DISORDERS OF THE PEDIATRIC AND ADOLESCENT SPINE
Back Pain in Children
Howard A. King, MDPage: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11
A child who has immediate relief of pain (including night pain) with use of nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin may have an osteoid osteoma. Patients with back pain and other joint symptoms relieved by NSAIDs may have ankylosing spondylitis or juvenile rheumatoid arthritis.
It is important to ask specifically about changes in bowel and bladder habits. Patients and their families may be embarrassed to discuss issues of bedwetting or incontinence and may not volunteer that information unless specifically asked.
It is critical to ask about changes in balance and coordination. These symptoms may be quite subtle, and therefore the question must be carefully asked and interpreted. Mild changes in gait and loss of previous motor skills suggest subtle neurologic changes.
It is also critical to inquire about similar symptoms in other family members or role models. Children can mimic the symptoms of their parents, grandparents, siblings, and friends. Conversion and psychosomatic conditions are a diagnosis of exclusion but must be considered. Families may not be aware of the similarity in conditions unless these concerns are specifically addressed. It cannot be overstressed that the diagnosis of psychosomatic disease must be a diagnosis of exclusion.
Numerous other medical problems can initially present as back pain. It is important to note such symptoms as weight loss, fever, chills, lethargy, skin rashes, infections, and rheurnatologic conditions can initially present with back pain as the primary complaint.
PHYSICAL EXAMINATION
The physical examination should be done in a comfortable, well-lighted space. The patient should be clothed only in underpants and a hospital gown. Cavus feet, calf atrophy, andother subtle findings might indicate significant neurologic problems and would be completely overlooked if the patient were allowed to leave shoes and socks in place.
The initial step should be a thorough orthopedic screening examination, including review of the head, neck, upper and lower limbs, and gait pattern. Gait changes of spasticity, ataxia, and instability definitely suggest a neurologic problem and indicate a neurology consultation and evaluation. The spine evaluation should start with a general review of trunk balance, alignment, posture, and cutaneous skin patterns. Any skin or midline defect, such as a hair patch, hemangioma, or cyst, should be considered to communicate with the underlying neurologic structures until completely ruled out.