Low back pain in children and adolescents, while largely ignored previously, has become an area of increased interest of late. Back pain in adolescents is most prevalent between ages 13 and 15 and can vary between 7-58%, and affects males and females equally. Most common causes of back pain in young people are: increasing age, increased height, family history, increased physical activity and competitive sport, psychological distress, smoking, manual work, and carrying a heavy backpack
Spondylolysis and Spondylolisthesis:
Spondylolysis is a stress or fatigue fracture in part of a vertebra, in the lower lumbar spine. Spondylolisthesis refers to a fracture in both sides of the vertebra, which means that the vertebra above slips forwards on the one below – see the diagram below. Together, these two pathologies are the most common serious causes of back pain in children over age 10.
These injuries are more common in boys and those engaged in sports that involve repetitive extension, flexion and rotation, for example ballet or gymnastics. Diagnosis is made through imaging, with plain films and CT scanning the most commonly utilized and most reliable. Treatment generally begins with rest and avoidance of aggravating activities and can also include non-steroidal anti-inflammatory medication, bracing and manual therapy which may be physiotherapy or chiropractic, which emphasizes hamstring stretching and core strengthening, which may help and is worth trying for a few treatments (4 – 6). Surgery is reserved only for patients who do not respond to conservative management.
Lumbar Intervertebral Disc Prolapse:
Lumbar disc prolapse is exceedingly rare in children and adolescents, with less than 10% of children with low back pain having a prolapsed disc. Disc injuries in children also present clinically in a very different manner than adults, with 30-60% of childhood disc injuries resulting from trauma or sport-related injury. Most children with disc prolapsed experience tightness of the low back muscles and the hamstrings, with minimal back pain and often no associated sciatica (which is, of course, common in adult patients). Scoliosis – see image below in the upper lumbar area often accompanies this injury.
Adolescents do not respond as well to non-surgical treatment as adults, which may be due to the often traumatic mechanisms of injury and respond well to surgical correction once the disc is actually prolapsed.
Fracture along the edge of the vertabra:
The junction between the top and bottom of a vertebra between the vertebra and the disc is relatively weak in adolescence. As a result, trauma can cause prolapse of the disc and fracture or fragmentation of the vertebra growth area. Symptoms tend to mimic those of adolescent disc injury and occur more often in males (ratio is 2:1). Diagnosis is generally made through x-ray or scanning. Non-operative treatment is often sufficient such as rest, pain control and appropriate manual therapy such as chiropractic and rehabilitation).
Scheuermann’s disease is the most common cause of hyperkyphosis, which is too much forward curve in adolescents, occurring in between 1-8% of the adolescent population.
The deformity occurs most frequently in the thoracic spine, but can also present between the thoracic and lumbar spine. Diagnosis is often delayed, as the kyphosis itself is often attributed to poor posture – such as slumping over a lap top. Scheuermann’s disease presents as a dull, non-radiating pain around the peak curve of the deformity, with local tenderness. The increased kyphosis is often accompanied by increased neck and low back forward curves, which can also contribute to symptoms. Diagnosis is confirmed via c-rays. The following findings are indicative of Scheuermann’s:
Kyphosis exceeding 45 degrees (normal range is 20-45 degrees)
Anterior wedging of at least 5 degrees of three adjacent segments
Irregularities of vertebral end plates +/- loss of disc height
Occasional protrusion of disc material into vertebral body (Schmorl’s nodes)
Treatment traditionally consists of anti-inflammatory medication and physiotherapy, including strengthening exercises. Bracing is an option for skeletally immature patients with severe or progressive curves, but the type of brace to utilize and overall efficacy remains controversial. Surgery is reserved for extreme cases where skeletally mature patients exhibit a curve of greater than 70 degrees with pain and concerns about appearance.
Idiopathic scoliosis affects 1-3% of children and adolescents and can be seen if you ask your child to bend forwards.
Often the shoulders are of different heights, a flank crease, prominence of the ribs, and back pain, although the latter is not present in all cases. A recent retrospective study of over 2000 patients found that only 23% of patients with idiopathic scoliosis had back pain on presentation and an additional 9% developed it during the study period.
Intervertebral discs in children have a greater blood supply than in adults which accounts for the higher rate of inflammation in discs in adolescence. Other common infectious causes of back pain in children include tuberculous osteomyelitis, epidural abscess and sacroiliac joint infections.
Ankylosing Spondylitis (AS) is the most common of the inflammatory diseases involving the spine, occurring in 0.2-1.2% of the Caucasian population. Its initial symptoms can be noted in adolescence and early adulthood, such as dull pain over the lower back and buttocks and morning stiffness eased by exercise and worsened with inactivity. If a child does not respond to manual therapy and shows the above symptoms, we need to refer them on to a specialist rheumatologist. AS usually responds well to non-steroidal anti-inflammatories (NSAIDs).
These are rare in children but we would refer on any children or adolescents do not respond to manual therapy, rest, exercise for further investigation.