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Beware the Child with Back Pain!

Mark Shillington *, Simon Journeaux#, Johanna Elliott*

* Orthopaedic registrar
 Department of  Orthopaedic Surgery, Mater Hospital, Brisbane.

Address for Correspondence:
Mark Shillington
Mater Adult Hospital
, Raymond Tce, South Brisbane 4101
one: (07) 38408111
: (07) 38408877


Much research has been published on aspects of back pain adults, however, there is comparatively little on the condition in children. This has occurred despite the fact that back pain is a common reason for presentation at the pediatric orthopedic department. In children with back pain an organic cause is more common than in adults. It is therefore important that orthopedic surgeons are vigilant to the possible ‘serious’ organic causes of back pain in children. This case report documents a common presentation in our emergency department of a child with back pain who has a non-specific history. The back pain is subsequently found to be caused by a crush fracture occurring secondary to acute lymphocytic leukemia. A discussion of the biological causes of back pain in children follows.
Keywords: Spine; Pain; Paediatric; Leukemia

J.Orthopaedics 2007;4(2)e34

Case Report:

An eight-year girl presented to the emergency department with acute onset of midline lumbar back pain after minor trauma – a soccer ball had hit her leg with "force" in the playground.   She had been transferred to hospital by ambulance as she had been unable to stand initially.  She was reviewed by the orthopaedic registrar on call and a detailed history revealed that the pain had been present intermittently for two weeks. There were no specific aggravating movements, however the pain was exacerbated by general activity and sneezing.  There were no radicular or systemic symptoms. She gave a vague history of back injury 2 years prior. 

On examination loss of the lumbar lordosis was noted.  There was no tenderness to percussion, but axial compression exacerbated the mid-lumbar pain.  She had a normal straight leg raise and normal neurological examination. 

Plain radiographs were performed and were thought to demonstrate subtle loss of height of the L2 vertebral body. 

Routine bloods were normal, and the low back pain resolved in the emergency department following the administration of oral ibuprofen. A bone scan was organized with follow-up as an outpatient.

At a follow-up appointment one week later the patient gave a history of worsening pain.  Repeat examination revealed tenderness in midlumbar region, exacerbated by percussion of the lumbar spine.  There were no gross motor, sensory or reflex changes. Full blood count, electrolytes, erythrocyte sedimentation rate, and C-reactive protein were once again within normal ranges. The working diagnosis at this stage was infection or eosinophilic granuloma.  Bone scan was performed and a subtle abnormality in the superior aspect of L2 was reported. There was no abnormal blood pool activity or extension across the disc space. It was concluded that a diagnosis of discitis was unlikely. Repeat bloods two weeks after initial presentation were again normal.   A renal ultrasound was performed to exclude a renal cause.  An MRI scan demonstrated an infiltrative process involving several levels at the lumbar spine.  The oncology team was involved and the diagnosis of ALL was confirmed with bone marrow biopsy.  On retrospective review of initial plain radiographs, it was agreed that there was osteopenia and pathological fracture of the superior end plate of L2, consistent with the diagnosis of an infiltrative process.

Discussion :

The incidence and prevalence of back pain amongst the paediatric population is not as established as that in adults.  A review of the literature1 found lifetime prevalence rates to vary between 7-63% in children and adolescents. In the adult population true bony pathology, aside from degeneration, is rare. Significantly, in the paediatric population, an acute organic cause is common2. The differential diagnosis of back pain in children is included in table 2.

Although occult malignancy is a rare cause of organic back pain in children, it should form part of the differential diagnosis of children presenting with musculoskeletal complaints. Atypical features inconsistent with the provisional orthopaedic diagnosis should alert the clinician to consider an alternative diagnosis. Atypical features of a patient’s pain are often known as ‘red flag’ symptoms (see table 3). History taking can be challenging in trying to establish an adequate pain description from child. Because of this it is easy to neglect the need to check for ‘red flag’ symptoms suggestive of serious pathology. It is essential that children and their parents are questioned about these symptoms to avoid delays in diagnosis of a serious condition.

In a child with red flag symptoms the differential diagnosis would include.

·        Juvenile rheumatoid arthritis

·        Septic arthritis

·        Osteomyelitis

·        Discitis

·        Acute lymphoblastic leukaemia (ALL)

·        Hodgkin’s lymphoma

·        Langerhans cell histiocytosis

·        Tuberculosis of the spine

·        Seronegative spondyloarthritis  

In our case the patient’s back pain was caused by ALL. Acute leukaemia is the most frequent malignant childhood disease with a peak frequency at two to five years of age. 75% of cases are lymphocytic in origin (ALL as in our case), 15-20% are myelogenous leukaemias, and 5-10% are of the non-lymphocytic type. 

Patients may present with ALL in a variety of ways. Symptoms are usually related to infiltration of leukaemic cells into the bone marrow leading to suppression of normal marrow activity. Presenting symptoms are manifestations of the underlying anemia, thrombocytopenia, and neutropaenia, and may include fever, pallor, lethargy, and bruising. Bone pain, particularly affecting the long bones, is considered to be the result of the massive proliferation of haemopoietic tissue within the medullary cavity or periosteum. 

In our case, the only clinical feature was musculoskeletal pain due to acute pathological fracture.

Bone pain is not an uncommon initial presentation of leukaemia. In a study5 of 295 children diagnosed with ALL or malignant lymphoma, 7.1% initially presented to the orthopaedic department with bone pain. Among these patients 25% specifically had spinal pain. Of concern Jonsson et al6 reported that patient who listed bone pain, limp, or other musculoskeletal symptoms as their chief complaint received a significant delay in diagnosis of acute leukaemia compared with those that had no musculoskeletal symptoms. 

Routine blood tests, including inflammatory markers such as ESR and CRP, are not very useful in categorically excluding malignancy in the paediatric population.  In the study by Kobayashi et al5 it was noted that the majority of patients with ALL presented with mostly normal full blood counts. In their laboratory data CRP was the most sensitive indicator at initial presentation. It was suggested an elevated CRP without leukocytosis may be an important finding in patients with leukaemia who complain of musculoskeletal conditions at initial presentation. 

A significant and encouraging finding in a recent multicenter case control study by Jones et al7  concluded that in children presenting with musculoskeletal complaints, the three most important factors that predicted a diagnosis of ALL were low WCC, low-normal platelet count, and a history of night-time pain. In the presence of all 3 of these findings the sensitivity and specificity for the diagnosis of ALL were 100% and 85% respectively. 

It is imperative to investigate sites of bony pain and tenderness with an imaging technique. Gray8 recommends that every child that presents with back pain that cannot confidently be classified as innocent should have, at least, standing anterior-posterior and lateral radiographs of the spine. Findings on pain x-ray suggestive of malignancy are listed in Table 4. Kobayashi et al5  found that 94% of patients with ALL had a radiographic abnormality at presentation, the most common of which was osteopaenia at the symptomatic area. In contrast Cabral and Tucker9  found that plain x-ray films provided diagnostic information in only a quarter of patients. Importantly, however, they noted that nearly two thirds of either plain x-rays or bone scans, which were initially reported as normal before the rheumatology consultation, were then found to have abnormalities on careful re-examination by a paediatric radiologist.

In conclusion, musculoskeletal pain is a common presentation of paediatric malignancy.  As discussed above the results of routine investigations are often non-specific. Therefore, if there is an index of clinical suspicion one should have a low threshold for specialist referral, as MRI scanning, peripheral blood smear and bone marrow biopsy may need to be undertaken.

Reference : 

  1. Kovacs F, Gestoso M, del Real M, Lopez J, Mufraggi N, Mendez J . Risk factors for low back pain in schoolchildren and their parents: a population based study. Pain. 2003;103:259-268. 

  2. Weinstein J, Boriani S, Campanacci L. Spine neoplasms.    In: Weinstein S (ed). The Pediatric Spine: Principles and Practice. 2nd ed. Philadelphia, PA: Lippincott, Williams, & Wilkins;2001:685-707. 

  3. Sumeet G, Dormans J. Tumours and Tumour-like Conditions of the Spine in Children. Journal of the American Academy of Orthopedic Surgeons. 2005;13:372-381. 

  4. Waddell G. The back pain revolution. Edinburgh: Churchill Livingston; 1998 

  5. Kobayashi D, Satsuma S, Kamegaya M, Haga N, Shimomura S, Fujii T, Yoshiya S.  Musculoskeletal Conditions of Acute Leukemia and Malignant Lymphoma in Children. Journal of Pediatric Orthopedics B. 2005;14:156-161. 

  6. Jonsson OG, Sartain P, Ducore J, Buchanan G. Bone pain as an initial symptom of childhood acute lymphoblastic leukaemia: Association with nearly normal hematologic indexes. Journal of Pediatrics. 1990;117:233-237. 

  7. Jones O, Spencer C, Bowyer S, Dent P, Gottlieb B, Rabinovich C. A Multicenter Case-Control Study on Predictive Factors Distinguishing Childhood Leukaemia From Juvenile Rheumatoid Arthritis. Pediatrics. 2006;117:e840-844. 

  8. Gray A. Back pain in children and adolescents. Medicine Today. 2005;6:27-33. 

  9. Cabral D, Tucker L. Malignancies in children who initially present with rheumatic complaints. Journal of Pediatrics. 1999;134:53-57.


This is a peer reviewed paper 

Please cite as :Mark Shillington : Beware the Child with Back Pain!

J.Orthopaedics 2007;4(2)e34





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