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Causes of Back Pain

Back pain in children is more common than previously thought and is frequently mechanical with contributory factors such as poor posture, physical inactivity, overweight, or abnormal loading (such as carrying heavy school bags on one shoulder).

Back pain in children is more likely to have pathology identified, compared to adults where mechanical back pain is very common. It is important to consider and exclude red flag conditions which include infection (abscess) and malignancy. Prolapsed intervertebral disc in young people does occur but is more likely in adolescents.

Certain sporting activities such as cricket, bowling or gymnastics pose increased risk of back pain, due to spondylolysis and spondylolisthesis which arise due to congenital abnormality of the vertebral arch (spondylolysis) and if bilateral, then instability results with forward slip of one vertebra over another (spondylolisthesis) potential root or cord compression. The clinical presentation can be acute, or acute on chronic pain, with pain on spine extension ("Stork's test - see pREMS spine) and also with localised tenderness.

The figure below shows spondylolysis (due to an abnormality in the neural arch) and if bilateral can result in forward slip of one vertebra over the other (spondylolisthesis) - the latter seen on an oblique radiograph with 'break in the neck of the scottie dog' - see below.

Scheuermann’s 'disease' results from vertebral wedging due to an osteochondosis of the thoracic spine and may or may not be symptomatic (i.e. may be a coincidental finding on radiograph), although it can result in thoracic kyphosis, and in which case warrants referral to orthopaedics.

Scoliosis can result from a variety of causes. However scoliosis - rarely causes back pain and if it does, then this is a 'red flag' and urgent referral (orthopaedics) is warranted. 

The radiograph below shows severe thoracolumbar scoliosis

Inflammatory back pain occurs in adolescents. It is unusual in isolation as a feature of Juvenile Idiopathic Arthritis (Enthesitis Related Arthritis or psoriatic arthritis) but can occur in association with inflammatory bowel disease. Symptoms are similar to adults with morning stiffness, tenderness over the sacroiliac joints and limited forward flexion.

The photograph below shows an adolescent who has Crohn's disease. He has restriction of both hips and lower back with severe sacroiliitis and hip disease on radiographs. 

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