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Persistent or severe back pain and stiffness are ominous symptoms requiring prompt attention
P J Grattan-Smith1, M M Ryan, P G Procopis
1Department of Paediatrics, Westmead Hospital, Department of Neurology, Royal Alexandra Hospital for Children, Sydney, New South Wales, Australia. addyG@nch.edu.au
Insights
Children with severe back pain may have serious underlying causes like spinal cord compression. Prompt diagnosis with Magnetic Resonance Imaging (MRI) is crucial to prevent permanent paralysis.
Area of Science:
- Pediatric Orthopedics
- Pediatric Neurology
- Pediatric Radiology
Background:
- Severe or persistent back pain in children often indicates an organic cause, yet diagnosis is challenging due to a broad differential and rarity in general practice.
- Diagnostic and management delays are common in pediatric patients presenting with severe or persistent back pain or stiffness.
Observation:
- A review of 10 pediatric cases with severe back pain highlighted diagnostic and management difficulties.
- Underlying causes identified included infection, inflammation, neoplasm, trauma, and vascular malformation.
- Four children experienced spinal cord compression requiring urgent surgical decompression.
Findings:
- Magnetic Resonance Imaging (MRI) of the spine is the preferred diagnostic tool.
- Delays in investigation and management were noted, with some organic cases initially misdiagnosed as conversion disorder.
- The risk of permanent paraplegia was underestimated in cases of delayed diagnosis.
Implications:
- Early consideration of spinal cord compression is vital for children with severe or persistent back pain.
- Prompt MRI investigation is recommended when the diagnosis is not immediately apparent.
- Timely diagnosis and intervention are critical to prevent severe neurological deficits in pediatric patients.
Background:
Children with severe or persistent back pain and stiffness often have an underlying organic cause but there is a large differential diagnosis, examination may be difficult and the problem is relatively rare in general paediatric practice. These difficulties appeared to lead to delays in diagnosis and management of children with this problem.
Objectives:
To provide an approach to the diagnosis and management children with severe or persistent back pain or stiffness based on our clinical experience and the literature.
Methodology:
The case histories of 10 children with severe back pain seen by the authors over a 5-year period were reviewed. They were chosen as illustrative examples of the diagnostic and management problems and did not represent a systematic review of all cases seen by the authors over that time.
Results:
Underlying causes included infection, inflammation, neoplasm, trauma and vascular malformation. Four of the children had spinal cord compression which required urgent decompression. There was one child with a conversion disorder but three children with organic disease were initially felt to have a conversion disorder. Investigations generally proceeded relatively slowly and the problem was not regarded as a semi-urgent situation carrying the risk of permanent paraplegia. Magnetic resonance imaging (MRI) scan of the spine was the investigation of choice.
Conclusion:
Children with severe or persistent back pain and stiffness have a wide variety of underlying causes. The possibility of underlying spinal cord compression should always be considered in children with this presentation. If the diagnosis is not obvious, MRI scan of the spine should be arranged without delay.