Low back pain in youth: Recognizing red flags
Although low back pain in children and teens is usually benign, recognizing red flags that indicate the need for imaging, referral, bracing, or surgery is critical.
PRACTICE RECOMMENDATIONS
› Be aware that low back pain is rare in children < 7 years but increases in incidence as children near adolescence. A
› Consider imaging in the setting of bony tenderness, pain that awakens the patient from sleep, or in the presence of other “red flag” symptoms. A
› Consider spondylolysis and spondylolisthesis in adolescent athletes with low back pain lasting longer than 3 to 6 weeks. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Other causes of low back pain—including inflammatory arthritis, infection (eg, discitis), and tumor—are rare in children but must always be considered, especially in the setting of persistent symptoms.4,19-21 More on the features of these conditions is listed in TABLE 1.1-7,13-15,17-30
History: Focus on onset, timing, and duration of symptoms
As with adults, obtaining a history that includes the onset, timing, and duration of symptoms is key in the evaluation of low back pain in children, as is obtaining a history of the patient’s activities; sports that repetitively load the lumbar spine in an extended position increase the risk of injury.10
Specific risk factors for low back pain in children and adolescents are poorly understood.4,9,31 Pain can be associated with trauma, or it can have a more progressive or insidious onset. Generally, pain that is present for up to 6 weeks and is intermittent or improving has a self-limited course. Pain that persists beyond 3 to 6 weeks or is worsening is more likely to have an anatomical cause that needs further evaluation.2,3,10,21
Identifying exacerbating and alleviating factors can provide useful information. Pain that is worse with lumbar flexion is more likely to come from muscular strain or disc pathology. Pain with extension is more likely due to a structural cause such as spondylolysis/spondylolisthesis, scoliosis, or Scheuermann disease.2,4,10,17,18,21 See TABLE 2 for red flag symptoms that indicate the need for imaging and further work-up.
The physical exam: Visualize, assess range of motion, and reproduce pain
The physical examination of any patient with low back pain should include direct visualization and inspection of the back, spine, and pelvis; palpation of the spine and paraspinal regions; assessment of lumbar range of motion and of the lumbar nerve roots, including tests of sensation, strength, and deep tendon reflexes; and an evaluation of the patient’s posture, which can provide clues to underlying causes of pain.
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