Back pain is one of the most common causes for patients to seek emergency care. It has a broad range of potential etiologies for both adult and pediatric populations. The etiologies differ depending on the patient population, but most commonly it is mechanical or non-specific in nature. Back pain causes significant rates of disability and can be a problem that persists from childhood into adulthood. It is essential to be able to evaluate patients of all ages and understand the unique differences in the presentation in these different populations. Knowing the common red flags of back pain in both children and adults can guide the provider to appropriate evaluation and treatment.
Back pain is a broad topic with many potential etiologies that are broken mainly in four major categories
It is important to note, however, that many non-back-related disorders may result in pain that patients perceive in the back such as biliary colic, pneumonia, and obstructive or infectious renal disease. Therefore, it is prudent not to exclude these processes from your differential diagnosis while evaluating the patient.
Back pain is widespread in the adult population. Some studies have shown that up to 23% of the world’s adults suffer from chronic low back pain. This population has also shown a one-year recurrence rate of 24% to 80%. Some estimates of lifetime prevalence are as high as 84% in the adult population.
However, the prevalence is much less apparent in the pediatric literature. One Scandinavian study demonstrated that the point prevalence of back pain was approximately 1% for 12-year-olds and 5% for 15-year-olds, with a with a cumulative incidence increasing to 50% by age 18 for females and by age 20 for males. An extensive systematic review demonstrated an annual rate of adolescents suffering from back pain of 11.8% to 33%.
A thorough history and physical exam are critical in the evaluation of the patient with back pain in both adult and pediatric populations.
The historical characteristics of the pain that require elucidation are very similar for the two populations. The mechanism of injury (if one is present), the intensity and the quality of pain, whether the pain radiates, what the alleviating and provoking factors for the pain are, and what treatments have been tried (and whether those treatments were effective) are all critical for the gathering a thorough history of present illness. It may also be helpful to assess what the impact on the patients daily living the pain has caused, such as work/school absenteeism, as useful clues for functional impairment. Past medical and family history (including the history of cancers or inflammatory conditions) and social history (including periods of injection drug use, exercise regimens, periods of exposure to tuberculosis) can also change the most likely working diagnosis
The physical exam is also performed similarly between the age groups as long as the patient is old enough to communicate and participate in the exam. The physical exam should include inspection, palpation, the range of motion, strength testing, provocative maneuvers, and neurologic (limb strength, sensation and deep tendon reflex) assessments. Several provocative maneuvers are helpful for demonstrating or decreasing suspicion of different processes.
Straight leg raise (SLR): performed by raising the patient’s leg to 30 to 70 degrees. Ipsilateral leg pain at less than 60 degrees is a positive test for lumbar disk herniation. Likelihood ratio (LR) of 2, negative likelihood ratio (NLR) of 0.5. If the pain reproduction occurs contralaterally, it is a positive test for lumbar disk herniation with LR of 3.5 and NLR of 0.72.
One leg hyperextension test/stork test: Have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. Pain with hyperextension is positive for a pars interarticularis defect.
Adam test: Have the patient bend over with feet together and arms extended with palms together. The practitioner should observe from the front. If a thoracic lump is present on one side or the other, it is an indication for scoliosis.
There are numerous other examination techniques; however, they have mixed evidence for inter-practitioner reliability and poor sensitivities or specificities.
Red flag historic or physical exam features that, when present, should raise the provider’s suspicion for a process that may require imaging for proper diagnosis. These differ slightly from adults to children based on the incidence of diseases in these age groups:
While typically history and physical exam are sufficient for evaluation of back pain, the presence of red flags or pain that is protracted may require further investigation. Early imaging in the adult population correlates with worse outcomes and more invasive treatments without a commensurate improvement in outcomes. Imaging for adults should be reserved for symptoms that last longer than six weeks with appropriate with appropriate conservative management. Protracted pain in children should have imaging; however, the definition of protracted has not been as clearly defined as it is in adults.
Anteroposterior and lateral plain films should be sufficient to evaluate for boney pathology, whereas MRI may be necessary to evaluate for soft tissue lesions, nerve root/cord compression from a bulging disc, malignancy, and inflammatory conditions of the spine and surrounding tissues. Bone scans may demonstrate osteomyelitis, discitis and stress reactions, but remains inferior to MRI to evaluate these conditions. In adolescents with MRI evidence of herniated disc, one may consider CT to confirm or rule out apophyseal ring separation as this occurs in 5.7% of these patients.
In addition to imaging, one may consider laboratory evaluation if red flags are present. Rheumatologic assays such as HLA-B27, ANA, RF, and Lyme are typically not helpful in the evaluation due to their unspecificity. Inflammatory markers such as CRP and ESR along with CBC and blood cultures may assist in the diagnosis of inflammatory, infectious, or malignant etiologies. The addition of LDH and Uric acid may assist in diagnosing a condition with rapid marrow turnover such as leukemia.
There are various treatments for pain based on etiology, age, and chronicity of the back pain. The best evidence in adult back pain according to the "Noninvasive treatments for low back pain: current state of the evidence" clinician summary published by the Agency for Healthcare Research and Quality in 2016:
For radicular low back pain, nonpharmacologic interventions such as exercise, traction, and spinal manipulation have shown some benefits but have relatively weak levels of evidence to support it. NSAIDs has moderate evidence of benefit, however other pharmacologic interventions such as diazepam and systemic steroids do not seem to provide benefit. [AHRQ, 2016].
For non-radicular acute or subacute low back pain, acetaminophen appears to have weak evidence of no benefit. However, NSAIDs, heat, and muscle relaxants have moderate evidence for positive benefit. Massage has weak evidence that leans toward benefit.[AHRQ 2016]
For non-radicular chronic low back pain, there is moderate evidence to support physical therapy[AHRQ 2016], particularly utilizing the McKenzie method. , Acupuncture also has moderate-strength evidence to support its benefit in this population. Tai chi, Yoga, psychological techniques (such as biofeedback and progressive relaxation), Spinal manipulation, and multidisciplinary rehab all have weak evidence that leans toward benefit.[AHRQ 2016], Back schools also have very weak evidence of benefit. As far as pharmacologic management of chronic low back pain, NSAIDs and duloxetine demonstrate ongoing benefit, while opioids only demonstrate short-term benefits.[AHRQ 2016] Gabapentin is a very commonly used anticonvulsant for chronic pain; however, it has not demonstrated a significant benefit for patients with chronic low back pain.Topiramate, however, has been found to be more effective than placebo. Topical anesthetics such as lidocaine patches and transcutaneous electrical nerve stimulation (TENS) units do not appear more effective than placebo.,
According to the American Pain Society, surgical referral should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year. However, there is mixed evidence, for some of the most commonly performed invasive procedures such as injection therapy of the epidural space, facet joints, or local sites, Spinal fusion, or lumbar disk replacement.,,
In pediatrics, treatments for pain are less well studied. However, activity modification, physical therapy, and NSAIDs have broad support as first-line therapies. If there is an underlying malicious cause present, treatment of those underlying disorders is the standard of care. A majority of spondylolysis may be managed conservatively as above, but some will need a referral for surgical intervention. Persistent symptoms after greater than 6 months of conservative therapy or Grade III or IV spondylolisthesis may be referred to a pediatric spine surgeon for further evaluation.,,, In patients with Scheuermann’s kyphosis, physical therapy and guided exercise may be sufficient for patients with less than 60 degrees curvature, bracing may be added for patients with curvature less than 70 degrees. Surgical correction may be indicated for the patient with greater than 75 degrees curvature, especially if they have failed conservative measures and are skeletally mature., Scoliosis of 20 degrees or more during peak growth, significant scoliosis, progressive curvature, and atypical scoliosis are all indications for surgical referral.
The differential diagnosis for back pain is very broad, especially when considering the pediatric population. Below is a review of the more common diagnoses along with history or physical exam features that may increase your index of suspicion. This list is not comprehensive but represents the more likely and more concerning conditions that make up the differential.
Many factors seem to predict worse outcomes for patients who suffer from back pain. Prior episodes of back pain, greater intensity of back pain, and the presence of leg or widespread symptoms are all associated with worse “chronic disabling pain.” Lifestyle activities also seem to play a role including patients having higher body mass indexes (greater than 25) and smoking contributing to worse outcomes. Depression, catastrophizing, and fear avoidance behavior all worsen outcomes, including disability rates. There are also underlying social factors that have significant prognostic accuracy. These factors all have significant interplay such as low educational attainment, having a job that requires significant physical workloads, poor compensation, and poor job satisfaction all negatively impact outcomes.
There is less clear prognostic evidence for pediatrics. However, one valid assumption is that the prognosis largely relies on the underlying etiology of the pain. The pain caused by cancer will likely have a different impact on disability than a muscle strain. Similarities exist in the pediatric population and adults, however. In regards to non-specific back pain, some studies lean toward increasing back pain with behavioral comorbidities such as conduct problems, ADHD, and psychological distress, passive coping strategies, and fear-avoidance behavior.
Complications are largely determined based on underlying etiology; however, they can mostly subdivide into physical and social complications. Physically, complications can include cauda equina syndrome, chronic pain, and deformity (in select conditions). Socially, complications are usually measured by disability, decreased gross domestic product, and increased absenteeism. A study in 2015 found that back pain was responsible for 60.1million years lived with disability worldwide. This data represents the most common cause of disability globally. In the US low back pain accounts for the most common reason for disability.
After review of the evidence, it would seem that the best patient education that can be provided to prevent back pain is to maintain healthy body weight with a BMI less than 25, as higher BMI correlates with worse outcomes. Patients of all ages should avoid smoking, as increases rates of back pain in all ages. Continuing to engage in physical activity as fear-avoidant behaviors worsen disability. There is strong evidence that intensive patient education lasting for 2.5 hrs discussing activity modification, staying active, and early return to normal activity is more effective for returning to work. There is mixed evidence about whether book bag weight plays a role in pediatric back pain, but despite the unclear evidence the American Academy of Pediatrics recommends that book bags do not exceed 10 to 20% of the child’s body weight.[AAP 2004]
There are practice pearls worth remembering in the evaluation and treatment of back pain.
Back pain, if not treated appropriately, can become chronic and debilitating over time. There is some debate as to the most appropriate treatment for back pain to maximize outcomes. The confusion lies within the way studies have been framed in the past, by isolating the pain away from the other factors that make up the patient. Disease-oriented medicine, with treating back pain as a primarily isolated issue has proven to have relatively poor outcomes in regards to chronic back pain. Approaching the treatment of pain from a multi-disciplinary approach maximizes your chances of having better outcomes. Bearing in mind the clinical clues which provide worse prognostic outcomes such as underlying mental health disorders, kinesiophobia, obesity, and smoking, it is likely to be helpful to treat the whole patient with a multi-disciplinary team. Screening for some of these comorbidities as a primary care provider may be of assistance if the patient is not responding to conservative therapy. The primary physician can also offer smoking cessation and other lifestyle management counseling to the patient.
Addition of early physical therapy has shown benefit more rapid improvement of health care utilization and opioid use. [Level I] Addition of a provider skilled in cognitive behavioral therapy may assist with patients with an underlying mood disorder that can contribute to symptoms as well as the development of coping skills. [Level I] Interventions aimed at lowering the patient's weight may also provide significant back pain relief; however, the evidence is not as compelling. [Level IV]
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