Dangerous Back Pain in Children: Evaluation and Management in the ED

Emergency Department Management of Dangerous Back Pain in Children

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Table of Contents

About This Issue

Evaluating back pain in children can be challenging. Red-flag signs and symptoms identified on a thorough history and physical examination can help guide the decision of which patients should undergo imaging or laboratory evaluations. This issue reviews rare but dangerous etiologies of pediatric back pain, highlights potential red-flag signs and symptoms, and provides recommendations for evaluating and managing children with undifferentiated back pain in the emergency department. In this issue, you will learn:

Common causes of pathologic back pain in children, including musculoskeletal/structural, infectious, oncologic, and rheumatologic etiologies

Red-flag signs and symptoms that should raise suspicion for pathologic back pain

Maneuvers to evaluate the spine and help localize underlying pathology

Which patients require imaging and/or laboratory studies

Recommendations for managing patients with pathologic back pain, as well as those without red-flag signs or symptoms

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
    1. Nonspecific Versus Pathological Back Pain
    2. Anatomy
  7. Differential Diagnosis
    1. Musculoskeletal/Structural Etiologies
    2. Infectious Etiologies
    3. Oncological Etiologies
    4. Rheumatologic Etiologies
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. Red-Flag Risk Factors
    2. Focused History
    3. Focused Physical Examination
  10. Diagnostic Studies
    1. Radiographs
    2. Magnetic Resonance Imaging
    3. Computed Tomography
    4. Bone Scan With Single-Photon Emission Computerized Tomography
    5. Laboratory Studies
  11. Treatment
  12. Special Populations
    1. Athletes
    2. Remote-Learning Students
  13. Controversies
  14. Disposition
  15. 5 Things That Will Change Your Practice
  16. Risk Management Pitfalls for Pediatric Patients With Back Pain
  17. Summary
  18. Time- and Cost-Effective Strategies
  19. Case Conclusions
  20. Clinical Pathway for Imaging of the Otherwise Healthy Child or Adolescent With Back Pain
  21. Tables and Figures
  22. References


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

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?
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?
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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Clinical Pathway for Imaging of the Otherwise Healthy Child or Adolescent With Back Pain

Clinical Pathway for Imaging of the Otherwise Healthy Child or Adolescent With Back Pain

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Tables and Figures

Table 2. Red Flags for Dangerous Pediatric Back Pain
Table 1. Limited, Systems-Based Differential Diagnosis for Pediatric Back Pain
Table 3. Physical Examination Maneuvers for Evaluating Pediatric Back Pain
Figure 1. Anterior and Posterior Spinal Columns
Figure 2. Acute Fracture of the Pars Interarticularis

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

17. * Brooks TM, Friedman LM, Silvis RM, et al. Back pain in a pediatric emergency department: etiology and evaluation. Pediatr Emerg Care. 2018;34(1):e1-e6. (Retrospective review; 177 patients) DOI: 10.1097/PEC.0000000000000798

18. * Bhatia NN, Chow G, Timon SJ, et al. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop. 2008;28(2):230-233. (Prospective intervention; 73 patients) DOI: 10.1097/BPO.0b013e3181651bc8

19. * Biagiarelli FS, Piga S, Reale A, et al. Management of children presenting with low back pain to emergency department. Am J Emerg Med. 2019;37(4):672-679. (Retrospective cohort; 148 patients) DOI: 10.1016/j.ajem.2018.07.012

20. * Feldman DS, Straight JJ, Badra MI, et al. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop. 2006;26(3):353-357. (Prospective intervention; 87 patients) DOI: 10.1097/01.bpo.0000214928.25809.f9

25. * Ramirez N, Flynn JM, Hill BW, et al. Evaluation of a systematic approach to pediatric back pain: the utility of magnetic resonance imaging. J Pediatr Orthop. 2015;35(1):28-32. (Prospective interventional; 261 patients) DOI: 10.1097/BPO.0000000000000190

27. * Nitta A, Sakai T, Goda Y, et al. Prevalence of symptomatic lumbar spondylolysis in pediatric patients. Orthopedics. 2016;39(3):e434-e437. (Prospective observational; 136 patients) DOI: 10.3928/01477447-20160404-07

39. * Afshari FT, Rodrigues D, Bhat M, et al. Paediatric spondylodiscitis: a 10-year single institution experience in management and clinical outcomes. Childs Nerv Syst. 2020;36(5):1049-1054. (Retrospective review; 21 patients) DOI: 10.1007/s00381-019-04470-z

56. * Burgos-Vargas R. The juvenile-onset spondyloarthritides. Rheum Dis Clin North Am. 2002;28(3):531-560 (Review) DOI: 10.1016/s0889-857x(02)00033-9

67. * Expert Panel on Pediatric Imaging, Booth TN, Iyer RS, et al. ACR Appropriateness Criteria® Back Pain-Child. J Am Coll Radiol. 2017;14(5S):S13-S24. (Consensus statement) DOI: 10.1016/j.jacr.2017.01.039

68. Radiologyinfo.org. Radiation dose to adults from common imaging examinations. 2022; Accessed March 1, 2023. (Educational media)

73. Wu W, Miller E, Hurteau-Miller J, et al. Development and validation of a fast spine protocol for use in paediatric patientsResearch Square (Preprint). 23 Aug 2022. (Retrospective review; 105 patients)

91. Villalpando N, Austin American-Statesman. Kids learning about back pain from doing school virtually. 2021; Accessed March 1, 2023. (News article)

92. Stenson J, NBC News. Remote learning can be a pain for kids in more ways than one. 2020; Accessed March 1, 2023. (News article)

93. Duarte-Ladd D, amNY. Here are some expert tips on COVID back soreness and pain in kids. 2020; Accessed March 1, 2023. (News article)

Subscribe to get the full list of 98 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.


Publication Information

William C. Sokoloff, MD, MSEd; Matthew P. Kusulas, MD, MSEd

Peer Reviewed By

Mary Jane Piroutek, MD; Winnie T. Whitaker, MD

Publication Date

April 1, 2023

CME Expiration Date

April 1, 2026    CME Information

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.

Pub Med ID: 36961241

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