Originally published at Pediatric EM Morsels on March 1, 2014. Reposted with permission.

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The Ped EM Morsels often address common complaints that can be misconstrued as benign, but with vigilance subtle presentations of ominous conditions can be discerned. Those of us who take care of adults also know all too well the complaint of Back Pain and are comfortable looking for the Red Flags of serious etiologies of that complaint. Back pain in the pediatric ED is definitely not as prevalent as the adult ED, but actually warrants some additional concern.

Pediatric Back Pain – An adult problem in a little person?

The incidence of back pain increases with age. Teenagers are the most likely pediatric age group to have back pain… and it is most often similar to adult back pain (musculoskeletal). The younger children (essentially anyone less than a teenager) requires some more vigilance.

One orthopedic clinic study showed that, while the younger aged children represented only a small percentage of all of the back pain visits (< 2%), ~50% of them had serious etiologies of their pain. (understanding this was subject to a significant selection bias… it is still drives home the point that young kids and back pain can be a ominous thing.

of them had serious etiologies of their pain. (understanding this was subject to a significant selection bias… it is still drives home the point that young kids and back pain can be a ominous thing. Certainly, little kids can have musculoskeletal back pain too (particularly if they’ve had trauma or have scoliosis), but let’s actively look for signs of more ominous etiologies.

Historic Hints that point toward “badness”

Constitutional symptoms – Naturally evoke concerns for malignancies (lymphomas, leukemias) or infections (discitis, osteomyelitis, Pott Disease, pyelonephritis). Fever Night Sweats Malaise Weight Loss

(lymphomas, leukemias) or (discitis, osteomyelitis, Pott Disease, pyelonephritis). Easy Bruising and/or Bleeding

Bone Pain in other locations

Back Pain worse at night or that awakens child at night – Osteoid Osteoma is known to lead to severe back pain worse at night!

Neurologic abnormalities Bowel or bladder issues? LE weakness or numbness?

Pain that does not abate or is not improved with NSAIDs and typical symptomatic care

Constant Pain (not just with activity)

Physical Exam Findings that should be actively investigated

Thorough Neurologic Exam Certainly, this applies to all patients of all ages with back pain! Pretend you are a medical student trying to do every neuro test you can think of. Assessing someone’s gait is very helpful though… is there a foot drop? Also, a school-aged kid who refuses to walk is concerning! Consider diskitis high on the list of badness.

Inspect the Spine Scoliosis and Kyphosis often gets missed initially and can start becoming a issue before it is very apparent. Yes, officially, these would be musculoskeletal issues, but they can have profound ramifications if not picked up on early. Make note of any asymmetry. Are the shoulders even? Are the tips or the scapula at the same point? Have the patient bend forward to help accentuate curvatures and asymmetries. Is there a lack of spinal mobility? – Ankylosing Spondylitis leads to loss of lumbar flexibility on forward bend also.

Palpate the Spine Step-offs? Focal Midline Tenderness? Subtle spinal curvature?

Inspect the Skin Petechiae? Purpura? Pallor? – all would raise concern for malignancy. Hairy patches over lower lumbar region or sacral dimples – may indicate a neural tube defect. Cafe au lait spots – neurofibromatosis may be the culprit.

Don’t forget the rest of the body! Is there Hepatosplenomegaly ? Is there significant Lymphadenopathy ? Is there Marfanoid features?



So, like so many other complaints in the Pediatric ED, it is important to not jump to conclusions. Grandma can diagnose a back strain. Our job is to think about possible cancer or infection or other badness. That doesn’t mean everyone gets an MRI. No. But they all deserve our constant vigilance and consideration of badness.