ONLINE EXCLUSIVE Shawn F. Phillips, MD, MSPT; Jessica Favero Butts, MD; Low back pain in youth: Matthew Silvis, MD Department of Family and Community Medicine, Penn Recognizing red flags State College of Medicine and Penn State Health Milton S. Hershey Medical Center, Although low back pain in children and teens is usually Hershey benign, recognizing red flags that indicate the need for sphillips6@pennstatehealth. imaging, referral, bracing, or surgery is critical. psu.edu. The authors reported no potential conflict of interest relevant to this article. doi: 10.12788/jfp.0076 ow back pain in not uncommon in children and ado- PRACTICE lescents.1-3 Although the prevalence of low back pain in RECOMMENDATIONS children < 7 years is low, it increases with age, with stud- ❯ Be aware that low back pain L ies reporting lifetime prevalence at age 12 years between 16% is rare in children < 7 years and 18% and rates as high as 66% by 16 years of age.4,5 Although but increases in incidence as children near adolescence. A children and adolescents usually have pain that is transient and benign without a defined cause, structural causes of low ❯ Consider imaging in the back pain should be considered in school-aged children with setting of bony tenderness, pain that persists for > 3 to 6 weeks. 4 The most common struc- pain that awakens the patient from sleep, or in tural causes of adolescent low back pain are reviewed here. the presence of other “red flag” symptoms. A Etiology: A mixed bag Back pain in school-aged children is most commonly due to ❯ Consider spondylolysis muscular strain, overuse, or poor posture. The pain is often and spondylolisthesis in adolescent athletes with low transient in nature and responds to rest and postural educa- 4,6 back pain lasting longer tion. A herniated disc is an uncommon finding in younger than 3 to 6 weeks. A school-aged children, but incidence increases slightly among older adolescents, particularly those who are active in collision Strength of recommendation (SOR) sports and/or weight-lifting.7,8 Pain caused by a herniated disc A Good-quality patient-oriented evidence often radiates along the distribution of the sciatic nerve and B Inconsistent or limited-quality worsens during lumbar flexion. patient-oriented evidence ❚ Spondylolysis and spondylolisthesis are important C Consensus, usual practice, opinion, disease-oriented causes of back pain in children. Spondylolysis is defined as evidence, case series a defect or abnormality of the pars interarticularis and sur- rounding lamina and pedicle. Spondylolisthesis, which is less common, is defined as the translation or “slippage” of one ver- tebral segment in relation to the next caudal segment. These conditions commonly occur as a result of repetitive stress. In a prospective study of adolescents < 19 years with low back pain for > 2 weeks, the prevalence of spondylolysis was 39.7%.9 Adolescent athletes with symptomatic low back pain are more likely to have spondylolysis than nonathletes (32% vs 2%, respectively).2,10 Pain is often made worse by extension of the spine. Spondylolysis and spondylolisthesis can be con- genital or acquired, and both can be asymptomatic. Children MDEDGE.COM/FAMILYMEDICINE VOL 69, NO 8 | OCTOBER 2020 | THE JOURNAL OF FAMILY PRACTICE E1 and teens who are athletes are at higher risk but must always be considered, especially in for symptomatic spondylolysis and spondy- the setting of persistent symptoms.4,19-21 More lolisthesis.10-12 This is especially true for those on the features of these conditions is listed in involved in gymnastics, dance, football, and/ TABLE 1.1-7,13-15,17-30 or volleyball, where a repetitive load is placed onto an extended spine. History: Focus on onset, ❚ Idiopathic scoliosis is an abnormal timing, and duration of symptoms lateral curvature of the spine that usually de- As with adults, obtaining a history that in- velops during adolescence and worsens with cludes the onset, timing, and duration of growth. Historically, painful scoliosis was symptoms is key in the evaluation of low back considered rare, but more recently research- pain in children, as is obtaining a history of ers determined that children with scoliosis the patient’s activities; sports that repetitively have a higher rate of pain compared to their load the lumbar spine in an extended posi- peers.13,14 School-aged children with scoliosis tion increase the risk of injury.10 were found to be at 2 times the risk of low back Specific risk factors for low back pain in pain compared to those without scoliosis.13 It children and adolescents are poorly under- is important to identify scoliosis in adoles- stood.4,9,31 Pain can be associated with trauma, cents so that progression can be monitored. or it can have a more progressive or insidious Screening for scoliosis in primary care is onset. Generally, pain that is present for up Hyperextension somewhat controversial. The US Preventive to 6 weeks and is intermittent or improving in a single- Services Task Force (USPSTF) finds insuffi- has a self-limited course. Pain that persists leg stance, cient evidence for screening asymptomatic beyond 3 to 6 weeks or is worsening is more commonly adolescents for scoliosis.15 This recommen- likely to have an anatomical cause that needs known as the dation is based on the fact that there is little further evaluation.2,3,10,21 Stork test, is evidence on the effect of screening on long- ❚ Identifying exacerbating and allevi- positive for term outcomes. Screening may also lead to ating factors can provide useful information. unilateral unnecessary radiation. Conversely, a position Pain that is worse with lumbar flexion is more spondylolysis statement released by the Scoliosis Research likely to come from muscular strain or disc when it Society, the Pediatric Orthopedic Society of pathology. Pain with extension is more likely reproduces pain North America, the American Association due to a structural cause such as spondyloly- on the ipsilateral of Orthopedic Surgeons, and the American sis/spondylolisthesis, scoliosis, or Scheuer- side. Academy of Pediatrics recommends scolio- mann disease.2,4,10,17,18,21 See TABLE 2 for red sis screening during routine pediatric office flag symptoms that indicate the need for im- visits.16 Screening for girls is recommended aging and further work-up. at ages 10 and 12 years, and for boys, once between ages 13 and 14 years. The statement The physical exam: Visualize, assess highlights evidence showing that focused range of motion, and reproduce pain screening by appropriate personnel has val- The physical examination of any patient with ue in detecting a clinically significant curve low back pain should include direct visual- (> 20°). ization and inspection of the back, spine, and ❚ Scheuermann disease is a rare cause pelvis; palpation of the spine and paraspinal of back pain in children that usually develops regions; assessment of lumbar range of mo- during adolescence and results in increasing tion and of the lumbar nerve roots, including thoracic kyphosis. An autosomal dominant tests of sensation, strength, and deep tendon mutation plays a role in this disease of the reflexes; and an evaluation of the patient’s growth cartilage endplate; repetitive strain posture, which can provide clues to underly- on the growth cartilage is also a contributing ing causes of pain. factor.17,18 An atypical variant manifests with Increased thoracic kyphosis that is not kyphosis in the thoracolumbar region.17 reversible is concerning for Scheuermann ❚ Other causes of low back pain—in- disease.9,17,18 A significant elevation in one cluding inflammatory arthritis, infection shoulder or side of the pelvis can be indica- (eg, discitis), and tumor—are rare in children tive of scoliosis. Increased lumbar lordosis E2 THE JOURNAL OF FAMILY PRACTICE | OCTOBER 2020 | VOL 69, NO 8 LOW BACK PAIN IN YOUTH TABLE 1 Common causes of low back pain in children and adolescents Condition Definition Prevalence Treatment Mechanical low back pain1,4 Low back pain that does Most common form of Treatment is generally not always have a clear low back pain in children conservative. Relative rest anatomical cause. Often and adolescents. Increases from activities that increase associated with muscle strain, in prevalence with age. pain. Physical therapy may be overuse, or poor posture Reported prevalence is 16%- indicated if pain is persistent 66%4,5 Adolescent idiopathic An abnormal lateral Reported prevalence of Little evidence exists to scoliosis13-15,28-30 curvature of the spine that scoliosis is 2%-4%. Prevalence guide treatment of back usually develops during of pain associated with pain associated with scoliosis. adolescence and worsens scoliosis ranges from 34.7%- Treatment similar to that for with growth 42%28 nonspecific mechanical low back pain is reasonable in patients with curvature < 20°. Limited evidence shows benefit for physical therapy and bracing in preventing progression of curvature. Referral to Pediatric Orthopedics is indicated for Cobb angle ≥ 20°. Cobb angle 10-19° can be monitored by the family physician with repeat imaging every 6-12 months Spondylolysis and Spondylolysis is a defect of Prevalence of spondylolysis is Relative rest from activity is spondyolysthesis2,3,24-27 the pars interarticularis and 39.7%.6 Adolescent athletes recommended for 4-6 weeks. surrounding lamina and with symptomatic low Rehabilitation with range- pedicle. Spondylolisthesis back pain are more likely of-motion (especially into is translation or “slippage” to have spondylolysis than lumbar extension) and spinal of one vertebral segment in nonathletes (32% vs 2%, stabilization exercises have relation to the next caudal respectively)7 been shown to be effective segment. It is a result of treatments to both reduce pain repetitive stress with the and restore functional range spine moving into extension of motion and strength.22,23 Use of heavy backpacks should be avoided Scheuermann disease17,18 Increased thoracic kyphosis Reported prevalence is 2.8%17 Avoid repetitive loading of due to autosomal dominant the spine including overhead mutation affecting collagen weight-lifting and sports such matrix leading to disease as football and gymnastics.