Monday, December 7, 2009

Back pain in children - not so straightforward

Fourth day of the Pediatrics ward. I submitted the clinical vignettes and wrote my previous blog post.
Today we had many interesting cases; we had a classic croup case, and I emphasized about the evidence based approach to croup, the demonstrated lack of effectivity of cool mist, and the classic JAMA study comparing low and high humidity with cool mist. The patient did very well with racemic epinephrine alone. We decided not to treat ourselves with cool mist.

We discussed a patient discharged over the weekend that was admitted with low back pain. A toddler with back pain should be approached in a very careful way. Fortunately for the pleasant kid, the pain lasted a few hours and faded away. However, we did asked the parents about all the potential red flags which are nicely summarized in this excellent article from Archives of Diseases in Childhood: Education and Practice:

History:
Pre-pubertal children especially < 5years
Functional disability
Duration > 4 weeks
Recurrent or worsening pain
Early morning stiffness and/or gelling
Night pain
Fever, weight loss, malaise
Postural changes: kyphosis or scoliosis
Limp or altered gait

Examination:
Fever, tachycardia
Weight loss, bruising, lymphadenopathy or abdominal mass
Altered spine shape or mobility
Vertebral or intervertebral tenderness
Limp or altered gait
Neurologic symptoms
Bladder or bowel dysfunction


Fortunately the child essentially didn't met any of the criteria. His personal history was negative for any suggestion of uveitis (red eye, ocular pain, photophobia), inflammatory arthritis, rash, micrognathia, limping; his growth was normal, he was afebrile, his exam was unremarkable with no spinal or paraspinal tenderness and with normal range of motion of all joints.

The patient did well after a single dose of ibuprofen and his acute phase reactants were mildly elevated. Before his admission he had a CT of the lumbosacral spine in the ED which were both unremarkable. A hip X-ray was done to r/o referred hip pain and was normal. An abdominal ultrasound was unrevealing with no nephrolithiasis or hydronephrosis, as well as no psoas abscess. Back pain can be elicited by multiple extraaxial causes such as retrocecal appendix, nephrolithiasis, psoas abscess, hip arthritis, etc.

His lack of cervical spine involvement essentially ruled out a Juvenile Rheumatoid arthritis (JRA), but he as well didn't have the manifestations suggestive of it; the CT scan ruled out spondylosis and spondylolisthesis, bone tumors as well as intervertebral disk pathology such as disk herniation or diskitis (and although an MRI would have been a better image it was not warranted given the rapid improvement of the symptoms). The lack of fever and systemic symptoms was reassuring as well against an inflammatory or infectious process. His gait was normal, with no urinary or fecal incontinence and his neurologic exam was nonfocal.
In addition, the family history was negative for any rheumatologic or autoimmune disease.

The patient was admitted the night before and essentially we arrived to see a healthy appearing child that had a transient low back pain but whom was extensively worked-up in a different institution Emergency room and who was happy, playful and with a complete unremarkable examination.

The parents were satisfied with the questionnaire we asked and the explanation for the rationale of the questions. They were reassured of the lack of any data suggestive of a significant life threatening condition, but as always, encouraged to follow up with their Primary Care Pediatrician.

This case provided an excellent teaching opportunity to review causes of back pain in childhood. I taught the Pediatric residents about the fact that low back pain is a very frequent complaint in adults (perhaps the most frequent in the outpatient setting) and that we are facing a difficult struggle to avoid a lot of unnecessary MRI imaging (that patients demand with the belief that the cause of the pain will be easily found). However, most MRI's are unnecessary as the most common cause of back pain is musculoskeletal. This is an excellent review on back pain at the Cleveland Clinic Journal of Medicine.

The Pediatrics residents became more aware of the interrogation to elicit signs and symptoms of JRA, as well as to think "outside of the box" with all the different extraspinal etiologies. It was fascinating to have the opportunity to revisit this subject once again and to ensure an safe health delivery.

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