Evaluating and Treating Pediatric Lower Back Pain in the Primary Care Setting

Primary care pediatricians are often taught that lower back pain in school-aged children has a definitive cause. As a recent review published in JAMA Pediatrics highlights, studies conducted over the last decade have challenged that idea.

A full evaluation of a patient with low back pain is still necessary to exclude serious pathologies, says James P. MacDonald, MD, MPH, a physician in the Sports Medicine Program at Nationwide Children’s and lead author of the publication. Once those pathologies are ruled out, though, the specific causes still may not be apparent.

For the majority of children presenting with low back pain, a primary care doctor can provide appropriate evaluation and management.

“It is important for physicians to have a firm understanding of the relevant spinal anatomy and the etiological factors of low back pain in children and adolescents,” says Dr. MacDonald, who is also an associate professor of Pediatrics and Family Medicine at The Ohio State University College of Medicine.

“While some lower back pain needs to be treated by a specialist, most pediatricians who have a good understanding of the principles outlined in our article can help children and adolescents prevent and manage lower back pain. Most pain with no specific cause responds to rest, rehabilitation and identification of predisposing risk factors.”

The publication includes a list of conditions and symptoms that can be used in the differential diagnosis. Generally, when an etiology can be identified, it is associated with an injury to the posterior spine, such as spondylolysis or spondylolisthesis. The review also includes an evaluation guide. In brief:

• Take a complete history of the pain
• Inquire about activities, sports participation and how pain is affecting those activities
• Probe for red flags, such as pain while sleeping, bowel or bladder dysfunction, radicular symptoms, saddle paresthesia, fever and weight loss
• Ask about family history of scoliosis, autoimmune conditions and malignant neoplasms
• Ask certain questions that have been shown to correlate with an inflammatory cause of pain in some patients, such as “Does pain improve with exercise but not with rest?”
• Directly inspect the back for deformities, rashes, hair tufts or asymmetry of the spine
• Palpate certain areas for tenderness
• Check range of motion in flexion, extension, lateral bending and rotation
• Assess lower extremity sensation, motor strength and deep tendon reflexes
• Perform indicated special tests, which may include the stork test, the straight leg raise and the slump test (as discussed in the article)
• Consider imaging, especially if pain is present for longer than three weeks

Because children and adolescent musculoskeletal systems are still developing, they are at an increased risk for trauma and explosive muscle contractions, especially during periods of rapid growth. Previous studies suggest the importance of pre-season sports conditioning programs and neuromuscular training that will allow the athlete to gradually increase his or her training intensity and help reduce injuries, according to Dr. MacDonald.

Additionally, rest should be incorporated into the training regimen, especially for athletes who perform repetitive motions, such as tumbling in gymnastics. Young athletes should not participate in more hours of sports in a week than their number of age in years.

Reference:

MacDonald J, Stuart E, Rodenberg R. Musculoskeletal low back pain in school-aged children: A review. JAMA Pediatrics. 2017 Jan 30. [Epub ahead of print]