AdultPediatric
Back pain in children is uncommon and more likely to have a serious cause than in adults. Always pursue red flags. Spondylolysis is the most common cause of mechanical back pain in adolescent athletes. Suspect non-accidental trauma in young children.
🚩 Red-flag clues (must not miss)
- •Age < 4 y with back pain = workup mandatory (tumor, infection, abuse)
- •Night pain, rest pain, weight loss, fever = tumor or infection
- •Neurologic deficit, bowel/bladder change, saddle anesthesia = cord compression — MRI now
- •Fever + spinal tenderness = discitis, vertebral osteomyelitis, epidural abscess
- •Refusal to walk, won't flex spine = discitis (toddler) or osteomyelitis
History
- Duration > 4 wk, night pain, systemic symptoms
- Trauma, sports (gymnastics, football — spondylolysis), heavy backpack
- Bowel/bladder, weakness, paresthesias, gait change
- Constitutional symptoms, recent infection, TB exposure
Exam
- Spine — alignment (scoliosis, kyphosis), step-off, focal tenderness
- ROM, single-leg hyperextension (stork test for spondylolysis)
- Neuro — strength, reflexes, sensation, gait, Babinski
- Skin — café-au-lait, hairy patch (spinal dysraphism), bruising
- Abdomen, GU exam (referred pain — pyelonephritis, ovarian)
Labs
- CBC, CRP, ESR, blood cx if febrile or red flags
- UA — pyelonephritis as referred pain
- Consider TB testing if risk factors
Imaging
- Plain films AP + lateral if persistent > 4 wk or red flags
- MRI with & without contrast — first-line for infection, tumor, cord compression, neurologic deficit
- Bone scan / SPECT for spondylolysis if XR negative; or MRI
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Muscular strain | Recent activity, paraspinal tenderness, no red flags | NSAIDs, activity modification, follow-up if not improving in 2 wk |
| Spondylolysis / spondylolisthesis | Adolescent athlete, hyperextension pain, + stork test | MRI or CT, brace, PT, ortho/sports med |
| Discitis | 1–4 y, refusal to walk/sit, low-grade fever, ↑ ESR | MRI with & without contrast, IV abx (anti-staph) |
| Vertebral osteomyelitis | Fever, focal tenderness, ↑ CRP/ESR, blood cx + | MRI, blood cx, IV abx |
| Epidural abscess | Fever + spine pain + neuro deficit | Emergent MRI, neurosurgery, IV abx |
| Disc herniation (rare in peds) | Adolescent, radicular pain, + SLR | MRI, conservative; surgery if deficit |
| Scheuermann kyphosis | Adolescent, rigid kyphosis, anterior wedging ≥ 5° on 3 vertebrae | PT, brace; surgery if severe |
| Scoliosis (painful is atypical) | Painful scoliosis = workup — tumor, syrinx | MRI, ortho |
| Vertebral compression fx | Trauma, focal tenderness; consider abuse if minor mechanism | XR, CT, MRI; child protective services if abuse |
| Bone tumor (osteoid osteoma, ABC, Ewing) | Night pain relieved by NSAIDs (osteoid osteoma) | MRI, oncology |
| Leukemia | Diffuse bone pain, pallor, bruising | CBC w/ diff, smear, hem/onc |
| Pyelonephritis / nephrolithiasis | CVA tenderness, dysuria, fever, hematuria | UA, urine cx, US/CT |
| Non-accidental trauma | Inconsistent history, multiple injuries, young child | Skeletal survey, child protection team |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Ibuprofen | 10 mg/kg PO q6–8h (max 600 mg) | |
| Acetaminophen | 15 mg/kg PO q4–6h (max 1 g) | |
| Vancomycin (empiric discitis/osteo) | 15 mg/kg IV q6h | |
| Ceftriaxone | 50–75 mg/kg IV daily (max 2 g) |
Management / next steps
- Any back pain in a child < 4 y → imaging and labs
- Neurologic deficit or bowel/bladder change → emergent MRI
- Adolescent athlete with hyperextension pain → spondylolysis workup
- Always consider non-accidental trauma in young children with unexplained back pain
Pearls
- Pediatric back pain is more likely organic than in adults — have a low threshold for imaging.
- Discitis classically presents as a toddler refusing to sit or walk.
- Osteoid osteoma — night pain dramatically relieved by NSAIDs.