Back Pain in the Pediatric ED

7/30/2019 Back Pain in the Pediatric ED

1/43

Back PaiResident PEM Lec

May 24, Brad Sobolewsk


2/43

The case

4 y/o male with abdominal and lower back pain for 3 weeks t

in pain at day care

PMHx of seasonal allergies

No trauma or prior history of pain like this

Intermittent fevers for 3 weeks - 101-103F, not daily

Seen by PMD 2 weeks ago, Dx w/ constipation and started on M


3/43

The case

Decreased PO for 2 days

Difficulty walking up stairs and picking things up off of the groun

Denies fatigue or weight loss

Tylenol helps (somewhat)

No respiratory, urinary or GI symptoms


4/43

He walkslike an old

man


5/43

Physical exam

General: alert, NAD, well appearing

HEENT: normal

Respiratory: normal

Cardiovascular: normal pulses and perfusion, no mur


6/43

Physical exam

Gastrointestinal: abdomen soft, nontender, nondiste

positive bowel sounds, no organomegaly, normal rect

Lymph: Bilateral inguinal lymphadenopathy

Genitourinary: normal external genitalia

Skin: no rashes


7/43

Physical exam

Neuro: sensation normal , normal reflexes, mildly ant

GCS=15, normal muscle strength

Spine: normal curvature, no point tenderness over sphe points to posterior hips as site of pain


8/43

In summary

4 year old male with 3 weeks of intermittent fand low back pain who walks like an old man

What would you like to do?


9/43

Back pain in children

Scandinavian study of 29,000 children

7% of 12 year olds experienced low back pain 50% have had back pain by age 20

Associations Female gender, increased TV time, negative aff

scores, family Hx

Leboeuf-Yde C; Kyvik KO Spine 199


10/43

Point prevalence of low back pain, individuals aged 12 to 4

Leboeuf-Yde C; Kyvik KO Spine 199


11/43

Epidemiology

Presenting complaint in 0.4% of ED visit

90% pain for


12/43

50%

9%

13%

13%

6%

Muscular

Infection

Idiopathic

Sickle Cel

Miscellane


13/43

Overloaded school

backpacks can causeback pain

Weight >15 percent of the

child's weight

AAP recommends


14/43

Red flags

Young age (before puberty)

Fever

Acute trauma

Weight loss

Constant or nighttime pain


15/43

Red flags

Sciatica

Repetitive microtrauma, especially lumbar hyperexte

History of malignancy or TB exposure

Bowel or bladder symptoms

Abnormal neurological examination


16/43


17/43

Location

Nerve root - brief; sharp and shooting, increased by s

better supine

Severe, constant back pain, persisting at night, sugge

neoplasm, infection, or nerve root compression

Sciatica suggests herniated disc usually stops at th

Pain radiating below the knee true radiculopathy


18/43

Concerning signs for spinal patho

Postural shift of the trunk

Neurologic abnormality

Limitation of motion


19/43

Neuro exam pearls

Reflexes Knee L3-4, Posterior Tibialis L5, Ankle S1

Cant rise from squatting? Proximal muscles

Gastrocnemius strength (S1) rising up on the toes

Ankle dorsiflexion weakness L4 or L5 nerve root


20/43

Neuro exam pearls

Sciatic pain may be increased by testing foot dorsifle

the knee extended - stretches the S1 or L5 root

Great toe extensor weakness is indicative of L5 nervinvolvement

Gluteus maximus weakness (S1) may cause buttock

Gluteus medius weakness (L5) may cause a lurchingwaddling (Trendelenburg) gait


21/43

Straight leg raise

Detects nerve root impingement by herniated discs

Supine, uninvolved foot on table w/ knee at 45 degr

Raise effected side w/ ankle at 90 degrees

In adults sens 80% spec 40% (LOTS OF FALSE POSIT

Likely due to hamstring tightness


22/43

Flex/Ex

Pain in flexion tumor,spondylolisthesis,herniation, discitis

Pain w/ extension

suggests spondylolysis


23/43

Musculoskeletal causes

Fractures

Nonspecific sprains/strains

Spondylolysis Inherited or repetitive microtrauma (lumbar hyperextens Aching low back pain exaggerated by extension

Spondylolisthesis From bilateral spondylolysis


24/43

Hold on a second,spondylowhatzit? Listhesis

Im confused by lots of lett


25/43

Anatomy review


26/43

Oblique scottie dog

Pars interarticularis

Located between the inferior and

superior articular processes of the

facet joint

In the transverse plane, it liesbetween the lamina and pedicle


27/43

Spondylolysis

Defect in the pars interarticularis

Most common in L5

Stress fractures

6% of population

Most common cause ofspondylolisthesis in children


28/43

Spondylolisthesis

Anterior displacement of a vertebrain relation to the vertebrae below

Due to a pedicle fracture


29/43


30/43

Musculoskeletal

Scoliosis

Musculoskeletal pain is more common in patiescoliosis

One cohort of 2000 patients had 23% with painpresentation

Disc disease

Degenerative most common in L4-5, L5-S1 Very rare less than age 10


31/43

Musculoskeletal

Scheuermann kyphosis (juvenile

kyphosis) anterior wedging of 5

degrees or greater in atleast three adjacentvertebral bodies, asmeasured on lateral spineradiographs

Onset in adolescence Inherited and common


32/43

Infectious

Discitis

Vertebral osteomyelitis

Epidural abscess

Paraspinal abscess

Pyelonephritis

Pneumonia

PID

Endocarditis

Viral illness induced


33/43

Inflammatory

Includes

ankylosing spondylitis, psoriatic arthritis, arthritis of inflabowel disease, and reactive arthritis

Symptoms

Morning stiffness & SI joint pain

HLAB-27 is common, but most back pain in HLAB-27

patients is not from sacroilitis


34/43

Neoplastic

Constant pain, nocturnal pain, and duration of pain le

three months associated with tumors

#1 is osteoid osteoma benign, nocturnal pain reliev

NSAIDs - Can lead to scoliosis

Leukemia, lymphoma, Ewing sarcoma, neuroblastom

osteoblastoma, osteosarcoma, neurofibroma, and Lacell histiocytosis


35/43

MiscellaneousSickle cell pain crisis

Syringomyelia

Cholecystitis

Pancreatitis

Ectopic pregnancy

Chronic pain syndromes 10-15% of Rheumatology referrals

Most are adolescents, isolated back pain uncommon


36/43

Labs

Inflammatory or infection?

CBC, Blood culture, ESR, CRP, urine studies


37/43

Radiography

Plain films

congenital or acquired pathology Usually include AP and lateral only Oblique view for pars (spondylolysis)

MRI Test of choice for evolving neurologic changes omalignancy

nonbony spinal tumors, discitis, and sacroiliac inflammation


38/43


39/43

Osteoid osteoma


40/43

Children with a short duration of sympto

preceding trauma of the back, a clear

musculoskeletal precipitant, normal neu

examination, and an otherwise benign

appearance can be managed conservatwithout laboratory or radiologic testing

B k h


41/43

Back to the case

In the ED we obtained CBC, B/C, U/A, U/C, ESR, and

Abdominal and Spine XRays both normal

S 34L 55M 8E 3

13

385248.2

ESR 66

CRP 0.7

Renal, Cal, Mag, Pho

B k t th


42/43

Back to the case

We consulted Ortho andRadiology and obtained

an MRI of the spine

L5-S1 discitis and S1

vertebral osteomyelitis

F ll


43/43

Follow up

Admitted to General Pediatrics with Ortho and ID con

Dx of Osteomyelitis/discitis

Remained afebrile in hospital. ID consulted and recotreating with Clindamycin for 6 weeks via PICC

Ibuprofen, with Tylenol #3 for breakthrough pain

Weekly CBC with diff and CRP

Documents

Back Pain in the Pediatric ED