Emergency Department Management of Dangerous Back Pain in Children -
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Publication Date: April 2023 (Volume 20, Number 4)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 04/01/2026.

Authors

William C. Sokoloff, MD, MSEd

Assistant Professor, Department of Pediatrics, Albert Einstein College of Medicine/Children‘s Hospital at Montefiore, Bronx, NY

Matthew P. Kusulas, MD, MSEd

Assistant Professor, Departments of Pediatrics and Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY

Peer Reviewers

Mary Jane Piroutek, MD

Associate Clinical Professor, Department of Emergency Medicine, University of California, Irvine; Fellowship Program Director Pediatric Emergency Medicine, Department of Pediatric Emergency Medicine, Children’s Hospital of Orange County, Orange, CA

Winnie T. Whitaker, MD

Division Director, Pediatric Emergency Medicine, Dell Children’s Medical Center of Central Texas, US Acute Care Solutions, Austin, TX; Associate Professor, Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX

Abstract

Back pain in the pediatric population remains an unusual and concerning complaint that may be an indicator of serious underlying pathology. This issue reviews rare but dangerous etiologies of pediatric back pain and highlights signs and symptoms that may raise a red flag for potentially dangerous etiologies of back pain among children and teens. The evaluation of these patients, including judicious and effective imaging recommendations, is also discussed. A data-driven algorithm for evaluating patients can save the majority of patients from the expense and anxiety of unnecessary testing while effectively identifying the most appropriate means (and locations) for working up pathologic pediatric back pain.

Case Presentations

CASE 1

A 5-year-old boy with back pain is brought into the ED by his mother after picking him up from school…

From the boy’s description, the pain started acutely, was vaguely localized to the lower lumbar and sacral areas, and has since resolved completely.
The boy’s vital signs are: temperature 37.2°C; heart rate, 112 beats/min; blood pressure, 104/66 mm Hg; respiratory rate, 20 breaths/min; and oxygen saturation, 100%.
How should you proceed in managing this patient?

CASE 2

A 14-year-old girl presents with worsening back pain for several weeks...

The girl is a competitive gymnast and is concerned that the pain may interfere with an upcoming competition. She denies any recent trauma and localizes the pain to her lower back. She says the pain is worse during practice and also toward the end of her school day.
The girl’s vital signs are: temperature, 36.7°C; heart rate, 70 beats/min; blood pressure, 108/62 mm Hg; respiratory rate, 14 breaths/min; and oxygen saturation, 100%.
What is on your differential for the cause of this young athlete’s pain?

CASE 3

A 7-year-old boy who is being treated for constipation is referred by his pediatrician for 2 weeks of persistent waxing and waning lower back pain...

The pain is in the lumbar region and improves with ibuprofen. For the last 2 days though, the pain has worsened, and the boy‘s pediatrician reported that he was limping in her office.
The boy’s vital signs are: temperature, 36.9°C; heart rate, 124 beats/min; blood pressure, 110/74 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 98%.
What other questions about the history might further raise your concern for a dangerous pathology?

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