Back pain in Children, Teens and Oldies

Different age groups have different causes for their sore back.

CHILDREN
Back pain in children is uncommon before age 8 years and should be investigated with a view to excluding infection, tumour or fracture.

Psychogenic back pain, back pain for which there is no cause and which is associated with abnormal family dynamics may require the help of a psychologist or psychiatrist.

Unexplained low back pain in children with negative investigations is not common. Management is by reassurance, judicious follow up and limited medicalization. Most will settle.

TUMOURS IN CHILDREN AND ADOLESCENTS

These are rare but may include osteoid osteoma and osteoblastoma. Referral to a Paediatric Orthopaedic Spinal or Paediatric Neurosurgeon is indicated. We can advise you.


ADOLESCENTS

Back pain in adolescents is common and not usually serious. Often we don’t find a cause. There may be psychological overlay. It is important to exclude serious conditions such as fracture, tumour and infection but in half of the cases no obvious cause will be found.

Scheuermann’s disease (adolescent osteochondritis of the spine). A condition of the growing thoracic and lumbar spine, more common in males, and associated with radiological (Xray) changes including wedging of more than 5° and Schmorl’s nodes (indentations of the end-plates). May produce spinal deformity (kyphosis). If progressive deformity occurs may need brace treatment or rarely surgery. Extension exercises and hamstring stretching can be useful. To be distinguished from adolescent round back which is a postural deformity only (can be voluntarily corrected) and without radiological changes.

Spondylolisthesis – a slipping forwards of one vertebra on another. Most commonly occurring at the level of the lowest disc, L5/S1, due to a defect (spondylolysis) in the bone at the back of the spine between the two joints (the pars interarticularis). Although frequently said to be congenital it is virtually never present at birth but becomes increasingly frequent in late childhood and adolescence, reaching 6% in adults. It is more common in persons with spina bifida occulta. There is a higher incidence in bowlers (cricket) and gymnasts. Most commonly thought to represent a stress fracture if diagnosed at an early stage it can heal (although this may require stopping sport for several months and/or using a brace).
Diagnosis and management may require the full range of imaging including radionuclide (Technetium) bone scanning – to diagnose an early stress fracture and to assess healing, CT scan with reverse angle imaging to assess healing and MRI scan to exclude other causes of back pain.

Occasionally surgery is required – either to bring about healing of the spondylolysis, to stabilize the spine by fusing the transverse processes to the sacrum, or to fuse the disc (usually only in adulthood). Rarely in childhood forms of the disease the degree of slip is severe requiring more complex procedures with anterior fusions (through the abdomen) and at times the whole bone is removed (Gaines procedure). See Surgery

Many patients with back pain due to spondylolysis or spondylolisthesis will settle with correction of sporting technique, limitation of activity and strengthening and stretching exercises (especially tight hamstrings).

THE ELDERLY

Back pain in the elderly can be difficult to diagnose and manage because of associated degeneration and osteoporosis. It is uncommon to treat older patients with fusion for back pain except for degenerative spondylolisthesis and less commonly degenerative scoliosis. Bracing can be helpful.