Back Pain in Children

Back pain in children is not like back pain in adults. Compared to an adult, a child with a backache is more likely to have a serious underlying disorder. This is especially true if the child is 4 years old or younger or if a child of any age has back pain accompanied by:

  • Fever or weight loss
  • Weakness or numbness
  • Trouble walking
  • Pain that radiates down one or both legs
  • Bowel or bladder problems
  • Pain that keeps the child from sleeping

Cause

Muscle strain is the most common cause of back pain. It usually gets better on its own with rest.

Many teenagers may have more persistent back pain. This is often related to tight hamstring muscles and weak abdominal muscles. These children seem to improve with a physical therapy program that stresses hamstring stretching and abdominal strengthening.

More serious causes of back pain need early identification and treatment or they may become worse. Always see a doctor if your child’s back pain lasts for more than several days or progressively worsens.

Doctor’s Examination

The doctor will begin by learning about how the problem developed. Then, he or she will conduct a physical examination of your child.

History

The doctor will need to know everything about the child’s health.

  • How is the child’s overall health?
  • Does he or she have any diseases or medical conditions?
  • Is there any family history of disease?
  • Has the child been in an accident?
  • The doctor will need to learn more about the back pain and any other medical problems.
  • What is the exact location of pain?
  • Does it extend into the legs?
  • Is there any numbness, tingling, or weakness?
  • Does the child have trouble with urination or bowel movements?
  • The doctor will want to know when and how the pain began.
  • Was the pain sudden, or did it develop slowly over time?
  • When does it hurt?
  • Does the pain occur all the time or only with movement?
  • Does it hurt at night?
  • What makes the pain better or worse?

It is important to let the doctor know whether the child is involved in sports or other activities.

  • If so, what sports?
  • How often does he or she train?
  • On what surfaces does the child play?

Physical Examination

During the physical examination of the child, the doctor carefully examines the muscles, bones, and nerves. The doctor will be checking the following:

The Spine

The doctor feels each vertebra and looks for deformities in the alignment and mobility of the spine.

Posture

The doctor will check the posture for how the child walks (gait); whether he or she can bend over to touch the toes; and whether he or she can extend forward and bend to the right and left.

Nerves in the Back

With the child lying face up, the doctor raises the legs (straight leg raising test). The doctor may also raise the legs with the child lying face down (reverse straight leg raising test).

Muscles

The size and tightness of muscles in the back and legs are tested. (i.e., the hamstrings)

Balance, flexibility, coordination and muscle strength
Muscle spasm and areas of tenderness
Reflexes and reactions to pain and light touch

Imaging

The doctor may use one or several diagnostic imaging tools to see inside the body.

  • X-rays: The doctor may take several X-ray pictures of the spine and pelvis from various angles.
  • Bone Scans: More sensitive than X-rays, bone scans use a substance the doctor injects into a vein to detect infections, tumors, and fractures with a special camera.
  • Computed Tomography (CT) scan: Specialized X-rays that show a three-dimensional image, computed tomography scans let the doctor see bone injuries more clearly.
  • Magnetic Resonance Imaging (MRI): Magnetic resonance imaging scans use radio waves to let the doctor see the spinal cord, nerve roots, disks, or other soft tissues.

Laboratory Tests

Laboratory tests may include checking white and red blood cells (complete blood-cell count) and looking for system-wide inflammation (measuring erythrocyte sedimentation rate).

Treatment

Musculoskeletal strain is most often responsible for back pain in children and adolescents. This type of pain frequently responds to rest, anti-inflammatory medications, and an exercise program.

Other more serious diagnoses must always be given consideration. Rounded back, stress fracture of the spine, slipped vertebrae, infections, and tumors are among these.

Rounded Back

In adolescents, rounded back, also called Scheuermann’s kyphosis, is a common cause of pain in the middle of the back (the thoracic spine). Vertebrae become wedged, causing a rounded, or hunched, back. The curved part of the back may ache and pain may get worse with activity. Boys get Scheuermann’s kyphosis more often than do girls. This usually occurs around 14 to 17 years of age.

An adolescent male presents with excessive roundback localized to the thoracic spine. The severe kyphosis is most obvious when he bends forward.

(Courtesy of Texas Scottish Rite Hospital for Children)

Treatment is usually nonsurgical and includes:

  • Using a brace as the child grows may improve the curve.
  • If the curve is rigid, the child may need a series of casts.
  • Exercises to stretch and strengthen muscles may ease pain, but will not change the rounded back.

Stress Fracture of the Spine

Spondylolysis, or stress fracture, may cause lower back pain in adolescents. Stress fractures may occur during adolescent growth spurts or in sports like gymnastics, diving, and football, that repeatedly twist and hyperextend the spine.

Pain is usually mild and may radiate to the buttocks and legs. The pain feels worse with activity and better with rest. A child with spondylolysis may walk with a stiff legged gait and only be able to take short steps.

Girls are more likely to get stress fractures.

There are a range of treatment options.

  • Rest from activities that caused the stress fracture
  • Nonsteroidal anti-inflammatory drugs (NSAIDS)
  • Strengthening exercises for back and abdominal muscles to help control symptoms
  • Bracing for several months and follow-up doctor appointments with X-rays to watch for changes
  • Surgery to treat painful spondylolysis that does not get better with conservative management

In a few cases, spondylolysis may lead to slipped vertebrae (spondylolisthesis).

Slipped Vertebra

This lateral radiograph of the lumbrosacral spine demonstrates the forward shift in the fifth lumbar vertebra on the sacrum (L5-S1 spondylolisthesis). (Courtesy of Texas Scottish Rite Hospital for Children)

A slipped vertebra, or spondylolisthesis, occurs when one vertebra shifts forward on the next vertebra directly below. It usually occurs at the base of the spine (lumbosacral junction). In severe cases, the bone narrows the spinal canal, which presses on the nerves.

Treatment may include:

  • Follow up examinations to ensure the slip is not getting worse
  • Restriction from vigorous physical activity in mild cases
  • Surgery to stabilize the spine in serious cases

Infection

In young children, infection in a disk space (diskitis) can lead to back pain. Diskitis typically affects children between the ages of 1 and 5 years, although older children and teenagers can also be affected.

A child with diskitis may have the following symptoms.

  • Pain in the lower back or abdomen and stiffness of the spine
  • Walking with a limp, or simply refusing to walk
  • Squatting with a straight spine when reaching for something on the floor, rather than bending from the waist

To treat diskitis, the child may need several days of bed rest and antibiotics taken through the blood stream (intravenous, or IV) or in tablets. In some cases, older children may need casting or bracing to immobilize the spine (for comfort) if infection narrows the disk space. Surgical drainage of the infection is rarely needed.

Tumor

On rare occasion, tumors can be responsible for back pain. When they occur, tumors of the spine are most often found in the middle or lower back. Pain is constant and usually becomes worse over time. This pain is progressive; it is unrelated to activity and/or happens at night.

Other symptoms vary, and can include any of the following:

  • Muscle spasms or a “tight” back, which may cause the child to lean to one side when bending forward (painful curvature)
  • Pain and/or weakness extending into the legs and causing the child to limp
  • Bowel or bladder problems