID 3406846
104: Kothbauer K, Abbott R. Intramedullary Spinal Cord Tumors. In: Albright AL, Pollack IF, Adelson PD, editors. Principles and Practice of Pediatric Neurosurgery. New York: Thieme, 2008:706-20.
105: Kriz PK, Kriz JP, Willwerth SB, et al. Characteristics of lumbar pars interarticularis and pedicle stress injuries by sport in 902 pediatric and adolescent athletes: a retrospective study. Am J Sports Med 2024;52(13):3388-95. PMID 39397737
106: Lamb M, Brenner JS. Back pain in children and adolescents. Pediatr Rev 2020;41(11):557-69. PMID 33139409
107: Lee DY, Ahn Y, Lee SH. Percutaneous endoscopic lumbar discectomy for adolescent lumbar disc herniation: surgical outcomes in 46 consecutive patients. Mt Somao K Med 2006;73(6):864-70. PMID 17117312
108: Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L. Lumbar spondylolysis: a review. Skeletal Radiol 2011;40(6):683-700. PMID 20440613
109: Lien G, Selvaag AM, Flato B, et al. A two-year prospective controlled study of bone mass and bone turnover in children with early juvenile idiopathic arthritis. Arthritis Rheum 2005;52(3):833-40. PMID 15751052
110: Logroscino G, Mazza O, Aulisa G, Pitta L, Pola E, Aulisa L. Spondylolysis and spondylolisthesis in the pediatric and adolescent population. Childs Nerv Syst 2001;17(11):644-55. PMID 11734982
111: Lonner BS, Newton P, Betz R, et al. Operative management of Scheuermann's kyphosis in 78 patients: radiographic outcomes, complications, and technique. Spine (Phila Pa 1976) 2007;32(24):2644-52. PMID 18007239
112: Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine (Phila Pa 1976) 1999;24(24):2640-8. PMID 10635527
113: Loughenbury PR, Tsirikos A. Scheuermann’s kyphosis: diagnosis, presentation and treatment. Orthopaedics and Trauma 2017;31(6):388-94.
114: Lovell DJ, Brunner HI. Evolution in the understanding of pediatric-onset axial spondyloarthritis. Arthritis Care Res (Hoboken) 2021;73(7):921-3. PMID 33331127
115: Lowe TG, Line BG. Evidence based medicine: analysis of Scheuermann kyphosis. Spine (Phila Pa 1976) 2007;32(19 Suppl):S115-9. PMID 17728677
116: Luo J, West N, Lauder GR. myoActivation®, a structured assessment and therapeutic process for adolescents with myofascial dysfunction and chronic low back pain: a case series. Cureus 2024;16(8):e68029. PMID 39347347
117: Lynch AM, Kashikar-Zuck S, Goldschneider KR, Jones BA. Psychosocial risks for disability in children with chronic back pain. J Pain 2006;7(4):244-51. PMID 16618468
118: MacDonald J, Stuart E, Rodenberg R. Musculoskeletal low back pain in school-aged children: a review. JAMA Pediatrics 2017;171(3):280-7. PMID 28135365
119: Mac-Thiong JM, Berthonnaud E, Dimar JR 2nd, Betz RR, Labelle H. Sagittal alignment of the spine and pelvis during growth. Spine (Phila Pa 1976) 2004;29(15):1642-7. PMID 15284510
120: Mac-Thiong JM, Labelle H, Roussouly P. Pediatric sagittal alignment. Eur Spine J 2011;20 Suppl 5(Suppl 5):586-90. PMID 21811824
121: Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the slump and the straight leg raising tests in patients with lumbar disc herniation. J Clin Rheumatol 2008;14(2):87-91. PMID 18391677
122: Marquardt RJ, Levin KH. Electrodiagnostic assessment of radiculopathies. Neurol Clin 2021;39(4):983-95. PMID 34602222
123: Marques A, Maldonado I, Peralta M, Santos S. Exploring psychosocial correlates of physical activity among children and adolescents with spina bifida. Disabil Health J 2015;8(1):123-9. PMID 25091554
124: Martinez-Lage JF, Fernández Cornejo V, López F, Poza M. Lumbar disc herniation in early childhood: case report and literature review. Childs Nerv Syst 2003;19(4):258-60. PMID 12715195
125: Matsui H, Kitagawa H, Kawaguchi Y, Tsuji H. Physiologic changes of nerve root during posterior lumbar discectomy. Spine (Phila Pa 1976) 1995;20(6):654-9. PMID 7604340
126: Mavrogenis A, Megaloikonomos D, Igoumenou V, et al. Spondylodiscitis revisited. EFORT Open Rev 2017; 2(11): 447–61. PMID 29218230
127: Mielants H, Veys EM, Goemaere S, Goethals K, Cuvelier C, De Vos M. Gut inflammation in the spondyloarthropathies: clinical, radiologic, biologic and genetic features in relation to the type of histology. A prospective study. J Rheumatol 1991;18(10):1542-51. PMID 1765980
128: Milatz F, Klotsche J, Niewerth M, et al. Participation in school sports among children and adolescents with juvenile idiopathic arthritis in the German National Paediatric Rheumatologic Database, 2000-2015: results from a prospective observational cohort study. Pediatr Rheumatol Online J 2019;17(1):6. PMID 30744659
129: Miller R, Beck NA, Sampson NR, Zhu X, Flynn JM, Drummond D. Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain. J Pediatr Orthop 2013;33(3):282-8. PMID 23482264
130: Milne N, Longeri L, Patel A, et al. Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review. BMC Pediatr 2022;22(1):721. PMID 36536328
131: Mohile NV, Kuczmarski AS, Lee D, Warburton C, Rakoczy K, Butler AJ. Spondylolysis and isthmic spondylolisthesis: a guide to diagnosis and management. J Am Board Fam Med 2022;35(6):1204-16. PMID 36526328
132: Murray PM, Weinstein SL, Spratt KF. The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am 1993;75(2):236-48. PMID 8423184
133: Nafissi S, Niknam S, Hosseini SS. Electrophysiological evaluation in lumbosacral radiculopathy. Iran J Neurol 2012;11(3):83-6. PMID 24250870
134: Nahle IS, Hamam MS, Masrouha KZ, Afeiche NE, Abdelnoor J. Back pain: a puzzle in children. J Paediatr Child Health 2016;52(8):802-8. PMID 27535879
135: Nardin RA, Patel MR, Gudas TF, Rutkove SB, Raynor EM. Electromyography and magnetic resonance imaging in the evaluation of radiculopathy. Muscle Nerve 1999;22(2):151-5. PMID 10024127
136: Neves NS, Ribeiro da Silva M, Cacho Rodrigues, Silva ML, Matos R, Pinto R. Symptomatic giant Schmorl's node treated by a decompression procedure. Orthop Traumatol Surg Res 2013;99(3):371-4. PMID 23507456
137: Nielsen E, Andras LM, Siddiqui AA, et al. 40% reoperation rate in adolescents with spondylolisthesis. Spine Deform 2020;8(5):1059-67. PMID 32378040
138: Nolte MT, Harada GK, LeDuc R, et al. Pediatric back pain: a scoring system to guide use of magnetic resonance imaging. J Pediatr Orthop 2022;42(2):116-22. PMID 34995265
139: Oen K. Long-term outcomes and predictors of outcomes for patients with juvenile idiopathic arthritis. Best Pract Res Clin Rheumatol 2002;16(3):347-60. PMID 12387804
140: Ogilvie JW, Sherman J. Spondylolysis in Scheuermann's disease. Spine (Phila Pa 1976) 1987;12(3):251-3. PMID 3589821
141: Oliveira A, Jácome C, Marques A. Physical fitness and exercise training on individuals with spina bifida: a systematic review. Res Dev Disabil 2014;35(5):1119-36. PMID 24612860
142: Olsen TL, Anderson RL, Dearwater SR, et al. The epidemiology of low back pain in an adolescent population. Am J Public Health 1992;82(4):606-8. PMID 1532116
143: Onan D, Ulger O. Investigating the relationship between body mass index and pain in the spine in children or adolescents: a systematic review. Child Obes 2021;17(2):86-99. PMID 33570458
144: O'Sullivan C, Jenkin RD, Doherty MA, Hoffman HJ, Greenberg ML. Spinal cord tumors in children: long-term results of combined surgical and radiation treatment. J Neurosurg 1994;81(4):507-12. PMID 7931582
145: Ozga J, Ostrogórska M, Wojciechowski W, Żuber Z. Single-centre analysis of magnetic resonance imaging of sacroiliac joints in a paediatric population. J Clin Med 2024;13(23):7147. PMID 39685606
146: Pacheco-Carrillo A, Medina-Porqueres I. Physical examination tests for the diagnosis of femoroacetabular impingement. A systematic review. Phys Ther Sport 2016;21:87-93. PMID 27150967
147: Papagelopoulos PJ, Mavrogenis AF, Savvidou OD, Mitsiokapa EA, Themistocleous GS, Soucacos PN. Current concepts in Scheuermann's kyphosis. Orthopedics 2008;31(1):52-8. PMID 18269168
148: Papanicolaou N, Wilkinson RH, Emans JB, Treves S, Micheli LJ. Bone scintigraphy and radiography in young athletes with low back pain. AJR Am J Roentgenol 1985;145(5):1039-44. PMID 2931965
149: Parisini P, Di Silvestre M, Greggi T, Miglietta A, Paderni S. Lumbar disc excision in children and adolescents. Spine (Phila Pa 1976) 2001;26(18):1997-2000. PMID 11547199
150: Peer KS, Fascione JM. Spondylolysis: a review and treatment approach. Orthop Nurs 2007;26(2):104-11. PMID 17414379
151: Pizzutillo PD, Hummer CD 3rd. Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis. J Pediatr Orthop 1989;9(5):538-40. PMID 2529267
152: Pizzutillo PD, Mirenda W, MacEwen GD. Posterolateral fusion for spondylolisthesis in adolescence. J Pediatr Orthop 1986;6(3):311-6. PMID 3519675
153: Porter RW. The pathogenesis of idiopathic scoliosis: uncoupled neuro-osseous growth? Eur Spine J 2001;10(6):473-81. PMID 11806387
154: Raghu AL, Wiggins A, Kandasamy J. Surgical management of lumbar disc herniation in children and adolescents. Clin Neurol Neurosurg 2019;185:105486. PMID 31445324
155: Ramadorai U, Hire J, DeVine JG, Brodt ED, Dettori JR. Incidental findings on magnetic resonance imaging of the spine in the asymptomatic pediatric population: a systematic review. Evid Based Spine Care J 2014;5(2):95-100. PMID 25278883
156: Ramirez N, Flynn JM, Hill BW, et al. Evaluation of a systematic approach to pediatric back pain: the utility of magnetic resonance imaging. J Pediatr Orthop 2015;35(1):28-32. PMID 24686297
157: Ramirez N, Olivella G, Valentín P, Feneque J, Lugo S, Iriarte I. Are constant pain, night pain, or abnormal neurological examination adequate predictors of the presence of a significant pathology associated with pediatric back pain? J Pediatr Orthop 2019;39(6):e478-81. PMID 30817418
158: Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet 2007;369(9563):767-78. PMID 17336654
159: Riccio I, Marcarelli M, Del Regno N, et al. Musculoskeletal problems in pediatric acute leukemia. J Pediatr Orthop B 2013;22(3):264-9. PMID 23407432
160: Ristolainen L, Kettunen JA, Heliövaara M, Kujala UM, Heinonen A, Schlenzka D. Untreated Scheuermann's disease: a 37-year follow-up study. Eur Spine J 2012;21(5):819-24. PMID 22101868
161: Rizzo A, Ferrante A, Guggino G, Ciccia F. Gut inflammation in spondyloarthritis. Best Pract Res Clin Rheumatol 2017;31(6):863-76. PMID 30509445
162: Rodriguez DP, Poussaint TY. Imaging of back pain in children. AJNR Am J Neuroradiol 2010;31(5):787-802. PMID 19926701
163: Roth M. Idiopathic scoliosis from the point of view of the neuroradiologist. Neuroradiology 1981;21(3):133-8. PMID 7231673
164: Sabharwal S, Zhao C, McKeon JJ, McClemens E, Edgar M, Behrens F. Computed radiographic measurement of limb-length discrepancy: full-length standing anteroposterior radiograph compared with scanogram. J Bone Joint Surg Am 2006;88(10):2243-51. PMID 17015603
165: Sahlin KB, Lexell J. Impact of organized sports on activity, participation, and quality of life in people with neurologic disabilities. PM R 2015;7(10):1081-8. PMID 25828205
166: Samartzis D, Karppinen J, Mok F, Fong DY, Luk KD, Cheung KM. A population-based study of juvenile disc degeneration and its association with overweight and obesity, low back pain, and diminished functional status. J Bone Joint Surg Am 2011;93(7):662-70. PMID 21471420
167: Sastre-Garcia B, Perez-Pelegri M, Martin JA, Santabarbara JM, Moratal D. Deep learning segmentation of lower extremities radiographs for an automatic leg length discrepancy measurement. Annu Int Conf IEEE Eng Med Biol Soc 2023;2023:1-4. PMID 38082685
168: Sato T, Ito T, Hirano T, et al. Low back pain in childhood and adolescence: assessment of sports activities. Eur Spine J 2011;20(1):94-9. PMID 20582557
169: Schafer ZA, Perry JL, Vanicek N. A personalised exercise programme for individuals with lower limb amputation reduces falls and improves gait biomechanics: a block randomised controlled trial. Gait Posture 2018;63:282-9. PMID 29804023
170: Scheuermann HW. The classic: kyphosis dorsalis juvenilis. Clin Orthop Relat Res 1977;(128):5-7. PMID 340099
171: Scoles PV, Latimer BM, DigIovanni BF, Vargo E, Bauza S, Jellema LM. Vertebral alterations in Scheuermann's kyphosis. Spine (Phila Pa 1976) 1991;16(5):509-15. PMID 2052992
172: Shabat S, Leitner Y, David R, Folman Y. The correlation between Spurling test and imaging studies in detecting cervical radiculopathy. J Neuroimaging 2012;22(4):375-8. PMID 21883627
173: Shea PA, Woods WW, Werden DH. Electromyography in diagnosis of nerve root compression syndrome. Arch Neurol Psychiatry 1950;64(1):93-104. PMID 15426455
174: Shillito J Jr. Pediatric lumbar disc surgery: 20 patients under 15 years of age. Surg Neurol 1996;46(1):14-8. PMID 8677479
175: Spencer SJ, Wilson NI. Childhood discitis in a regional children's hospital. J Pediatr Orthop B 2012;21(3):264-8. PMID 22015583
176: Spiegel PG, Kengla KW, Isaacson AS, Wilson JC Jr. Intervertebral disc-space inflammation in children. J Bone Joint Surg Am 1972;54(2):284-96. PMID 4405578
177: Srinivasalu H, Sikora KA, Colbert RA. Recent updates in juvenile spondyloarthritis. Rheum Dis Clin North Am 2021;47(4):565-83. PMID 34635292
178: Stoev I, Powers AK, Puglisi JA, Munro R, Leonard JR. Sacroiliac joint pain in the pediatric population. J Neurosurg Pediatr 2012;9(6):602-7. PMID 22656249
179: Stoll ML, Bhore R, Dempsey-Robertson M, Punaro M. Spondyloarthritis in a pediatric population: risk factors for sacroiliitis. J Rheumatol 2010;37(11):2402-8. PMID 20682668
180: Sundaresan N, Gutierrez FA, Larsen MB. Radiation myelopathy in children. Ann Neurol 1978;4(1):47-50. PMID 697325
181: Sundell CG, Bergström E, Larsén K. Low back pain and associated disability in Swedish adolescents. Scand J Med Sci Sports 2019;29(3):393-9. PMID 30421820
182: Taimela S, Kujala UM, Salminen JJ, Viljanen T. The prevalence of low back pain among children and adolescents. A nationwide, cohort-based questionnaire survey in Finland. Spine (Phila Pa 1976) 1997;22(10):1132-6. PMID 9160472
183: Tallarico RA, Madom IA, Palumbo MA. Spondylolysis and spondylolisthesis in the athlete. Sports Med Arthrosc Rev 2008;16(1):32-8. PMID 18277260
184: Tasso M, Uguccioni V, Bertolini N, et al. Role of Patrick-FABER test in detecting sacroiliitis and diagnosing spondyloarthritis in subjects with low back pain. Clin Exp Rheumatol 2023;41(11):2298-300. PMID 37650318
185: Taurog JD, Chhabra A, Colbert RA. Ankylosing spondylitis and axial spondyloarthritis. N Engl J Med 2016;374(26):2563-74. PMID 27355535
186: Taxter A, Chauvin N, Weiss P. Diagnosis and treatment of low back pain in the pediatric population. Phys Sportsmed 2014;42(1):94-104. PMID 24565826
187: Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine (Phila Pa 1976) 2002;27(2):156-9. PMID 11805661
188: Trindade CAC, Briggs KK, Fagotti L, Fukui K, Philippon MJ. Positive FABER distance test is associated with higher alpha angle in symptomatic patients. Knee Surg Sports Traumatol Arthrosc 2019;27(10):3158-61. PMID 29959447
189: Tsirikos AI, Garrido EG. Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br 2010;92(6):751-9. PMID 20513868
190: Turner PG, Green JH, Galasko CS. Back pain in childhood. Spine (Phila Pa 1976) 1989;14(8):812-4. PMID 2528813
191: van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev 2010;(2):CD007431. PMID 20166095
192: Veldhuizen AG, Wever DJ, Webb PJ. The aetiology of idiopathic scoliosis: biomechanical and neuromuscular factors. Eur Spine J 2000;9(3):178-84. PMID 10905433
193: Vella SA, Swann C, Allen MS, Schweickle MJ, Magee CA. Bidirectional associations between sport involvement and mental health in adolescence. Med Sci Sports Exerc 2017;49(4):687-94. PMID 27801745
194: Villarejo-Ortega FJ, Torres Campa-Santamarina JM, Bencosme-Abinader JA. Lumbar disc disease in adolescents. Rev Neurol 2003;36(6):514-7. PMID 12652411
195: Vucetic N, Svensson O. Physical signs in lumbar disc hernia. Clin Orthop Relat Res 1996;(333):192-201. PMID 8981896
196: Wall J, Cook DL, Meehan WP 3rd, Wilson F. Adolescent athlete low back pain diagnoses, characteristics, and management: a retrospective chart review. J Sci Med Sport 2024;27(9):618-23. PMID 38981776
197: Wallace CA. The use of methotrexate in childhood rheumatic diseases. Arthritis Rheum 1998;41(3):381-91. PMID 9506564
198: Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ 2025;388:e079971. PMID 39971346
199: Watkins RG IV, Watkins RG III. Lumbar spondylolysis and spondylolisthesis in athletes. Seminars in Spine Surgery. Vol. 22. No. 4. WB Saunders, 2010.
200: Watson KD, Papageorgiou AC, Jones GT, et al. Low back pain in schoolchildren: occurrence and characteristics. Pain 2002;97(1-2):87-92. PMID 12031782
201: Weiss HR, Dieckmann J, Gerner HJ. Effect of intensive rehabilitation on pain in patients with Scheuermann's disease. Stud Health Technol Inform 2002;88:254-7. PMID 15456045
202: Weiss PF, Xiao R, Biko DM, Chauvin NA. Assessment of sacroiliitis at diagnosis of juvenile spondyloarthritis by radiography, magnetic resonance imaging, and clinical examination. Arthritis Care Res (Hoboken) 2016;68(2):187-94. PMID 26212574
203: Wenger DR, Frick SL. Scheuermann kyphosis. Spine (Phila Pa 1976) 1999;24(24):2630-9. PMID 10635526
204: Whalen JL, Parke WW, Mazur JM, Stauffer ES. The intrinsic vasculature of developing vertebral end plates and its nutritive significance to the intervertebral discs. J Pediatr Orthop 1985;5(4):403-10. PMID 4019751
205: Wiltse LL, Jackson DW. Treatment of spondylolisthesis and spondylolysis in children. Clin Orthop Relat Res 1976;(117):92-100. PMID 1277690
206: Wiltse LL, Winter RB. Terminology and measurement of spondylolisthesis. J Bone Joint Surg Am 1983;65(6):768-72. PMID 6863359
207: Woerman AL, Binder-Macleod SA. Leg length discrepancy assessment: accuracy and precision in five clinical methods of evaluation. J Orthop Sports Phys Ther 1984;5(5):230-9. PMID 18806409
208: Wong C. Mechanism of right thoracic adolescent idiopathic scoliosis at risk for progression; a unifying pathway of development by normal growth and imbalance. Scoliosis 2015;10:2. PMID 25657814
209: Wood KB, Melikian R, Villamil F. Adult Scheuermann kyphosis: evaluation, management, and new developments. J Am Acad Orthop Surg 2012;20(2):113-21. PMID 22302449
210: Yang S, Werner BC, Singla A, Abel MF. Low back pain in adolescents: a 1-year analysis of eventual diagnoses. J Pediatr Orthop 2017;37(5):344-7. PMID 26368854
211: Yu H, Southerst D, Wong JJ, et al. Rehabilitation of back pain in the pediatric population: a mixed studies systematic review. Chiropr Man Therap 2024;32(1):14. PMID 38720355

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Ava Yun Lin MD PhD

Dr. Lin of Michigan Medicine has no relevant financial relationships to disclose.
See Profile

Editor

Bernard L Maria MD

Dr. Maria of Thomas Jefferson University has no relevant financial relationships to disclose.
See Profile

Former Authors

Daniel Foster DO
Hubert Labio MD
Maria Rosario S Alcaneses Ofek MD
Bhagwan Moorjani MD
Asiya Khan Shakir MD
Basheer Shakir MD
Ian Heger MD
Brittani Wild DNP APRN FNP-C
Stephen L Nelson Jr MD PhD
Justine Ker BA

This is an article preview.
Start a Free Account
to access the full version.

Nearly 3,000 illustrations, including video clips of neurologic disorders.
Every article is reviewed by our esteemed Editorial Board for accuracy and currency.
Full spectrum of neurology in 1,200 comprehensive articles.
Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660

Support: service@medlink.com

Editor: editor@medlink.com

ISSN: 2831-9125

Back pain in children

Differential Diagnosis

Intervertebral disc herniation
Spondylolysis, spondylolisthesis
Discitis
Vertebral osteomyelitis
Arachnoid diverticulum
- Scheuermann disease
- Scoliosis
- Spinal fusion
- Spinal stenosis
- Aneurysmal bone cyst
- Benign osteoblastoma
- Ependymomas
- Ewing sarcoma
- Lymphoma
- Neurofibroma
- Neurofibrosarcoma
- Osteoid osteoma
- Schwannoma
- Juvenile idiopathic arthritis
- Back pain
- Spinal injury
- Lumbago

Also Relevant

Ankylosing spondylitis
Back pain
Cervical disc disease
Lumbar disc disease
Lumbar spinal stenosis
- Metastatic epidural spinal cord compression
- Pain
- Spinal epidural abscess
- Spinal meningioma
- Vascular disorders of the spinal cord

Etiology	Differential diagnosis
Trauma	• Intervertebral disc herniation • Spondylolysis, spondylolisthesis
Infection	• Discitis • Vertebral osteomyelitis
Congenital deformities	• Arachnoid diverticulum • Scheuermann disease • Scoliosis • Spinal fusion • Spinal stenosis
Neoplasm	• Aneurysmal bone cyst • Benign osteoblastoma • Ependymomas • Ewing sarcoma • Lymphoma • Neurofibroma • Neurofibrosarcoma • Osteoid osteoma • Schwannoma
Systemic	• Juvenile idiopathic arthritis • Back pain • Spinal injury • Lumbago

Back pain in children

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Incidence and severity

Neurologic examination

Table 1. Neurologic Examination Findings

Special testing

Work-up

Associated condition 1: spondylolysis

Associated condition 2: discitis

Associated condition 3: Scheuermann kyphosis

Associated condition 4: scoliosis

Associated condition 5: disc herniation

Associated condition 6: apophyseal ring fracture

Associated condition 7: axial spondylarthritis

Associated condition 8: neoplasm

Table 2. Primary Tumors of the Spine

Associated condition 9: leg length discrepancy

Table 3. Clinical Evaluation of Leg Length Discrepancy

Clinical vignette

Biological basis

Anatomic localization

Pathophysiology

Epidemiology

Differential diagnosis

Diagnostic workup

Management

Outcomes

References

Contributors

Author

Editor

Former Authors

Patient Profile

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Suzetrigine

Ataxia-telangiectasia

Developmental delay in children: evaluation and management

Neonatal opioid withdrawal syndrome

Guillain-Barre syndrome in children

Nusinersen

Mirdametinib

Selumetinib

This is an article preview.
Start a Free Account
to access the full version.