Additionally, note any enthesitis in the peripheral joints or in the pelvic girdle. Other possible findings may include anterior uveitis, aortic incompetence, cardiac conduction disturbances, and pulmonary fibrosis.28
Note that limitations of forward and lateral lumbar flexion may not be as prominent in adolescents with juvenile ankylosing spondylitis compared with those with traditional ankylosing spondylitis. Upon diagnostic study, adolescents with juvenile ankylosing spondylitis have shown a greater prevalence of hip disease, including increased circumferential joint space narrowing, osteophytes, erosions, and protrusio acetabulae. With a solid understanding of juvenile ankylosing spondylitis, clinicians will be able to ascertain the atypical nature of the disease and possibly prevent severe damage as the adolescent ages.27
Degenerative disk disease and lumbar disk herniation
Disk-related pathology including degeneration and herniation represent a relatively larger proportion of adolescents with back pain among all diagnoses considered.11 The term degenerative disk disease may be used to describe a disk with a tear, loss of height, or mild bulging. A herniation develops when one of the intervertebral disks moves out of position and presses on adjacent nerves. Although herniation was found to be less likely in adolescents than most other causes of back pain—3.5% in one study—lumbar disk herniation also represents an important pathology to consider because it is a progressive disease that can worsen over time.30 Because of this, clinicians must be aware of notable risk factors for disk herniation, described below.31
Evaluate anthropometrics at each visit because rapid changes in weight or height, or being overweight in general, can put additional stress on the back, making it more susceptible to injury and disk herniation. Additionally, adolescent lumbar disk herniation commonly results from sports-related injuries, so obtaining a detailed history of activity for patients who participate in high-impact sports or weightlifting is essential.30
Family history is an equally important component of the patient interview. In a study by Karademir and colleagues, more than 50% of patients had a family history of lumbar disk herniation, which supports the idea that some adolescents may be genetically predisposed to degenerative disease of the spine.31 Finally, an additional risk factor for lumbar disk herniation is age; as adolescents get older, the risk for trauma-related lumbar disk herniation increases.31
Most commonly, adolescents with lumbar disk herniation present with radicular pain with or without associated neurologic deficits.30 Two important neurologic findings to screen for are sensory and motor weakness. Take special attention when examining the L4-L5 spinal level, as this is the most commonly affected area of disk herniation in adolescents.30 Unlike in adults, disk herniation in adolescents typically only affects a single level. When an adolescent is diagnosed with lumbar disk disease, follow-up for life is important because the chance that the disease will progress and involve additional levels increases with age.30
The most common type of bone cancer in adolescent patients is Ewing sarcoma, accounting for 1% of all childhood cancers.32 Most adolescents with Ewing sarcomas will have pain in the area of the tumor. Bone pain can be caused by the tumor spreading under the periosteum, or from a fracture in a bone that has been weakened by the tumor. Because these tumors commonly occur in the pelvis, patients often have low back pain. Although occurring slightly more frequently in white males, Ewing sarcoma is due to a gene abnormality of unknown origin, so predictive factors are nearly impossible.33 Clinicians should be highly suspicious of a malignant process if the patient has low back pain along with night pain, fatigue, fever, and unintentional weight loss.
Most Ewing sarcomas cause a lump or swelling, which can be warm to the touch, but tumors in the pelvis might not be noticed until they have grown quite large, making physical examination findings nonspecific. Additional neurologic signs, such as lower extremity numbness or weakness, loss of coordination of the legs, or loss of bladder or bowel function, could signify that the tumor has already invaded the spinal cord or that the primary cause is a spinal cord tumor, such as a neurofibroma, which is rare in adolescents.34
This older, generic term encapsulates any type of low back pain, especially of unknown origin. When a patient does not have a clear cause for low back pain, explore psychosocial factors. Mental health conditions such as anxiety and depression can manifest in somatic symptoms such as low back pain.35 Screen adolescents with low back pain for these conditions using surveys such as the Home, Education and employment, Activities, Drugs, Sexuality, Suicide/Depression (HEADSS) screening tool.36 Furthermore, studies show that children from lower-income families are more likely to experience back pain than are children in well-off families.4 Socioeconomic status is associated with parents' ability to affect their children's health and well-being in a positive manner due to lifestyle, health behavior, and knowledge.37 Thus, children growing up in disadvantaged families are predisposed to health adversities.38 Although family income is a nonmodifiable risk factor, talk to the patient's parents about healthful activity and eating behaviors.
Genitourinary tract pathology
Although not a musculoskeletal cause, problems in the genitourinary tract can cause acute low back pain in adolescents. Screen patients for urinary tract infections, kidney stones, and pyelonephritis. Ask about dysuria, hematuria, hesitancy, frequency, nocturia, and abdominal pain, as well as diet and hydration status. Abdominal tenderness, specifically suprapubic, and costovertebral tenderness may be noted in patients with any of the above conditions. Pay close attention to vital signs, assessing for hypotension, tachycardia, and fever, which may indicate acute infection.
The use of a standardized diagnostic algorithm when evaluating an adolescent with low back pain ensures that certain red flags are not missed.11 These red flags are early morning stiffness, gait alterations, irritability or malaise, night pain, numbness, pain lasting more than 4 weeks, muscle rigidity, motor weakness, unintentional weight loss, fever or chills, bowel or bladder changes, and recurrent or worsening pain.
If any of these red flags are found, further investigation and more urgent diagnostics are needed, which are described below.20,39,40 These diagnostics may be initiated by a primary care provider; however, if neurologic or vascular compromise is of concern, the patient should be seen right away in an ED.
Various imaging studies can be useful if the patient's history and physical examination provide minimal diagnostic clues.19 In any adolescent presenting with low back pain, if the clinician has no concern for acute fracture and no red flags are identified in the initial evaluation, imaging studies are not recommended until 1 month of conservative treatment has failed to produce improvement.
In general, plain radiographs are indicated when bony pathology such as spondylolysis, scoliosis, spondylolisthesis, or ankylosing spondylitis is suspected. MRI is appropriate for soft tissue or invasive pathology such as malignancy, disk herniation, or low back pain with radiculopathy.41 Bone scans are reserved for excluding occult fractures and following certain types of neoplasms.
Clearly, diagnostic imaging is not indicated for every adolescent seeking medical care for low back pain. These studies are expensive and can unnecessarily expose a young patient to radiation. Clinicians must rely on a careful history and physical examination to determine when diagnostic studies are necessary.
If the cause of low back pain is not clear based on imaging studies, other testing could include complete blood cell count with differential, urine analysis, and, if indicated, imaging of the kidneys.
Promptly refer patients for management and treatment of scoliosis, spondylolysis, spondylolisthesis, ankylosing spondylitis, degenerative disk disease and herniation, or malignancy. Although discussing and coordinating any testing with specialists first is the most cost-effective approach, primary care providers may elect to order laboratory tests and/or imaging studies before referring patients to any of the following specialists based on the suspected condition:
- Orthopedics: Scoliosis, spondylolysis, spondylolisthesis, degenerative disk disease, lumbar disk herniation
- Rheumatology: Ankylosing spondylitis
- Oncology: Ewing sarcoma, spinal cord tumor.
With the prevalence of low back pain in adolescents steadily increasing, PAs must provide patient education on appropriate strategies for prevention. Educate adolescents on the vulnerability of the back and their need for good overall health.41 Explain that increasing quadriceps, hamstring, and lumbar flexibility; increasing core (abdominal and lumbar) strength; and weight loss are associated with reducing their risk for the development of low back pain.42 Encourage patients to engage in regular physical activity in order to maintain a BMI below 30 kg/m2, which in children can be considered a healthful weight, depending on their height.18 The American Academy of Pediatrics recommends that a child's backpack should weigh no more than 10% to 20% of their body weight. Backpacks should be worn with both straps on the shoulders, high enough on the back so that the lowest portion of the pack rides an inch or more above the waist.43
Tell parents that the prevalence of physiologic abnormalities in adolescents increases with overall athletic activity.44 Direct education about specific red-flag symptoms for low back pain to adults who may be caring for adolescents. Through education and awareness, appropriate prevention techniques can help reduce the prevalence of adolescents with low back pain, reducing the number of medical appointments and healthcare costs.
A careful history and physical examination in adolescents presenting with low back pain increases early and accurate diagnosis while avoiding excessive use of unnecessary, costly, or harmful diagnostic tests. This article provides guidance for a thorough patient assessment in the initial workup of low back pain, which is increasingly important as its incidence rises in adolescents. Although the most common causes are rarely serious or life-threatening, clinicians should be aware of certain components in the history or physical examination that warrant diagnostic imaging or immediate intervention. Many causes of low back pain can be prevented by educating patients on the risk factors that predispose them to injury and the lifestyle modifications that may reduce risk.
1. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med
2. Adar T, Levkovich I, Castel OC, Karkabi K. Patient's utilization of primary care: a profile of clinical and administrative reasons for visits in Israel. J Prim Care Community Health
3. Finley CR, Chan DS, Garrison S, et al What are the most common conditions in primary care? Systematic review. Can Fam Physician
4. Joergensen AC, Hestbaek L, Andersen PK, Nybo Andersen AM. Epidemiology of spinal pain in children: a study within the Danish National Birth Cohort. Eur J Pediatr
6. Bhatia NN, Chow G, Timon SJ, Watts HG. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop
7. Fett D, Trompeter K, Platen P. Back pain in elite sports: a cross-sectional study on 1114 athletes. PLoS One
8. Sato T, Ito T, Hirano T, et al Low back pain
in childhood and adolescence: assessment of sports activities. Eur Spine J
9. O'Sullivan PB, Beales DJ, Smith AJ, Straker LM. Low back pain
in 17 year olds has substantial impact and represents an important public health disorder: a cross-sectional study. BMC Public Health
10. Jones MA, Stratton G, Reilly T, Unnithan VB. A school-based survey of recurrent non-specific low-back pain prevalence and consequences in children. Health Educ Res
11. Yang S, Werner BC, Singla A, Abel MF. Low back pain
: a 1-year analysis of eventual diagnoses. J Pediatr Orthop
13. Hershkovich O, Friedlander A, Gordon B, et al Associations of body mass index and body height with low back pain
in 829,791 adolescents
. Am J Epidemiol
14. Auvinen J, Tammelin T, Taimela S, et al Associations of physical activity and inactivity with low back pain
. Scand J Med Sci Sports
15. Mikkonen PH, Laitinen J, Remes J, et al Association between overweight and low back pain
: a population-based prospective cohort study of adolescents
. Spine (Phila Pa 1976)
16. Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents
. Am Fam Physician
19. Alqarni AM, Schneiders AG, Cook CE, Hendrick PA. Clinical tests to diagnose lumbar spondylolysis
and spondylolisthesis: a systematic review. Phys Ther Sport
20. Théroux J, Le May S, Fortin C, Labelle H. Prevalence and management of back pain in adolescent idiopathic scoliosis
patients: a retrospective study. Pain Res Manag
21. Menger RP, Sin AH. Adolescent and idiopathic scoliosis
. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2019.
22. Goodbody CM, Sankar WN, Flynn JM. Presentation of adolescent idiopathic scoliosis
: the bigger the kid, the bigger the curve. J Pediatr Orthop
23. Grødahl LH, Fawcett L, Nazareth M, et al Diagnostic utility of patient history and physical examination data to detect spondylolysis
and spondylolisthesis in athletes with low back pain
: a systematic review. Man Ther
24. Sundell CG, Jonsson H, Ådin L, Larsén KH. Clinical examination, spondylolysis
and adolescent athletes. Int J Sports Med
25. Chen HA, Chen CH, Liao HT, et al Clinical, functional, and radiographic differences among juvenile-onset, adult-onset, and late-onset ankylosing spondylitis. J Rheumatol
26. Sieper J, van der Heijde D, Landewé R, et al New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis
27. Hyphantis T, Kotsis K, Tsifetaki N, et al The relationship between depressive symptoms, illness perceptions and quality of life in ankylosing spondylitis in comparison to rheumatoid arthritis. Clin Rheumatol
28. McVeigh CM, Cairns AP. Diagnosis and management of ankylosing spondylitis. BMJ
29. Werner CM, Hoch A, Gautier L, et al Distraction test of the posterior superior iliac spine (PSIS) in the diagnosis of sacroiliac joint arthropathy. BMC Surg
30. Kumar R, Kumar V, Das NK, et al Adolescent lumbar disc disease: findings and outcome. Childs Nerv Syst
31. Karademir M, Eser O, Karavelioglu E. Adolescent lumbar disc herniation: impact, diagnosis, and treatment. J Back Musculoskelet Rehabil
34. Wilson PE, Oleszek JL, Clayton GH. Pediatric spinal cord tumors and masses. J Spinal Cord Med
. 2007;30(suppl 1):S15–S20.
35. Jonsdottir S, Ahmed H, Tómasson K, Carter B. Factors associated with chronic and acute back pain in Wales, a cross-sectional study. BMC Musculoskelet Disord
37. Harper S, Lynch J. Trends in socioeconomic inequalities in adult health behaviors among U.S. states, 1990-2004. Public Health Rep
38. Diderichsen F, Andersen I, Manuel C, et al Health inequality—determinants and policies. Scand J Public Health
. 2012;40(8 suppl):12–105.
39. Ramirez N, Flynn JM, Hill BW, et al Evaluation of a systematic approach to pediatric back pain: the utility of magnetic resonance imaging. J Pediatr Orthop
40. Rodriguez DP, Poussaint TY. Imaging of back pain in children. AJNR Am J Neuroradiol
41. Mettler F. Essentials of Radiology
. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2005.
42. Taxter AJ, Chauvin NA, Weiss PF. Diagnosis and treatment of low back pain
in the pediatric population. Phys Sportsmed
44. Feldman DE, Shrier I, Rossignol M, Abenhaim L. Risk factors for the development of low back pain
in adolescence. Am J Epidemiol
Keywords:Copyright © 2019 American Academy of Physician Assistants
low back pain; adolescents; scoliosis; spondylolysis; degenerative disk disease; malignancy