II. History

  1. Duration
    1. Acute: <2-3 months of back pain
    2. Chronic: >2-3 months of back pain
  2. Modifying factors
    1. Back flexion or extension
  3. Contributing conditions
    1. Immunocompromised state (diskitis)
    2. Malignancy
    3. Sickle Cell Anemia
    4. Back injuries (e.g. MVA)
    5. Hyperextension sports (e.g. swimming, gymnastics): Spondylolysis
  4. Red flags
    1. Fever
    2. Night pain
    3. Bowel or Bladder dysfunction
    4. Young age (esp. <4 years old)
    5. Urinary tract symptoms

III. Exam: Focused Pediatric Back Pain exam

  1. See Low Back Exam for a general back exam for children and adults
  2. Spine alignment abnormalities
    1. Scoliosis
    2. Kyphosis
    3. Leg Length Discrepancy
  3. Provocative Maneuvers
    1. Back forward flexion
    2. Back hyperextension
    3. FABER Test (Sacroiliac joint testing)
    4. Straight Leg Raise test
  4. Neurologic Exam
    1. Toe and heel walking
    2. Ataxia
    3. Toe raises on one leg (set of 10 on each side)
    4. Dermatomal sensation exam
  5. Skin changes
    1. Cafe Au Lait spots (Neurofibromatosis)
    2. Midline Hypertrichosis or Hemangioma (Cutaneous Signs of Dysraphism)

IV. Differential Diagnosis: Timing

  1. Acute back pain (<2-3 months)
    1. Low back strain or low back spasm
    2. Herniated intervertebral disc
    3. Spondylolysis
    4. Slipped Vertebral apophysis
    5. Vertebral Fracture
  2. Chronic back pain (>2-3 months): Diagnosable lesion in >85% of cases
    1. Scheuermann's Kyphosis
    2. Spondyloarthropathy (Juvenile Rheumatoid Arthritis, Ankylosing Spondylitis)
    3. Persistent acute cases (occult Fracture, Spondylolysis, infection, malignancy)
  3. Night-time back pain
    1. Infection (e.g. Osteomyelitis, diskitis)
    2. Malignancy (e.g. Osteoid Osteoma, Osteoblastoma, Leukemia, Ewing's Sarcoma)

V. Differential Diagnosis: Modifying factors

  1. Back pain with spinal flexion
    1. Herniated intervertebral disc
    2. Slipped Vertebral apophysis
  2. Back pain with spinal extension
    1. Spondylolysis
    2. Spondylolisthesis
    3. Posterior arch injury (pedicle or lamina)

VI. Differential Diagnosis: Back pain with associated findings

  1. Fever
    1. Infection (e.g. diskitis)
    2. Malignancy
  2. New-onset Scoliosis
    1. Idiopathic Scoliosis
    2. Herniated intervertebral disc
    3. Infection
    4. Malignancy
    5. Syrinx
  3. Urinary changes
    1. Pyelonephritis
  4. Bone pain
    1. Sickle Cell Anemia

VII. Imaging

  1. Spine Xray (Indicated in all cases except minor, short-term injury-related pain)
    1. Standard: Anteroposterior and lateral Views
    2. Spondylolysis suspected: Oblique views
  2. Additional modalities as indicated
    1. Spine MRI
    2. Spine CT
    3. Bone scan (if malignancy or infection are suspected)

VIII. Labs

  1. Initial
    1. Complete Blood Count
    2. Erythrocyte Sedimentation Rate (ESR) or C-Reactive Protein (CRP)
    3. Urinalysis (if urinary tract symptoms)
  2. Additional tests to consider
    1. Blood Cultures
    2. Antinuclear Antibody testing
    3. Rheumatoid Factor
    4. HLA-B27

IX. References

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