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AAP National Conference: Orthopedic surgeon demystifies back pain in children :

October 24, 2016

When a patient presents with back pain, it’s important to think about the child’s age and maturity, said Richard Schwend, M.D., FAAP, professor of orthopedic surgery and pediatrics at Children's Mercy Hospital in Kansas City, Mo.

“The younger children are the ones that we worry about most,” he said.

Back pain can signal a tumor or infection in children under 10, while pain in older children is more likely to due to mechanical issues such as spondylolysis or Scheuermann’s kyphosis, said Dr. Schwend, a member of the AAP Section on Orthopaedics.

Using illustrative cases, Dr. Schwend will discuss red flags in the history and physical exam during a session titled “Back Pain in Children: Avoiding Disasters (F4094),” which will be presented from 4-4:45 p.m. Tuesday in Room 103 of Moscone South.

Studies show that the prevalence of back pain increases as children get older. If asked to report on back pain in their lifetime, the rate can be as high as 80%, Dr. Schwend said. But when children are asked if they have pain right now, the numbers are a lot lower.

During the session, Dr. Schwend will review 10 history red flags and 10 examination red flags. Among things to look for in the history are recurrent or worsening pain, early morning stiffness, night pain, and missing school or sports due to pain.

“Night pain is a really big red flag,” he said, because it could indicate a tumor or infection.

Another concern is when a young child stops walking, which may be attributed to hip problems. However, if a hip exam is normal, pediatricians should think about other locations such as the spine, Dr. Schwend said.

“You always want to think about the back if you don’t have clear diagnosis of some another area,” he said.

Red flags in the examination include pain or discomfort that makes it impossible to examine the child, limp or altered gait, bruising, and bladder or bowel dysfunction.

In addition to red flags, Dr. Schwend will spend some time talking about common conditions seen in adolescents such as spondylolysis and postural kyphosis. These can be managed with core strengthening exercises or physical therapy. If spondylolisthesis is diagnosed in an athlete, the pediatrician may want to refer the patient to an orthopedic surgeon or sports medicine doctor, he said, because often it is an overuse injury.

Attendees also will be warned to avoid pitfalls, such as letting parents’ anxiety lead the evaluation and not paying attention to an initial X-ray.

Dr. Schwend related the case of an older child who had a lot of pain during the day and at night. After an initial X-ray was negative, the child underwent an MRI that was suggestive of an aggressive cancer. A subsequent CT scan, however, showed the child had osteoblastoma. It turns out the X-ray was not read properly.

“The pitfall there,” he said, “is not paying attention to the initial X-ray film and going straight to more advanced imaging.”

Dr. Schwend also will talk briefly about the role of backpacks in back pain and scoliosis.

He said his goal is to focus not only on back pain but also on how to do a good spine evaluation of a child.

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