MIAMI — Pediatric back pain is rarely serious unless it persists or impairs daily functioning, Dr. Harry L. Shufflebarger said, and most cases of postural roundback are not of grave concern and will resolve over time, despite some significant parental anxiety.
Trunk asymmetry, or scoliosis, is managed according to severity, he said at a pediatric update sponsored by Miami Children's Hospital.
Avoid labeling pediatric patients with the “S word” until a definitive diagnosis is made, said Dr. Shufflebarger, chief of the division of spinal surgery at the hospital.
Back pain is common among pediatric patients. Approximately 10% of children under 10 years will complain of back pain, and about 50% of adolescents.
Approximately 80%–90% will have no identifiable organic etiology for their pain, even after an extensive work-up, he said. “In the absence of stiffness, loss of appetite, energy change, apathy, or obvious illness, back pain is unlikely to be anything significant.”
However, if back pain persists more than 3 months, it warrants further evaluation. Also be concerned if the pain is tied to a deformity, if it is rated significant by the patient or parent, if it wakes a patient at night, and/or if it interferes with function during school or social activities.
If an x-ray is negative, Dr. Shufflebarger suggested a second image with either a 3-phase technetium scan or a single-photo emission computed tomography scan.
A postural or asthenic roundback—also called a “hunchback”—is a frequent parental complaint, Dr. Shufflebarger said. “The best treatment is reassurance of parents that this is not a structural problem of the back and most children will outgrow it.”
A prone, voluntary hyperextension test can differentiate postural from structural kyphosis. An inability to flatten the thoracic kyphosis might point to structural kyphosis or Scheuermann's kyphosis, Dr. Shufflebarger said. More severe kyphosis curvature, 50 degrees or more, might require bracing or surgery, he added.
Scoliosis is a general term for multiple etiologies. It can be idiopathic, congenital, neuromuscular, or other (such as neurofibromatosis). Clinicians can assess trunk asymmetry with the Adams forward bend test and/or a scoliometer and radiographs. If the bend test is positive, order a spinal x-ray, Dr. Shufflebarger said. “But radiology reports are not always reliable, so review the images.”
Scoliosis is confirmed with an erect radiograph that shows a curve greater than 10 degrees and when the scoliometer test shows trunk asymmetry over 5 degrees.
Idiopathic scoliosis can be juvenile onset (4–10 years) or adolescent (over 10 years). About 3%–4% of seventh graders will test positive on school screening, with 1%–2% having true scoliosis.
Most children and adolescents referred to a specialist for further evaluation can wait, but some should not, Dr. Shufflebarger said. Risk of progression is the primary concern with idiopathic scoliosis in children. Patients with more growth potential are at higher risk of quick progression, including children at a Tanner stage less than 3, those who are premenarche, and children with open triradiate cartilages. A more expeditious consult with a specialist might be warranted if the angle of trunk rotation is greater than 10–12 degrees, he added.
The gender distribution of small curves (less than 20 degrees) will be 2:1 girls to boys.
Observation, bracing, and surgery are the scoliosis management options. Observation is generally recommended for curves less than 25 degrees. With these, a specialist should repeat an x-ray in 3–4 months to monitor for any progression, he said.
“Bracing is suggested for children and adolescents with curves of 25 degrees or greater or an observed 10-degree curvature change,” Dr. Shufflebarger said. “A custom-made underarm orthosis has to be worn 20 hours per day. It is effective for 60%–70% of patients. Brace failure is therefore 30%–40%.”
Surgery is usually indicated for patients with curves greater than 40 degrees, he said. “Rarely are these urgent referrals, and the risks of surgery are rare.”
The Adams forward bend test can be used to assess asymmetry (left). The patient's x-ray confirms the extent of spinal curvature, also shown corrected post surgery. Photos courtesy Dr. Harry L. Shufflebarger
