RIME - Back Pain Marc Benayoun, MSIII March 7, 2011 History Intake Basic history Onset of pain- abrupt or gradual; associate history How long the pain persists and getting better or worse? Location of pain Does pain interfere with sports or normal activity? Aggravating and relieving symptoms Stiffness in the back in the mornings or after rest? Age of patient (worrisome if patient is prepubescent and especially if younger than school age) Associate history Recent Traumatic Injury? Associated fever? Unintentional Weight Loss? Bowel or bladder symptoms? (Indicating a neurologic component to the back pain) TB exposure? Recent or rapid increase in exercise intensity (without proper conditioning can lead to “Overuse” Syndrome) Physical Exam Examine how the child sits, stands, and walks for abnormalities Look for differences in shoulder height, scapular prominence, pelvic symmetry (can suggest scoliosis or leg length discrepancy) Midline skin lesions, such as dimples near the base of the spine or hair patches (indicative of spinal lesions) Look for café au lait spots (NF1) Do a full neuro exam to look for gait abnormalities (such as Trendelenberg gait), muscle fasciculations or atrophy, toe walking, and straight-leg-raising test), muscle weakness in the distribution of a peripheral neuropathy or radiculopathy, and check DTR’s Palpate for points of tenderness along the spine Check for full ROM in lower spine Causes Traumatic Injury (muscle strain, ligament strain) Musculoskeletal (Spondylolysis, Spondylolisthesis, Scoliosis, Disc Degeneration, Juvenile Kyphosis, Poor Posture) Infectious (Discitis, Osteomyelitis, Pott’s Disease, Sacroiliac Joint Infection. Pylenephritis, PID, viral Myalgia, or Endocarditis) Inflammatory (Ankylosing Spondylitis, Psoriatic Arthritis, IBD Arthritis, Reactive Arthritis) Neoplastic (Osteoid Osteoma, Leukemia or Lymphoma, Ewing’s Sarcoma, osteosarcoma) Neurologic (Disc Herniation, Epidural Abscess) Differential Diagnosis and Management Causes S&S Treatment Muscle Strain Recent Trauma, Poor posture, “Overuse” Syndrome Poor posture, muscle spasm, pain Ibuprofen, ice Fracture Recent Trauma such as automobile or bicycle accident Juvenile Kyphosis Poor posture or congenital Pain, numbness, tingling, or weakness, loss of bladder or bowel control Refer to orthopaedics Round back from kyphosis of thoracic spine NSAIDS and Other Infectious Inflammatory Neoplastic Neurologic Back pain, fever, weight loss, joint pain, depends on etiology All idiopathic back pain should compress, and rest, with gradual reintroduction of exercise www.uptodate.com , pedsinreview who may recommend surgical correction, percutaneous vertebroplasty, or back brace or plaster cast along with NSAIDS or muscle relaxants exercise, surgery may be warranted for severe symptoms or kyphosis greater than 75 degrees warrant a CBC, ESR, UA, and A/P and lateral spine X-rays. Other tests to consider are HLA B27, Rheumatoid Factor, ANA, oblique X-ray films, CT, electromyography, or radionuclide scanning