The authors explore current concepts related to back pain in the pediatric population. This article highlights the multifactorial nature of back pain in children and adolescents, with a systematic discussion on the history, varied clinical manifestations, pathophysiology, prognoses, treatments, and diagnostic modalities for each of the etiologies. Additionally, the authors address prenatal trunk development, cutting edge genetic research, and updated epidemiological data.
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• 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.
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• 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.
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• History and physical examination are imperative in guiding the correct diagnosis of back pain. Diagnostic modalities include x-rays, SPECT, and MRI scans, all of which can help investigators further pinpoint the diagnosis.
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• Back pain in children presents in a bimodal age distribution, which correlates with prepubertal and pubertal growth spurts.
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• Physical therapy, rehabilitation, education, steroid therapy as well as other medications, and surgery are treatment options for back pain.
Historical note and terminology
Back pain and spinal injury have been documented in texts dating as far back as 1550 BC. The Edwin Smith papyrus findings of Ancient Egypt include the earliest description and treatment of fractured vertebrae. Priests treated the sick by initiating a rest cure and applying bandages on any visible wounds (33). Studies of dinosaur remains, Neanderthals, crocodile autopsies, and Egyptian mummies reveal simple spinal degenerative changes as well as ankylosing spondylitis in these species (09; 02). Before the Dark Ages, Hippocrates and Galen included brief discussions of fleeting back and joint pain and consequent symptomatic treatment with warm baths and rest in their writings in 400 BC and 150 AD, respectively. However, when medical discovery became limited during the Dark Ages, back pain was given mythological etiology like “witch’s shot” and was treated by maneuvers that gave special powers to the feet of a mother who had carried a breech child (30; Black 1883). The Renaissance brought with it the rebirth of modern medicine as anatomy and circulation were correlated with disease signs and symptoms. In 1642, Biallou used the Greek term rheuma to offer an explanation for back pain. Until the nineteenth century, the term rheuma, thought to be brought on by cold and damp, referred to an evil humor or watery discharge that flowed from the brain to cause pain in joints and muscles (02). Trauma and spinal irritation were introduced as a possible cause of back pain in the 1800s. Although Paulus of Aegina was removing bone fragments from the spinal column in order to treat back pain as early as the seventh century AD, it was not until 1886 that Mac Ewen published a detailed description of a laminectomy (33). The “Dynasty of the Disc,” which refers to the few decades when all back pain was attributed to disc prolapse, was birthed at Massachusetts General Hospital in 1932 (57). Neurosurgeon William J Mixter and orthopedist Joseph S Barr collaborated and consequently popularized discectomies when they diagnosed and operated on a spinal tumor in a patient with a history of spinal trauma (34).
Spina bifida, a pediatric back pathology, was mentioned in the writings of Hippocrates around 400 BC. In the Hippocratic Corpus, Hippocrates writes of a fluid sac that “makes violence in the sacral bone” (67). Spondylitis was first mentioned as a cause of paraplegia in the late 1800s, independently by Strumpell, Marie, and von Bechterew (10). Spondylitis, spondylosis, and spondylolisthesis originate from the Greek word spondylo, or “vertebrae.” Spondylosis, also known as spondylosis deformans, refers to a generalized disc disease related to the degeneration of intervertebral discs (49). Spondylolisthesis, from the Greek –olisthesis, or “to slip,” refers to displacement of the vertebral body (82). Sciatica, thought to be first coined by Hippocrates in 400 AD, arises from the Greek word ischios, or “hip,” and can cause radiating leg pain (59). Sciatica is sometimes referred to as lumbosacral radicular syndrome, ischia, and nerve root pain (35). Radiculopathy refers to diseases of the nerve root, from the Greek –radix, or “root” (32).
Scheuermann kyphosis was first described by the Danish surgeon Holger Werfel Scheuermann in 1920 as a “round back” deformity radiographically distinguished from postural kyphosis (64). This condition, sometimes referred to as juvenile osteochondrosis of the spine, is characterized by anterior wedging of 3 adjacent vertebral bodies by 5 degrees or more. Additionally, this disease process presents with kyphosis greater than 45 degrees between T5-T12 (70; 23). There are 2 major types of Scheuermann kyphosis: type I, classic, and type II, thoracolumbar (74). An atypical lumbar form, with an unknown prevalence, is also reported in literature (44).
Back pain has been consistently documented in very early historical texts. It is only in recent times that specific structural causes and treatment have been attributed to this ailment.