1. • RECENT STUDIES- >50% children experience
some back pain by 15yrs of age

2. HISTORY
NATURE OF PAIN
• ACUTE- #S,LIGAMENTOUS SPRAIN,
DISC HERNIATIONS,SLIPPED VERTEBRAL
APOPHYSIS. WITHIN 24HRS
• SLOW-ONSET-TUMORS,SCHEUERMANN’S
KYPHOSIS
• MILD PAIN FOLLOWING ACTIVITY-MUSCLE
STRAIN
• RECURRENT PAIN
SPONDYLOLYSIS,SPONDYLOLISTHESIS,HERNIATED
DISC
• PERSISTENT,NIGHT PAIN-TUMOURS, INFECTIONS

3. • LOCALISED PAIN-
SPONDYLOLYSIS/NEOPLASMS
• GENERALISED,DIFFUSE PAIN-
INFLAMMATORY PROCESSES
• PAIN RADIATING TO LOWER LIMB-
VERTEBRAL APOPHYSIS #,EPIDURAL
ABSCESS,HERNIATED LUMBAR DISC,
INTRASPINAL TUMOUR

4. CONSTITUTIONAL SYMPTOMS
• MALIGNANCY-fever, chills, malaise, anorexia,
weight loss
• DISCITIS- antecedent bacterial or viral
infections
Neurological symptoms-numbness,weakness,
gait abnormalities

5. AGGRAVATING AND ALLEVIATING
FACTORS
-Sport activities-increase risk of spondylolysis,
spondylolisthesis
-Pain –worse at night maybe due to malignancy
-Back pain due to osteoid osteoma-relieved by
NSAIDs
-Rest usually alleviates pain
in most cases

6. AGE-RELATED CONDITIONS
<4yrs –infection,neoplasms
<10yrs- discitis , vertebral osteomyelitis
>10yrs-spondylolysis,spondylolisthesis, disc
herniation
• Teenagers-Scheuermann’s kyphosis
• Tumors such as osteoid osteoma and
aneurysmal bone cysts

7. PSYCHOSOMATIC PAIN
• Maybe seen in Preadolescents or adolescents
• diagnosis by exclusion

8. ASSESSMENT OF GENERAL
SYMPTOMS
• GENERAL INSPECTION
Neurocutaneous markers assoc with
intraspinal defects-midline skin defects
Can communicate with underlying deeper
structures- indicate spinal cord
abnormality or dysraphism

9. ASSESSMENT OF THE SPINE
• POSTURE, ALIGNMENT
• SCOLIOSIS
• SPINAL FLEXIBILITY ASSESSED- stiffness,
listing,dysrhythmia indicates pathological
cause
• STRAIGHT LEG RAISING TEST-r/o herniated
discs, apophyseal #
• Hyper extending the spine while child stands
on one leg- spondyolysis, spondylolosthesis

10. NEUROLOGIC ASSESSMENT
Spinal cord anomaly- clonus or
abnormal Babinski sign or
abnormal abdominal reflex

11. DIAGNOSTIC STUDIES
• RADIOGRAPHY
VERTICAL ALIGNMENT
DISC SPACE NARROWING
VERTEBRAL SCALLOPING
LYTIC OR BLASTIC LESIONS
LATERAL VIEW- PARS INTERARTICULARIS DEFECT

12. • BONE SCAN
sensitive in infections, stress #, benign and
malignant neoplasms
• COMPUTED TOMOGRAPHY
bone tumours, and fractures to assess
spondylitic lesions in lumbar spine
• SINGLE-PHOTON EMISSION CT-localizing spinal lesions,
diagnosing spondylosis,stress #
• MAGNETIC RESONANCE IMAGING-
evalute spinal cord and neural elements

13. LABORATORY TESTS
• COMPLETE BLOOD COUNT
• ESR
• C-REACTIVE PROTEIN
• URINALYSIS

14. MECHANICAL DISORDERS
• MUSCLE STRAIN- adolescent athelete,
no radiation on pain,
neurologic findings normal
Treatment-modification of
activity, application of ice
first then cold, NSAIDs

15. • APOPHYSEAL RING FRACTURE/SLIPPED
VERTEBRAL APOPHYSIS-
-posteroinferior apophysis avulses
from vertebral body,displaced into spinal cord
-Presents with sudden onset back pain
-Treatment-surgical removal of bony fragment
with attached cartilage and disc

16. DEVELOPMENT
DISORDERS
• SPONDYLOLYSIS –defect in pars interarticularis,
caused by repetitive microtrauma
• SPONDYLOLISTHESIS-pars defect b/l at same
level,fwd slippage or subluxation of upper
vertebral segment on the one below.

17. •Caused by repititive hyperextension
•Mild to mod severity-radiates to lower limb
•Postural defects,shuffling,stiff legged gait

18. • Xray-lytic lesions pars interarticularis
Scotty dog sign
• MRI detects early spondylolysis
• Treatment-modify patients activities,
If a/c # TLSO can relieve pain
-Surgery is indicated for slips
>50% translation

19. SCHEUERMANN’S KYPHOSIS
• Anterior wedging of 3consecutive vertebrae
→kyphotic deformity
• Intravertebral herniation of disc material
(Schmorl’s nodules) seen
• Localised pain, more on sitting and standing
• O/E- thoracic kyphosis ,hamstring tightness
• Xray-thoracic kyphosis >50degrees
• Treatment-extension exercise,Milwaukee brace
surgical intervention-spinal fusion

21. LUMBAR SCHEUERMANN’S DISEASE
• Similar to Scheuermann’s kyphosis
• Involves thoracolumbar spine
• Xray –end plate irregularities,disc space
changes,Schmorl’s nodules
• Orthosis- decreases pain

22. IDIOPATHIC SCOLIOSIS
• Painful left thoracic curves –
indicate pathology
SYRINGOMYELIA
Cavitation of spinal cord.
c/o headache,neckpain,cavus foot, abnl
gait,painful thoracic scoliosis

23. TETHERED SPINAL CORD
• Low back pain, recent onset scoliosis, ↓motor function
• Bladder dysfunction, Babinski’s sign
• MRI
• Treatment-cord release
IDIOPATHIC JUVENILE OSTEOPOROSIS
Long bone pain due to
compression #s,
difficulty walking

24. VERTEBRAL OSTEOMYELITIS
• Osteomyelitis a continuation of discitis
• Two disorders converge- infectious spondylitis
• More significant bony change
ANKYLOSING SPONDYLITIS
Males, Adolescence
Loss of spinal flexibility, abnl
kyphosis,limited chest expansion during sleep
inspiration
MRI-inflamed sacro-iliac joint

25. • EOSINOPHILIC GRANULOMA
Seen in 10-15%
Xray -lytic lesions
D/D leukemia,infectious processes
• ANEURYSMAL BONE CYST
15-20%
Treated by-curettage, bone grafting

26. MALIGNANCIES
• A/C LYMPHOCYTIC LEUKEMIA
Common malignancy producing back pain
X ray-osteopenia,vertebral body compression,
metaphyseal leukemic lines
Lab investigations- ↑WBC count, ↓platelet
count ,anemia, ↑ESR

27. • SPINAL TUMOURS-Ewings sarcoma, osteogenic
sarcoma, chondroma
CT/MRI-staging tumour
• SPINAL METASTASES- neuroblastoma
• SPINAL CORD TUMORS- astrocytomas,
ependymomas

28. INTRAABDOMINAL AND
INTRATHORACIC CAUSES
OF BACK PAIN
• Inflammatory bowel d/s,
hydronephrosis, UTI,ovarian cysts
• More constant pain,worse at night
• Pneumonia-thoracic back pain

29. PSYCHOSOMATIC BACK
PAIN
(CONVERSION REACTION)
• Diagnosis is one of exclusion,
• Made only after all other possibilities ruled
out
• Detailed history to be take

30. THANK YOU