Tiziana Greggi*, Antonio Scarale, Francesco Vommaro, Konstntinos Martikos, Luca Boriani, Paola Zarantonello and Gianluca Colella
Surgery of Spine Deformity, Orthopedic Institute Rizzoli of Bologna, Italy
Received: 03 April 2019
Accepted: 09 June 2019
Version of Record Online: 17 June 2019
Greggi T, Scarale A, Vommaro F, Martikos K, Boriani L, et al. (2019) The Reasons for Back Pain in Children. Deform Bone Muscles 2019(1): 27-36.
Correspondence should be addressed to
Tiziana Greggi, Italy
Copyright © 2019 Tiziana Greggi et al. This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and work is properly cited.
Back pain is a relatively common complaint among children and teen-agers. The most common cause of back pain in children is muscle strain injury during daily activities (sports, backpack weigh over 8 Kg, etc.). These mild injuries almost always resolve without any residual consequences. In the pediatric population, normal physiological growth results in constant developmental changes that can further be a source of pain.
In this work we will focus on the presentation and analysis of the rare, but often more severe spinal pathologies that can cause pain children population . These uncommon disorders are often a challenge to promptly diagnose. An accurate diagnosis could be challenging but it is of the utmost importance to differentiate these outliers from the more common aches and pains of childhood.
A specific low back pain
In this context, risk factors that can cause mild dysfunction or inflammation of a tissue (bones, muscles, ligaments, tendons, nerves, etc.) should be investigated . During the developmental phase, postural adaptations are subject to continuous changes due to biological, psychological or social factors. Numerous studies have explored the risk factors that can aggravate or create back pain. Obesity and excessive elasticity of the joints are not relevant according to current scientific knowledge. Inactivity and participation in very intense sports activities could be included among the risk factors. It is unclear whether backache is due to poor muscle strength, while it is certain that muscle strengthening does not prevent back pain. Muscle control and coordination are important in resolving acute back pain and preventing the future flair-ups.
We will analyze 10 causes of back pain as shown in table 1.
Table 1: Causes of back pain.
Scheuermann’s Disease (Figure 1) is typical of adolescent growth, and can cause pain and stiffness in the spine. It is supported by osteochondrosis of the endplate localized at the vertebral accessory nucleus . It can cause a “wedge” deformation of the vertebral bodies and thus an increase of the dorsal kyphosis.
Figure 1: Thoracic hyperkyphosis in osteochondrosis with Schmorl nodes.
It is more common in males at the peak of puberty with back pain sometimes radiating to the interscapular and ribs areas. In early stages, the curved back is flexible both in sitting and standing positions, while more advanced deformity can show stiffness and pain with limited flexibility.
Spondylolysis (Figure 2a) means there is a defect in the part of the vertebral arch between the two articular processes, the so-called pars interarticularis. If it is bilateral, it may lead to forward sliding of a vertebral body over the one below, thus resulting in spondylolisthesis (Figure 2b). Pediatric spondylolysis and spondylolisthesis present with a wide spectrum of pathology and clinical findings, including back pain, leg pain, crouch gait, or neurological deficits. The treatment of spondylolysis alone is typically conservative with bracing, non-steroidal anti-inflammatory drug, and activity restriction, but refractory pain can be successfully surgically managed with intralaminar compression screw, wires, or pedicle screws with rods and laminar hook constructs. The treatment of dysplastic spondylolisthesis is aggressive to prevent neurological deficit, whereas even high-grade isthmic slips can be treated safely with nonoperative measures if no significant neurological deficits are present .
Figure 2: A) TC image of spondylolysis L3 L4. B) Xray image of spondylolysthesis L5 S1.
Lumbar Disc Herniation (LDH) is a common disorder among adults with degenerated lumbar intervertebral discs. However, its occurrence in childhood and adolescence is much less frequent mostly because children and adolescents tend to have a healthier lumbar spine as compared with adults. This difference indicates that children and adolescents are far from being just little adults. Syntomathic disc disease earlier than 21 years of age are 1.3%, and before 16 years are 0-5%. Feature: Painful stiffness of the spine (Figure 3) .
Figure 3: MRI image of herniated disk L4 L5.
Often in infancy, seronegative spondyloarthropathies may be mistakenly diagnosed as juvenile rheumatoid arthritis, but the analysis of the various clinical manifestations may help to make a correct diagnosis. Ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, and arthritis associated with inflammatory bowel disease are arthritis most commonly present in young adults but may also be present in children. Extra-articular manifestations include inflammation of the eyes, skin, gastrointestinal tract, genitourinary tract associated with tendon inflammation. Correct diagnosis will allow treatment choices different from those normally used for youth rheumatoid arthritis. Early diagnosis and treatment often lead to early recovery and a return to normal daily activities.
Other spondyloarthropathies: juvenile spondyloarthropathy, induration spondyloarthropathy, early assail spondyloarthropathy, reactive arthritis, enteropathic arthritis, psoriatic arthritis (Figure 4) .
Figure 4: Rx image of sacroiliitis spondyloarthropathy.
Scoliosis can be defined as a spinal curvature greater than 10º in association with vertebral rotation and deformity of the chest cage (Figure 5).
They are classified as follow:
Idiopathic: There is no known etiologic agent. They are not the consequences of another entity.
Congenital: Congenital Spine Diagnosis. Defects of formation, segmentation or mixed.
Syndromic: Marfan, Arthrogryposis, Neurofibromatosis, Prader Willi, Mucopolysaccharidosis, Imperfect Osteogenesis, etc. [7-10].
Figure 5: Rx image of adolescent idiopathic scoliosis.
Spinal infections are uncommon but significant causes of morbidity and hospitalization in the pediatric population. These infections encompass a broad range of conditions, from discitis to osteomyelitis and spinal epidural and intramedullary abscesses (Figure 6a-c). Pediatric spinal infections can be caused by a range of bacterial, viral, fungal and parasitic agents. Ultrastructural differences of the vertebrae and associated structures result in distinct mechanisms of pathogenesis of spinal infections in children compared to adults.
Initial symptoms are often a specific (fever, pain, disturbance of walking), rarely leukocytosis, almost constantly elevation of logistic indexes. Positive hemoculture are described in less than 30% of cases.
Spondylodiscitis is an inflammatory process of the vertebral disk with variable involvement of the adjacent bone. It is a rare, pediatric disease whose actual incidence is unknown. The etiology is most commonly infectious and the most affected segments are mainly the lumbar vertebrae, the diffusion pathway is mostly hematologic, unlike in adult forms, that are mainly secondary to surgery .
Frequently skin flora (S. aureus)
Causes: skin lesions, hematologic spread
High fever, chills, headache, weakness
ESR, CRP elevated
Figure 6a-c: TC scan axial - coronal - sagittal plane of spondylodiscitis.
Diagnosis and Treatment
CT guided biopsy for antibiogram
Angioma is the most common benign tumor in pediatric age and it can cause back pain. It is made up of a set of capillaries often dilated and stuffed with blood, located in the body of the vertebrae. It is a very common tumor and in the same patient can be present in multiple vertebrae. It is well underlined by Magnetic Resonance (MR). Generally, these are small tumors without any clinical significance because they do not cause symptoms.
Rarely, they invade enough of the vertebral body to cause structural compromise. In this case the angioma should be followed in time with MR, but do not require any treatment. Sometimes the angioma can erode the back wall of the vertebral body and/or extend to the posterior arch.
Aggressive lesions often need to be treated in the setting of continued pain or neurologic dysfunction. The treatment consists in the selective artery embolization that discharges the vertebral body. Surgery can remove the portion invaded by the tumor, to eliminate the medial compression or, very rarely, the entire vertebral body (Figure 7) [12,13].
Figure 7: CT image of vertebral hemangioma.
An Aneurysmal Bone Cyst (ABC) is a benign, locally proliferative vascular disorder of non-neoplastic osseous lesions in children and young adults. Seventy-five percent of ABCs occur before the age of 20 years. It presents with severe localized lower back pain at vertebral level which increases on lying supine, stiff pains and neuro- logical signs in 50% of the cases (Figure 8) .
Figure 8: TC lumbar image of L1 Aneurysmatic cysts.
Osteoid Osteoma is a benign bone lesion with a central “nidus” of less than 2 cm surrounded by a bone reaction zone. This pathology represents approximately 10% of benign bone tumors. The spine is affected in 10-14% of patients; Mainly the posterior spinal elements are involved (Figure 9a,b).
Figure 9: A) TC scan - axial and sagittal plane of Osteoid Osteoma of L4. B) Image of “nidus”.
Osteoid osteoma presents a characteristic clinical symptom of acute pain that occurs at night and disappears within about 20-30 minutes after intake of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).
The classic radiological appearance is a radiotransparent “nidus” surrounded by a marked area of reactive sclerosis at the bony cortex. The center of the lesion may vary from partially mineralized to osteolytic or totally calcified. The lesion can affect only the cortical bone, both cortical bone and bone marrow, or only bone marrow. Reactive sclerosis may be present or absent.
Treatment is advised only if the lesion is symptomatic. Radio frequency ablation is an ideal option .
The diagnosis is based on traditional X-ray but, above all, on bone scintigraphy. Computational Axial Tomography and Nuclear Magnetic Resonance complete the Imaging Study. Histology is dirty. The treatment involves radical removal of the tumor with respect to vertebral stability.
Benign, similar to the osteoid osteoma, made of osteoblast that produces osteoid. Osteoblastoma is locally aggressive and may have malignant evolution.
The clinical picture is characterized mainly by spinal pain (often at night), stiffness and radiculitis (Figure 10) .
Figure 10: TC axial image of lumbar osteoblastoma - posterior arch.
Exostosis is a malformation of cartilaginous origin that originates at the metaphyseal level of long bones. Exostoses can be solitary or multiple. Multiple exostosis is a familiar inheritance disease. Non-ossification fibrous is the second most common benign bone tumor. M>F over 5 years of age.
They manifest themselves as periarticular, painless and slow-growing, hard masses. The possible presence of pain is due to the inflammation of the mucous membrane that forms on the cartilage cap of the exostosis. Exostoses can be located in the metaphysis of all bones that develop through endochondral ossification. All long bones, ileum, and, rarely vertebrae, can be affected. Rarely the bones of the hand and the foot are affected too. It is often asymptomatic but when developing within the neural arch may cause neurological symptoms. Surgical treatment is advised in these cases (Figure 11) .
Figure 11: Tc image of lumbar Osteochondroma.
Eosinophilic granuloma or Histiocytosis X
Langerhans Cell Histiocytosis (LCH) is a rare disease, most commonly diagnosticated in children population, with an estimated incidence between 0.2 and 2.0 cases per 100,000 children under 15 years of age and a peak incidence between 2 and 4 years old.
It is an uncommon proliferative disorder of the Langerhans cells and antigen-presenting cell of the dendritic cell line. The usual clinical presentation reveals pathological masses or granulomatosis with destruction of surrounding tissues. Lichtenstein (1953) grouped the Eosinophilic Granuloma, the Hand-Schüller-Christian disease, and the Letterer-Siwe disease, three different syndromes with the same histology, under the term “Histiocytosis X”. In the spine it can present with local pain and stiffness only, but also with progressive deformity (Figure 12a-c) .
Figure 12: A) MRI image of Eosinophilic granuloma of thoracic vertebra. B) Histological examination of Eosinophilic granuloma. C) RX image of Eosinophilic granuloma of thoracic vertebra.
In most cases, observation. Spontaneous pain regression. Use of brace to prevent the kyphosis to increase. Steroid local injection.
Surgical treatment warranted in severe cases with persistent pain, neurological symptoms, vertebral stability compromise: Curettage, decompression and stabilization.
Osteosarcoma rarely affects the spine. Primary spinal osteosarcoma represents 0,85-3% of all osteosarcomas. (1122 osteosarcomas studied “Mayo Clinic” 1909-1980). Spinal osteosarcoma can occur in an older age group compared to other skeletal sites, which affect more commonly young people. It is localized particularly in anterior vertebra and posterior arch (Figure 13a,b) [19,20].
Figure 13a,b: Tc scan - sagittal and axial plane - of Vertebral osteosarcoma.
Ewing vertebral sarcoma
10% of the cases described in literature are <20 years old. The lesion can involve soft tissue (Figure 14a,b) .
Figure 14a,b: MRI scan - sagittal and axial plane - of Ewing thoracic vertebral.
Sudden onset of pain a) after trauma, b) without traumatic causes. Subtle onset without trauma.
Pain is present during night time.
It comes in the morning with stiffness and fatigue. Only after starting activities.
Improve with rest or acute sitting for a long time.
There are movements or particular activities that make the pain worse.
It is located at a precise point of the column or propagates proximally or distally.
It also radiates to the limbs.
Other associated symptoms: fever or weight loss, weakness, urine dip/leaking, pain that prevents sleep.
Rare and usually transient back pain,
More common Spondylolysis or spondylolisthesis, Hematogenic Spondylodiscitis, osteoid osteoma.
Infections, Spondylolisthesis, Osteoarthritis, Osteoblastoma, Ewing Osteosarcoma or Sarcoma (rare), Degenerative Pathologies (disc protrusion).
In children back pain is different from the adult one. The most common cause of back pain is a muscular strain, and the condition almost always self-limited with rest. If the child is younger than 4 years old, and if the pain is accompanied by fever or weight loss, weakness, pain that radiates to one or both legs, incontinence, sleep pain, a more serious disorder should be suspected.
In adolescence, back pain can become more persistent, and is often associated to rigidity of the back muscles and weakness of the abdominal muscles. The most serious causes of back pain require early identification and a specific and appropriate treatment.
If the back pain is reported as extremely intense, if it lasts for more than 20-30 days, then it will be important to contact a spine specialist to make the appropriate assessments.
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