THE BACK PAGE RESEARCH REVIEW Exploring causes of back pain in young patients, part 2 REVIEWED BY SHAWN THISTLE Study title: Back pain in children and adolescents Authors: Altaf F, Heran MKS, Wilson LF Publication information: Bone & Joint Journal 2014; 96-B: 717–23. T • he etiology of back pain in children is significantly dif-ferent from that of adults and, although serious pathol-ogies are rare, there are sev-eral that require consideration. Continuing from last issue, this study reviewed the important causes of back pain in children and adolescents. Infectious diseases Intervertebral discs are more vascular-ized in children than in adults, which accounts for the higher rate of discitis in adolescence, versus overt vertebral osteomyelitis. Other common infec-tious causes of back pain in children are tuberculous osteomyelitis, epidural abscess and sacroiliac joint infections. Discitis is a rare condition, with an estimated incidence of one to two cases in 30,000. It has a characteristic bipha-sic distribution, affecting toddlers and older adolescents. Discitis presents as general irritability, a refusal to walk or to stand due to abdominal pain, ham-string spasm or back pain and it may be associated with a limp. White cell count and C-reactive protein are gen-erally normal; erythrocyte sedimenta-tion rate is mildly raised; blood cultures are usually negative. MRI often con-firms the diagnosis. share a common genetic predisposition – namely, the HLA-B27 gene. Of the common spondyloarthropathies, Anky-losing Spondylitis (AS) is the most common, occurring in 0.2 to 1.2 per cent of the Caucasian population. Its initial symptoms can be noted in ado-lescence and early adulthood, such as dull pain over the lower back and but-tocks, and morning stiffness eased by exercise and worsened with inactivity. Of concern is the frequent lengthy delay between symptom onset and di-agnosis (often up to eight years), an issue clinicians should keep in the front of their minds with characteristic pa-tients with this symptom pattern. AS usually responds well to non-steroidal anti-inflammatories (NSAIDs), al-though in more progressive/severe cases, tumour necrosis factor inhibitors have shown good results. Patients sus-pected of having AS, or other inflam-matory disease, should be promptly referred to a rheumatologist. • • Neoplasm Inflammatory diseases The spondyloarthropathies are a group of inflammatory rheumatic disorders characterized by axial and/or periph-eral arthritis. The diseases in the group Neoplastic disease of the spine, while rare in kids, can occur in both the pos-terior column (osteoid osteoma, oste-oblastoma, aneurysmal bone cyst) and anterior column (eosinophilic granu-loma, also known as histiocytosis X): • Osteoid Osteoma: one per cent of all tumours and 11 per cent of all primary benign tumours in pa-tients between 10 and 25; primarily located in the pedicle and lamina; back pain is usually present at night and relieved by aspirin and/ or NSAIDs; definitive treatment is surgical resection. Osteoblastoma: one per cent of all primary benign tumours, 40 per cent are located in the spine; pri-marily located in the pedicle and lamina; NSAIDs are ineffective; tumours are often locally expan-sive and destructive; surgical treat-ment ranges from intralesional curettage to complete resection. Aneurysmal Bone Cyst: bubbly, cystic appearance with a thin rim of surrounding bone, in the poste-rior column of the spine and visible on plain films; treatment includes selective arterial embolization followed by either complete curet-tage or en bloc marginal excision. Radiotherapy has a limited role. Eosinophilic Granuloma (Histio-cytosis X): a subgroup of syn-dromes related to abnormally functioning monocytes, mac-rophages and dendritic cells; pres-ent in 10 to 15 per cent of children with histiocytosis; back pain local-ized to area of granuloma forma-tion (usually anterior vertebral body); plain films can show col-lapsed vertebrae, due to the lytic nature of the tumour; treatment options are controversial, as some patients undergo spontaneous resolution; surgery is reserved for patients with neurological deficits or polyostotic involvement. DR. SHAWN THISTLE is the founder and CEO of RRS Education (rrseducation.com), which helps busy clinicians integrate current research evidence rationally into practice. He also maintains a practice in Toronto, lectures at CMCC and provides chiropractic medicolegal consulting services. Reach him at: [email protected] 30 Canadian Chiropractor June 2015 Diagnosis and treatment of back pain in children can be challenging and requires a thorough history and exam-ination. Appropriate imaging and diag-nostic testing can rule out serious pathologies and facilitate referral for specialist intervention when required for neoplastic and rheumatological disorders. www.canadianchiropractor.ca
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