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Clinical Review & Education

JAMA Pediatrics | Review

Musculoskeletal Low Back Pain in School-aged Children


A Review
James MacDonald, MD, MPH; Emily Stuart, MD; Richard Rodenberg, MD

Supplemental content
IMPORTANCE Low back pain (LBP) in children and adolescents is a common problem. The
differential diagnosis of LBP in this population is broad and different from that seen in the
adult population. Most causes of LBP are musculoskeletal and benign in their clinical course.
Clinicians should have an understanding of the relevant anatomy and the most commonly
encountered etiologic factors of LBP in children and adolescents to provide effective care.

OBSERVATIONS Low back pain is rarely seen in youth before they reach school age.
Subsequently, rates of LBP rise until age 18 years, at which age the prevalence of LBP is similar
to that in adults. The differential diagnosis of LBP in this population is broad, and individual
etiologic factors are most often associated with musculoskeletal overuse or trauma. Sinister
etiologic factors are rare. The patients history and physical examination are the foundation of
evaluating a child with LBP. The indication for and timing of specific imaging or other studies
Author Affiliations: Division of
will vary depending on the etiologic factor of concern. Most treatment of LBP in this
Sports Medicine, Department of
population is centered on relative rest, rehabilitation, and identification of predisposing risk Pediatrics, Nationwide Childrens
factors. Pharmacologic treatment may be used but is typically a brief course. Orthopedic, Hospital, Columbus, Ohio
rheumatologic, and other subspecialty referrals may be considered when indicated, but most (MacDonald, Rodenberg); The Ohio
State University College of Medicine,
of these patients can be managed by a general pediatrician with a good understanding of the Columbus (MacDonald, Rodenberg);
principles described in this article. Department of Orthopedics,
Childrens Hospital Colorado,
CONCLUSIONS AND RELEVANCE Low back pain in children and adolescents is a common Orthopedic Institute, Aurora (Stuart);
University of Colorado School of
problem. It is most often nonspecific, musculoskeletal, and self-limiting. Pediatricians should Medicine, Aurora (Stuart).
recognize the importance of a proper history, physical examination, and general knowledge Corresponding Author: James
of the lumbar spine and pelvic anatomy relevant to the child in their evaluation with this MacDonald, MD, MPH, Division of
presenting symptom. Sports Medicine, Department of
Pediatrics, Nationwide Childrens
Hospital, 584 County Line Rd,
JAMA Pediatr. doi:10.1001/jamapediatrics.2016.3334 Westerville, OH 43082
Published online January 30, 2017. (james.macdonald
@nationwidechildrens.org)

L
ow back pain (LBP) in school-aged children is a common oc- previous back injury, and family history of LBP are all potential risk
currence; nevertheless, it is often underappreciated.1 The factors for school-aged children to develop LBP.9-12 Although there
prevalence of LBP rises with age: 1% at age 7 years, 6% at has been concern about a potential association of LBP and back-
age 10 years, and 18% at ages 14 to 16 years.2 By age 18 years, the packs, the evidence pointing to use of backpacks as a risk factor is
lifetime prevalence rates of LBP approach those documented in weak.9 No single risk factor for a first episode of LBP in school-aged
adults, with an estimated yearly prevalence of 20% and a lifetime children has been definitively validated (level of evidence, 1).13
prevalence of 75%.3 More than 7% of adolescents experiencing LBP Historically, it has been taught that most LBP in school-aged chil-
will seek medical attention.1 dren has an identifiable diagnosis. More recent research has chal-
The effect of LBP on this population can be considerable and lenged this thinking. A high-quality prospective study of 73 pediat-
may significantly restrict instrumental activities of daily living for this ric patients with LBP (level of evidence, 2) followed up for 2 years
population, such as attendance at school and gym or sports found that nearly 80% had no definitive diagnosis.14 Most cases of
participation.4 Low back pain in this age group is a significant risk LBP in school-aged children are nonspecific and self-limiting.15,16
factor for developing LBP as an adult.5
Several potential risk factors for developing LBP in school-
aged children have been investigated. The prevalence of LBP cor-
Discussion and Observations
relates with participation in sports and level of competition.4,6,7 There
is a U-shaped association between physical activity and the inci- Relevant Anatomy
dence of LBP in school-aged children, with both low and high levels Pediatricians need a basic but solid understanding of the anatomy
of physical activity associated with a higher risk.8,9 Female sex, of the lumbosacral spine to provide effective care to school-aged chil-
growth acceleration, adverse psychosocial factors, increasing age, dren with LBP. The lumbar spine is composed of 5 vertebrae

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Clinical Review & Education Review Musculoskeletal Low Back Pain in School-aged Children

Figure 1. Bony Anatomy of Lumbar Spine


Key Points
A L5 Spondylolysis seen on CT scan B Lateral radiograph of lumbar Question What is the most common cause of low back pain in
spine with L4 apophyseal ring
fracture school-aged children?

Findings This review discusses the causes of low back pain in


school-aged children and finds that most cases are
musculoskeletal and have a benign clinical course. Although
pediatric training has historically emphasized that low back pain in
this population is caused by specific etiologic factors, most cases
of low back pain in this age group have no identifiable pain
A generator.

A Meaning Pediatricians should be vigilant for identifiable and


B
B C serious causes of low back pain, but most presentations are
self-limiting and will respond to conservative treatment.
C

perlordotic LBP. This term is used synonymously with the terms pos-
terior overuse syndrome, mechanical LBP, or muscular LBP.7,23
A, Classic spondylolytic lesion at the left pars interarticularis of the L5 vertebra In general, when the clinician is able to identify a specific etio-
seen on computed tomography (CT) scan (arrowheads); also shown are the logic cause for LBP in school-aged children, it involves injury to the
vertebral body (A), right pars interarticularis (B), and spinous process (C). B, posterior elements of the spine, such as spondylolysis, which is much
Apophyseal ring fracture at the superior vertebral end plate of the L4 vertebra
more common than pathologic disc characteristics in this
(arrowhead) seen on lateral radiographs taken while the patient was standing;
also shown are the vertebral body (A), pars interarticularis (B), and spinous population.15,37 The remainder of this section briefly discusses the
process (C). pathophysiological features of the more common, specific diagno-
ses affecting the posterior elements of the spine; Table 115,18,20-36
and eTables 1 and 2 in the Supplement contain an in-depth discus-
(L1-L5), with an intervertebral disc between each vertebra and be- sion of other diagnoses, including herniated nucleus pulposus (HNP),
tween L5 and the sacrum. The sacrum articulates with the ilium of apophyseal ring fractures, atypical Scheuermann disease, lumbar
the pelvis at the sacroiliac (SI) joint, a diarthrodial joint with limited facet syndromes, compression fractures and transverse process frac-
motion.15 tures, SI joint dysfunction, and benign hypermobility syndrome.
The most significant components of the vertebra are the body Spondylolysis is a condition in which there is a defect in the pars
and the posterior elements, which include the pars interarticularis interarticularis of a lumbosacral vertebral body.39 There are differ-
and the spinous and transverse processes.17 The vertebrae them- ent types of spondylolyses, including congenital: in 1 series of 500
selves articulate posteriorly at the zygapophyseal facet joints. In the children, 4.4% of the study group had a pars defect at age 6 years.39
pediatric spine, the superior and inferior portions of the vertebral Isthmic spondylolysis, an acquired overuse injury of the pars inter-
body and the spinous processes are composed of physeal cartilage articularis, is the most common type among school-aged children
and are secondary ossification centers that become radiographi- with LBP who present to the pediatrician.40,41 It is often sympto-
cally apparent between ages 8 and 12 years and fuse by matic, especially in young athletes, and the incidence is higher in the
adulthood.18,19 Before that fusion occurs, these areas are more prone athletic population.37,42 The most common sites are L5 and, less of-
to injury than is the solid bone of an adult (Figure 1). ten, L4.43 Isthmic spondylolysis is often bilateral, affecting both the
The spinal nerves will bilaterally exit the foramina of the lum- right and left pars of an individual vertebral body and can be acute
bar spine below their corresponding vertebral body level. For ex- or chronic (Figure 1 and Figure 2).
ample, the L2 nerve root exits below L2 through the foramen be- Spondylolisthesis may occur with bilateral pars defects, allow-
tween L2 and L3. This anatomical feature is important to remember ing a forward translation of a vertebral body over the body subja-
in the evaluation of potential radiculopathies that may be associ- cent to it (Figure 2). Spondylolisthesis is graded, with the grade based
ated with LBP and their associated findings on neurologic exami- on the percentage of slip of the superior body over the inferior one
nation (discussed in the Evaluation section). (grade I, 0%-25%; grade II, 26%-50%; grade III, 51%-75%; grade IV,
76%-100%; and grade V, >100%, which is also known as spondy-
Differential Diagnosis and Pathophysiological FIndings loptosis). The condition is further divided into low-grade slips (grades
The differential diagnosis of LBP in school-aged children is broad and I and II) and high-grade slips (grades III, IV, and V), with high-grade
different from that seen in an adult population (Table 115,18,20-36 and slips at risk for higher degrees of pain and the presence of radicular
eTable 1 and eTable 2 in the Supplement).37 The most common cause or neurologic symptoms. Slips can progress, although this is un-
of LBP is acute or subacute musculoskeletal pain with no identifi- usual after skeletal maturity.39 Spondylolisthesis most often oc-
able pain generator.38 A tight thoracolumbar fascia results as a con- curs at the level of L5 and S1.22,44,45
sequence of rapid growth and can be compounded by existing in- Although historically adolescent idiopathic scoliosis was thought
flexibility, which results in a hyperlordosis, producing a flat midback not to be associated with higher rates of LBP, more recent studies
and thoracic kyphosis, which can lead to a syndrome known as hy- have found this not to be so and demonstrate as much as a 2-fold

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Musculoskeletal Low Back Pain in School-aged Children Review Clinical Review & Education

Table 1. Differential Diagnosis of LBP in School-Aged Children: Clinical Presentation and Potential Diagnostic Tools
Common History and
Diagnosis Defining Characteristics Examination Findings Diagnostic Tools Comments
Isthmic spondylolysis Stress fracture of the pars interarticularis Pain with extension; AP and lateral More frequent at L5 than at
often owing to repetitive loading or extension-based, twisting radiographs (sensitivity, L4; may be bilateral;
trauma athlete; positive result of 72%-78%), SPECT scan typically insidious onset;
Stork test (sensitivity, (sensitivity, 84%), MRI MRI used more frequently
50%-73%; specificity, (sensitivity, 92%), or CT for diagnosis21
17%-32%)20 scan (sensitivity, 90%)21
Spondylolisthesis Anterior slip of superior vertebrae in Pain with extension; Standing AP and lateral Grading based on slip; in
relation to inferior vertebrae positive result of Stork radiographs; repeat females, high-grade slips,
test; step-off on palpation radiographs every 3-6 and increased growth
(sensitivity, 60%-88%; mo until patient is velocity increase risk of
specificity, 87%-100%)20; skeletally mature to progressive slip
tight hamstrings determine if slip is
progressing22
Atypical Scheuermann disease Schmorl nodes, vertebral end-plate Dull, achy pain at AP and lateral NA
flattening, narrowing of disk spaces23-25 thoracolumbar junction; radiographs will show
tight thoracolumbar characteristic findings
fascia; may have flattening
of lumbar lordosis
Discogenic disease and Protrusion or rupture of a disc; may have Pain worse with flexion or MRI (sensitivity, 75%; Typically at L4 and L5 and
herniated nucleus pulposus degenerative disc disease without true Valsalva maneuver; 5% of specificity, 77%), with L5 and S1; most are
herniation school-aged children have positive predictive value centrolateral26; straight leg
leg pain without LBP26; of 84% and negative raise test has sensitivity of
35% of children have predictive value of 67%-91% and specificity
radiating sciatic pain27 64%28 26%29
Apophyseal ring fracture Fracture of the cartilaginous ring Presents similar to disc May be seen on Occurs in 28% of
apophysis herniation; positive result radiograph or CT scan school-aged children with
of straight leg raise test; but best visualized on CT disc herniations27
tight hamstrings scan30,31
Hyperlordotic back pain Increased lordosis, mechanical LBP Weak core; positive Diagnosis based on NA
Trendelenburg sign; results of clinical
increased lumbar lordosis examination as all results
with thoracic kyphosis of imaging are normal
Facet arthropathy Inflammation of the facet joints Extension-based pain or SPECT scan or CT scan NA
pain with axial loading; will show irregularities of
presents similar to the facet joints or
spondylolysis hypertrophy32
Sacroiliac pain May have a sprain or joint degeneration Pain in the medial Results of radiographs NA
buttocks and posterior are typically normal; MRI
thigh; LBP recreated with may show joint
FABER test degeneration or sacral
stress fracture33
Benign hypermobility Generalized hypermobility; often a Beighton score >4 of Results of all imaging May have instability in
diagnosis of exclusion 934,35 studies will be normal other joints (eg,
subluxation or dislocation
events)
Transitional vertebrae Inflammation of a variant in which the Nonspecific LBP; insidious Radiographs have NA
lumbar transverse process fuses with onset accuracy of 76%-84%;
the sacrum SPECT scan shows
increased uptake of
radiotracers; CT scan will
show any abnormal
anatomy32,36
Inflammatory conditions Spondyloarthropathies, including Morning stiffness >30 min, MRI of the pelvis with May have a family history
conditions positive for HLA-B27, pain that wakes child from intravenous contrast will of autoimmune conditions
enthesitis, or juvenile idiopathic arthritis sleep, alternating buttock show early inflammation
pain, pain that improves of the sacroiliac joints15
with exercise; may have
positive result on modified
Schober test
Tumors Benign (eg, osteochondroma) or Fevers, weight loss, CBC, ESR, CRP, LDH; MRI NA
malignant (eg, leukemia, lymphoma, malaise, night pain, bowel or CT scan may be
or osteosarcoma) or bladder dysfunction required15,18
Infections Discitis, vertebral osteomyelitis, Irritability, limping, fever, CBC, ESR, CRP, blood NA
epidural abscess back pain or abdominal culture; bone scan may
pain; decreased motion show early changes, but
and prefer one position an MRI is more
over another15 specific15,18
Abbreviations: AP, anteroposterior; CBC, complete blood cell count; LBP, low back pain; LDH, lactate dehydrogenase; MRI, magnetic resonance
CRP, C-reactive protein; CT, computed tomography; ESR, erythrocyte imaging; NA, not applicable; SPECT, single-photon emission computerized
sedimentation rate; FABER, Flexion-Abduction-External Rotation; tomography.

increase in LBP in school-aged children with adolescent idiopathic Pediatrician training has traditionally focused the evaluation of
scoliosis.46,47 A detailed description of scoliosis is beyond the scope LBP in children on the need to identify serious pathologic condi-
of this article. tions, such as infection or malignant neoplasms.15 Although pedia-

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Clinical Review & Education Review Musculoskeletal Low Back Pain in School-aged Children

There should be adequate exposure of the spine during the


Figure 2. Imaging of Spondylolysis and Spondylolisthesis
physical examination. It is crucial that clincians directly inspect the
A Bilateral L5 spondylolysis lesions B Severe grade 3-4 spondylolisthesis back for signs of significant modifying conditions associated with LBP,
(L5 on S1) such as deformities (eg, spondylolisthesis), rashes (eg, psoriasis), hair
tufts (eg, spina bifida occulta), or asymmetry of the spine (eg, sco-
liosis). The patient should be examined both in the coronal and sag-
ittal planes while standing, sitting, and walking.54 Abnormal spinal
alignment, scapular asymmetry, or pelvic obliquity may suggest sco-
liosis or leg length discrepancy, while a kyphotic deformity may sug-
gest atypical Scheuermann kyphosis.26 A positive Trendelenburg
sign, indicated by a downward pelvic tilt to the unaffected side, may
suggest decreased core strength or a neurologic deficit, which could
be contributing to the LBP; patients with a positive Trendelenburg
sign should have a complete hip examination to further evaluate any
underlying issues of the lower extremity.49
The clinician should palpate for tenderness over the spinous pro-
A, Uptake of technetium 99-m as seen classically on acute spondylolytic lesions
cesses, paraspinal musculature, and SI joints. Tenderness of the spi-
with single-photon emission computerized tomography imaging (yellow
arrowheads). B, High-grade spondylolisthesis (grade 3-4) at the L5 on S1 nous process may suggest fracture or ligamentous injury, while ten-
vertebrae (red arrowhead) seen on a lateral lumbar radiograph taken while the derness of the paraspinal musculature is more indicative of muscle
patient was standing. spasm but can also be nonspecific.26 Range of motion is checked in
flexion, extension, lateral bending, and rotation. Pain that is worse
tricians must be vigilant in their evaluations to exclude more seri- when the back is in extension is typically owing to involvement of
ous pathologic conditions, such as spondylodiscitis, vertebral the posterior elements (as in spondylolysis), while flexion-based pain
osteomyelitis, and neoplasm, these conditions are uncommon, and is suggestive of HNP.26,49
most school-aged children will have a mechanical, musculoskeletal A complete neurologic assessment including lower extremity
etiologic cause for their LBP.15,16,48 sensation, motor strength, and deep tendon reflexes should be in-
cluded in the examination. The reflexes of the patellar tendon (L4)
Evaluation and Achilles tendon (S1) should be elicited, and sensation in the der-
Children with LBP require a thorough clinical evaluation based on matomes of T12 and S1 and motor function of the hip flexors (L2 and
the history and physical examination. A complete history including L3), quadriceps (L3 and L4), and extensor hallucis longus (L5) should
onset, duration, frequency, location, and severity of pain, as well as be assessed.26 Patients who are unable to walk on their heels or toes
factors that alleviate or aggravate pain, should be elicited.26 Acute- and those with abnormal sensation of the medial (L4), dorsal (L5),
onset pain is typically caused by trauma, while insidious-onset pain or lateral (S1) aspect of the foot may have injury to the nerve root in
may be caused by muscular, bony, inflammatory, or biomechanical the absence of a lower-extremity injury.55 The straight leg raise and
issues.49 Pediatricians should inquire about the childs activities and slump tests can be performed for nerve root compression, and ab-
sports participation as well as how much the pain is affecting these normal Babinski or abdominal reflexes suggest a pathologic condi-
activities. Visual analog scales for pain and pediatric-oriented func- tion of the upper motor neurons.26
tional disability scales may be used to assess the degree to which Finally, the clinician should perform any indicated special tests.
LBP is affecting the childs life.50 Although clinicians should probe The stork test is performed by having the patient stand on 1 leg and
for red flags, including pain while sleeping, bowel or bladder dys- hyperextend his or her back (Figure 3A). A positive test result is in-
function, radicular symptoms, saddle paresthesia, fever, and weight dicated by re-creation of LBP and suggests spondylolysis.49 The
loss, a Cochrane Database review of LBP in patients of all ages indi- straight leg raise test is performed by passively flexing a supine pa-
cates that there is insufficient evidence regarding the diagnostic ac- tients hip with the knee extended. The test result is positive if the
curacy of these signs and symtpoms.51 Finally, clinicians should ask patient has pain radiating into the posterior thigh and knee and is
about family history of scoliosis, autoimmune conditions, and ma- typically positive in those with HNP.15 The slump test is slightly less
lignant neoplasms. specific but more sensitive than the straight leg test in adults with
Four questions have been shown to correlate with an inflam- HNP.56 This test is performed with a seated patient rounding the back
matory cause of LBP in patients younger than 45 years with symp- while flexing the head forward. The examiner passively extends the
toms that have lasted longer than 3 months: knee with the foot flexed; the test result is positive if the patient ex-
1. Does back stiffness in the morning last more than 30 minutes? periences radicular pain. The Flexion-Abduction-External Rotation
2. Does back pain awaken you during the second half of the night? (FABER) test, which suggests a pathologic condition of the SI joint
3. Does the pain alternate from one buttock to the other? if the patient develops SI pain, is performed by passively placing the
4. Does pain improve with exercise but not with rest? supine patients leg into a figure-4 position while gently pressing on
When a patient with prolonged symptoms answers 2 of the 4 the knee and the opposite anterior iliac crest; the test result is posi-
questions positively, the sensitivity and specificity for an inflamma- tive if the patient experiences pain in the contralateral SI joint to the
tory etiologic cause reach 70% and 81%, respectively. When an- knee in the figure-4 position.15 The modified Schober test is per-
swers to 3 of 4 questions are positive, the sensitivity drops to 33% formed by making marks 10 cm proximal and 5 cm distal to the pos-
while specificity approaches 100%.52,53 terior superior iliac spine on a patient who is standing. The patient

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Musculoskeletal Low Back Pain in School-aged Children Review Clinical Review & Education

flexes forward at the hips with the knees extended and the marks process.19 Laboratories may include tests for antinuclear antibody,
are remeasured: a distance less than 21 cm suggests a spondyloar- rheumatoid factor, and HLA-B27, but these tests should be or-
thropathic condition, although this test may have a positive result dered cautiously and are most helpful when a rheumatologist is con-
in other disorders in which a patient has limited forward flexion (eg, firming a suspected autoimmune diagnosis, as up to 20% of the gen-
HNP).15 Evaluation of overall mobility can be assessed with the Beigh- eral population may have positive results for antinuclear antibody.59
ton criteria, with a score of 5 or higher suggestive of global joint As there are a variety of etiologic causes of LBP in children, there
hypermobility.34 Although all these examination maneuvers may be are notable specific history, examination findings, and imaging re-
performed on any patient with LBP, they are specifically indicated sults that are suggestive of certain conditions (Table 115,18,20-36 and
on the basis of suspected diagnoses (Table 115,18,20-36 and eTable 2 eTable 2 in the Supplement).
in the Supplement).
Anteroposterior and lateral radiography should be considered in Treatment
children with LBP, especially if pain has been present for more than 3 The specifics of treatment for individual etiologic causes of LBP can
weeks.7 The lateral view should be performed while the patient is vary widely (eTable 1 in the Supplement). This section discusses gen-
standing, as a spondylolisthesis may not be revealed on a recumbent eral principles the pediatrician should keep in mind when caring for
examination. Owing to increased radiation with little increase in di- this population.
agnostic utility, oblique radiography is best avoided.18 If results of ra- The foundations of treatment are accurate diagnosis when pos-
diography are nonrevealing, advanced imaging may be considered. sible and an understanding of the nuances of the spinal anatomy of
Single-photon emission computerized tomography scan, computed children, who are skeletally immature. Most school-aged children
tomography, and magnetic resonance imaging have had changing
roles in the workup of pediatric patients with LBP. Although single- Figure 3. Stork Test and Thoracolumbar Spinal Orthosis
photon emission computed tomography scans are useful for identi-
fying subtle bony injuries, especially in the acute setting, they con- A Stork test performed on the right leg B Rigid thoracolumbar spinal orthosis
tain a nuclear isotope (technetium-99) and expose organs throughout
the body to higher doses of radiation than any other types of imaging
studies.21 Resultsofcomputedtomographycanprovideexquisitebony
and cartilage detail, but it also exposes patients bone marrow and co-
lon to higher doses of radiation than do radiography or magnetic reso-
nance imaging.15,21,57 Although computed tomography and single-
photon emission computed tomography scans can be excellent
diagnostic tools, increased concerns with radiation, especially in pe-
diatric patients, have led to decreased use in recent years.18,21 Mag-
netic resonance imaging, which has typically been used in the evalu-
ation of soft-tissue pathologic conditions, is also now used more
frequently for evaluation of bony pathologic conditions21 (Table 2).
Although there is good literature regarding the sensitivity and speci-
ficity of computed tomography and magnetic resonance imaging for
common conditions, such as spondylolysis and HNP, there is little pub-
lished about the diagnostic accuracy of advanced imaging tools for less
A, Stork test is performed if a clinician suspects a spondylolysis. It is performed
common causes of pediatric LBP.21,57,58 with the patient standing on 1 leg with the clinician guiding the patients lumbar
A complete blood cell count and tests for erythrocyte sedimen- spine in extension. A positive test result is one that reproduces the patients
tation rate and C-reactive protein level may be indicated if there is pain. B, Rigid thoracolumbar spinal orthosis, a type of brace sometimes used in
the treatment of spondylolysis.
high suspicion for an inflammatory, infectious, or malignant

Table 2. Principal Diagnostic Imaging Tools Available and Considerations for Use

Imaging Modality Best Use Advantages Disadvantages


Radiographs Fractures, including Low cost, fast, Radiation; high false-negative
spondylolysis and fractures of readily available rates for many causes of back pain
the spinous process and
transverse process
CT scan Apophyseal ring fracture; bony Fast; specific for Radiation
pathologic features, including bony pathologic
any suspected fractures features
Bone scan or SPECT scan Bony pathologic features, Highly specific for Radiation; injections (pain);
including suspected fractures bony pathologic nuclear medicine imaging
features provides physiological
information but poor anatomical
detail
MRI with intravenous Disc pathologic conditions, No radiation; Costly; time consuming; potential Abbreviations: CT, computed
contrast indicated if masses, ligamentous and detailed soft-tissue need for sedation in younger tomography; MRI, magnetic
inflammatory condition soft-tissue pathologic findings children resonance imaging; SPECT,
suspected conditions; pain associated with single-photon emission
neurologic symptoms computerized tomography.

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Clinical Review & Education Review Musculoskeletal Low Back Pain in School-aged Children

present with nonspecific and self-limiting symptoms and will re- assessing the use of muscle relaxants in nonspecific LBP found they
spond to conservative treatment, including relative rest from of- are effective in the treatment of pain, but clinicians must take care
fending activities causing pain and often some form of physical in prescribing these medications owing to their associated central
therapy.7,14-16 Several rehabilitation programs have been described nervous system adverse effects, including drowsiness and
for children with LBP based on specific diagnoses, but, to our knowl- dizziness.65 Systemic glucocorticoid treatment may provide par-
edge, there is little evidence in the literature supporting their use. tial pain relief for select patients with acute lumbosacral radiculopa-
These rehabilitative programs tend to be empirically driven.24 Re- thy, but existing evidence suggests that systemic glucocorticoid
habilitation is a multifactorial process and relies first on the treat- therapy has limited or no benefit.66
ment of the effects of the acute injury, including losses in mobility Consultation may be considered by the pediatrician in the un-
and function, as well as recognition of any deficits in biomechanical common instance that a patients LBP is not responsive to conser-
function leading to alterations in technique or performance of a spe- vative treatment. Surgery and other invasive interventions are rare
cific activity that could promote injury (eg, the proper mechanics of treatments for the conditions described in this article. Surgical re-
throwing a baseball).24,60 pair of the pars is infrequently used for a painful nonunion of a spon-
Rehabilitation progresses through specific stages that initially dylolytic lesion that has failed to respond to conservative therapy
focus on preserving and promoting range of motion and strength. for a year.67 Watchful waiting of the asymptomatic child with a high-
Hip flexibility is crucial and promoted by emphasizing exercises to grade spondylolisthesis is safe and does not lead to complications.68
stretch the hip flexors and hamstrings.61 Strength and motion re- Surgical fusion may be indicated in individual patients with a high-
covery is coupled with proprioceptive training, which then leads to grade spondylolisthesis who have persistent radicular or neuro-
correcting deficits noted in the kinetic chain, motion patterns, and logic symptoms.67 Conservative treatment is less effective in pedi-
neuromuscular control.60 A mainstay of therapy is core stabiliza- atric vs adult HNP, but it is still first-line treatment owing to fear of
tion, which refers to improving neuromuscular control, strength, and the skeletally immature pediatric spine being more vulnerable to sur-
endurance of the muscles central to maintaining dynamic spinal and gical trauma and iatrogenic deformity.69 Long-term success with con-
trunk stability. These muscle groups include the abdominals, lum- servative care is estimated at 25% to 50% for HNP without neuro-
bar multifidi, and erector spinae, as well as other paraspinal, pelvic, logic deficits.69 Occasionally, pediatric patients with musculoskeletal
and cervicothoracic musculature.60,61 The literature is unclear as to LBP will have no identifiable etiologic cause but will have persis-
which exercises are best to rehabilitate the core musculature.61 tent, recalcitrant, high levels of pain; consultation with rheumatol-
Therapy for issues such as spondylolysis (associated with pain on ogy and pain specialists may be considered if the clinician suspects
back extension) traditionally revolves around a flexion-based therapy amplified musculoskeletal pain.15
program (Williams flexionbased therapy program), whereas con-
ditions such as HNP (associated with pain on back flexion) are treated Prevention
with an extension-based therapy program (McKenzie extension Skeletally immature individuals are more vulnerable to trauma and
based therapy program).61,62 Last, the patient focuses on a func- explosive muscle contractions, especially during periods of rapid
tional progression aimed at correcting biomechanics and activity- growth.41 Preventive programs aimed at improving age-associated
specific techniques, which allows for a controlled and pain-free deficits in flexibility have been used to reduce injury, but no causal
progression back to activity (sport, play, or work) or activities of daily relationship between flexibility and risk of injury has been docu-
living.60 Any program must be reinforced with a home exercise rou- mented, to our knowledge.7,41 More evidence exists to support pre-
tine that the patient performs during therapy and then as mainte- season sports conditioning programs and neuromuscular training in
nance after its completion. It is the clinicians challenge to motivate reducing injury rates.41 Children should begin strength and condi-
the pediatric patient to adhere to this home exercise routine. tioning programs several weeks before the start of a sport season,
Bracing can be used in the treatment of LBP and includes soft allowing for gradual increases in frequency and intensity of training.7
lumbar corsets as well as rigid braces, such as thoracolumbar spinal Appropriate rest from training and specific repetitive motions (eg,
orthoses (Figure 3B). One of the major controversies noted in the tumbling in gymnastics) allows for proper recovery.7,41 Most back in-
care of school-aged children diagnosed with acute spondylolysis is juries, and overuse injuries in general, can be avoided if the pedia-
whether to use thoracolumbar spinal orthoses or other rigid trician keeps a simple, evidence-based rule of thumb in mind: young
bracing.43 The current evidence does not support the use of rigid athletes should not participate in more hours of sports in a week than
bracing in spondylolysis: a meta-analysis revealed that most pa- their number of age in years.70 Finally, LBP lingering longer than 2
tients have a successful clinical outcome with conservative treat- to 3 weeks in this population is not normal; if persistent, the child
ment (83.9% treatment success rate) regardless of bracing or no should be evaluated by a pediatrician.7
bracing (level of evidence, 4).40 Some clinicians will use rigid brac-
ing or soft lumbar corsets to provide analgesia by further restrict-
ing any extension activity in patients not responding to rest alone,
Conclusions
although there is no evidence to support this use of bracing.63
To our knowledge, there are no specific evidence-based stud- Lowbackpainiscommoninschool-agedchildrenandiscausedbyava-
ies examining oral medication in the treatment of LBP in school- riety of individual conditions, most of which are of a benign, musculo-
aged children. Most populations studied are adults or do not specify skeletalorigin.Specificsoftheevaluation,workup,andtreatmentofLBP
an age. A Cochrane review revealed that nonsteroidal anti- in this population will vary with the specific underlying cause. Ongoing
inflammatory drugs are effective for short-term symptomatic pain research is needed to establish evidence-based best practices for the
relief for both acute and chronic LBP.64 Another Cochrane review treatment of many of the diagnoses discussed in this review.

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Musculoskeletal Low Back Pain in School-aged Children Review Clinical Review & Education

ARTICLE INFORMATION 12. Balagu F, Skovron ML, Nordin M, Dutoit G, Pol nerve root compression. Arch Phys Med Rehabil.
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Author Contributions: Dr MacDonald had full episode of low back pain in children are
access to all the data in the study and takes 31. Kumar TV R, Rao R, Gadi D, Grover A. Lumbar
infrequently validated across samples and apophyseal ring fracturea case report. J Clin Diagn
responsibility for the integrity of the data and the conditions: a systematic review. J Physiother. 2010;
accuracy of the data analysis. Res. 2015;9(5):RD01-RD02.
56(4):237-244.
Study concept and design: MacDonald, Rodenberg. 32. Trout AT, Sharp SE, Anton CG, Gelfand MJ,
Acquisition, analysis, or interpretation of data: 14. Bhatia NN, Chow G, Timon SJ, Watts HG. Mehlman CT. Spondylolysis and beyond: value of
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Drafting of the manuscript: All authors. back pain: a prospective study. J Pediatr Orthop. and young adults. Radiographics. 2015;35(3):819-834.
Critical revision of the manuscript for important 2008;28(2):230-233.
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Administrative, technical, or material support: All evaluation of low back pain in children and
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Study supervision: MacDonald. criteria for general joint hypermobility and benign
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Conflict of Interest Disclosures: None reported. back pain in children and adolescents. J Am Acad reproducible and valid tests? a review of the
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illustrated in Figure 3 for granting permission to 17. Denis F. The three column spine and its 35. Fabry G. Clinical practice: the spine from birth
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