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Back Pain is Common in Children
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Posted on: 02/25/2009
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There's been a trend in medicine to provide evidence that a particular treatment works for any given medical condition. Likewise, guidelines for the accurate diagnosis of conditions like low back pain are based on evidence when it's available. But no such guidelines exist for dealing with low back pain in children and teens.
Developing evidence-based diagnostic and treatment guidelines for adults is one thing. Providing the same for children is something else entirely. When there's a lack of evidence, then physicians rely on what's called consensus-based evidence. They gather panels of experts who collectively compare opinions and experiences and develop something they can all agree on until proven true or false.
When a consensus-based approach is used, the next step is to gather case reports and case series of patients presenting with a particular problem. This approach is not ideal but it's necessary until larger studies can be done.
What have these case series told us so far? First, back pain in children and teens is far more common than ever thought before. Second, there's rarely a known (pathologic) cause such as a tumor, fracture, or infection. Alternately stated, most children with back pain don't have a definitive diagnosis.
Even with careful examination and evaluation, only 18 to 36 per cent of the children have a specific diagnosis. Most of the time, they are labeled with a condition called nonspecific low back pain. So, the question has been raised: is it necessary to do extensive and exhaustive tests and studies on children to come up with a diagnosis for low back pain?
Again, there are no large-scale studies to answer this question. Physicians are currently relying on information from case series. And only a few case series are even available. The best evidence available suggests that a history, exam, X-rays and other imaging studies, and lab work is simply overkill for most cases of low back pain in this younger age group.
Based on two case series of 73 and 86 children, here's what the current decision-making process looks like:
Start with a good history and physical exam as always.
Order X-rays to rule out fractures, scoliosis, or conditions such as spondylolysis or spondylolisthesis. These last two conditions occur when a fracture develops in the pars articularis (one of the supporting columns of the vertebra). Spondylolysis is the presence of the undisplaced fracture. Spondylolisthesis is a fracture of the pars and a separation of the bone so that the body of the vertebra shifts forward over the vertebral body below it.
Reserve CT scans to confirm the presence of spondylolysis and bone tumors.
Order MRIs when there are abnormal neurologic findings or the patient's symptoms are getting worse instead of better.
When looking for the cause of low back pain in children and teens, as the old saying goes -- think horses not zebras. Physicians should look for the obvious and not chase after serious pathology when there's no sign that any exists. Using a checklist of red flags to identify serious conditions is still advised. Studies are needed to verify the accuracy of red flag checklists to identify serious pathologic conditions.
Health care providers should remember that too many tests don’t always add more information. At the same time, these tests are expensive. In the case of X-rays and some other imaging studies, young children are exposed to radiation when it may not be needed. The bottom-line is that an exhaustive number of tests just aren't needed for most children with back pain.
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References:
Should Back Pain in Children and Adolescents Be Worked-Up Aggressively? In The BackLetter. February 2009. Vol. 24. No. 2. Pp. 16-17.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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