Back Pain

Back pain in children is common and is frequently non-specific in nature. The causes of back pain are varied, and like pain in all joints it can be affected by factors such as reduced physical inactivity, low mood and anxiety, social and psychological issues.

Neck pain is also common and may be mechanical but serious causes of pathology need to be considered including inflammatory arthritis, infection and tumours. Torticollis is a cause of neck pain and can be congenital or acquired. 

Certain sporting activities such as cricket, bowling or gymnastics may pose increased risk of back pain, with possible consequences such as spondylolysis (where a unilateral or bilateral interruption of the pars is present) and spondylolisthesis (an anterior displacement of the affected vertebra) which present as acute, or acute on chronic pain, with pain on spine extension ('Stork's test - see pREMS spine) and also with localised tenderness. 

Scheuermann’s 'disease' results from vertebral wedging due to an osteochondrosis of the thoracic spine. This is often asymptomatic (and may be a coincidental finding on radiograph); it can result in thoracic kyphosis, 'slouching appearance', in which case referral to physiotherapy or paediatric orthopaedics is warranted.

Infections such as vertebral osteomyelitis and Tuberculosis (TB) may present with backache and need to be excluded in endemic regions. Pott's spine is a complication of TB spine.

Scoliosis (lateral curve of the spine) is often asymptomatic, may be more obvious on forward bending and can result from a spectrum of causes. 

Inflammatory back pain (often with morning stiffness) and with tender sacroiliac joints can be a feature of Juvenile Idiopathic Arthritis (especially Enthesitis Related Arthritis, Psoriatic Arthritis) and also arthritis in association with inflammatory bowel disease.

Other causes of back pain in children are less frequent compared to adults - e.g., a herniated disc and tumours. In young children, disciitis can occur. 

A detailed history and examination identifying red flag symptoms and signs prompts urgent referral and helps identify the cause.

Red flags for urgent referral include:

• painful scoliosis.
• night waking.
• neurological symptoms suggestive of nerve root entrapment or cord compression - such as bladder and bowel disturbances.
• systemic findings to suggest malignancy or sepsis.
• very young children (<5 years).
• suggestion of inflammatory back pain.
• acquired torticollis. 

The photograph below shows a thoracolumbar scoliosis 

The radiograph below shows a collapsed vertebra (arrow) and scoliosis due to TB infection (this appearance is called Pott's spine)