Throughout the past decade, the prevalence of low back pain and the number of office visits for this complaint have steadily increased.1 More than 10% of all appointments made with primary care physicians are for complaints about back or neck pain.1 Low back pain constitutes the fifth most common reason for all doctor visits and costs about $86 billion in healthcare spending annually.1-3 Low back pain is on the rise in adolescents as well. One study showed that about 11% of boys and 17% of girls ages 11 to 14 years have experienced moderate or severe low back pain in the past year.4
This article follows the World Health Organization definition of adolescents (ages 10 to 19 years).5 This group encompasses early (11 to 14 years), middle (15 to 17 years), and part of late (18 to 21 years) adolescence. Of all adolescent groups combined, an estimated 24% seek medical attention annually for low back pain.5,6 The stage of adolescence is important as it changes the predisposition for certain diseases. Nonmodifiable risk factors such as sex, age, and ethnicity play a role in the pathology of certain causes of low back pain. Additionally, modifiable risk factors such as increased childhood obesity, sport specialization during adolescence, and compounding psychosocial and socioeconomic factors also may contribute to the rise in adolescent low back pain.4,7,8 Low back pain can impair quality of life because it correlates with greater healthcare use and can increase the number of days absent from school.9 Adolescents with low back pain also are more likely to develop chronic low back pain as adults.10
A thorough history and physical examination can increase early detection and accurate diagnosis of low back pain while ensuring that costly diagnostic tests are used judiciously.
Muscle strain is the most common diagnosis among adolescents who present with low back pain. However, clinicians also must be able to recognize more severe musculoskeletal conditions such as scoliosis, spondylolysis, spondylolisthesis, ankylosing spondylitis, degenerative disk disease and herniation, and, rarely, malignancy. Although underlying serious pathology is unusual in adolescents with low back pain, clinicians should recognize the specific signs and symptoms that require further evaluation and intervention.11 This article focuses on using a thorough history and physical examination to guide the initial diagnostic workup and enhance early detection and accurate diagnosis of adolescents who present with low back pain.
ANATOMY AND PHYSIOLOGY
The lumbar spine and surrounding musculature are common locations for back injury because they bear the weight of the torso and head, as well as provide cushion and absorb pressure during impact (Figure 1).12
HISTORICAL RISK FACTORS
Recognizing risk factors is essential when conducting the initial interview in an adolescent with low back pain. During the history, note or ask about:1,8,13
- Female sex
- Family history of low back pain
- Personal past medical history
- Concomitant complaints such as leg numbness or fevers
- Time spent studying in bed or watching television
- Posture during computer use
- Weight and position of backpack
- Height and body mass index
- Hours, type, and intensity of activity.
Hours and intensity of activity have a bimodal risk for the development of low back pain in adolescents, so weekly physical activity should be quantified. Very active participation in physical activities, defined as more than 6 hours per week of brisk activity that results in sweating and shortness of breath, is associated with low back pain in male and female adolescents alike.14 One study showed that low back pain has a 1-year prevalence rate of 57% in adolescent athletes compared with 23% in nonathletes of the same age.7 Alternatively, low levels of physical activity can predispose an adolescent to become obese, also increasing the risk for low back pain.7,15
Although most low back pain in adolescents is not linked to a clear underlying cause, nonspecific lumbar strain is the most common subsequent diagnosis.11 In a study by Bernstein and colleagues, 24% of adolescents who presented to the ED with low back pain suffered from a muscle strain injury.16 Playing sports that involve pushing and pulling heavy weights, such as weightlifting and football, put patients at risk for acute lumbar muscle strain.17 A chronic strain usually results from overuse after prolonged, repetitive movements such as rowing or tennis.17 Additionally, adolescents who carry heavy backpacks or who are obese (BMI greater than 30), both which contribute to poor posture, are at risk for chronic muscle strains. Patients who are not obese, but who engage in very limited physical activity, will in turn also have muscle weakness due to deconditioning, predisposing them for muscle strain.18
Clinical examination findings offer advantages as initial indicators for diagnosis of muscle strain. If an early diagnosis can be made, associated risks of radiation and further costs of radiology can be eliminated.19 Diagnostic criteria for a muscle strain should include:16
- Acute, reproducible, muscle tenderness
- No radiculopathy
- Pain is related to an injury.
This presentation largely differs from other possible causes of low back pain that manifest in a more insidious and chronic manner, often without injury. In patients who present with muscle strain, imaging often is unnecessary.11
This condition, a lateral curvature of the spine, is a structural alteration that occurs in a variety of conditions and is a significant risk factor for back pain in adolescents. Although not all adolescents with scoliosis experience back pain, such pain is estimated to be twice as common in adolescents with idiopathic scoliosis than in those without.20 Among adolescents suffering from back pain, the lumbar region is the most commonly affected area.20 Research shows that in some cases, genetics plays a role in the development of scoliosis. About 30% of patients with adolescent idiopathic scoliosis have a family history of the condition.21 Scoliosis also is more common in females than in males.
Diagnosing and properly managing back pain in adolescents with idiopathic scoliosis is crucial, as it may be predictive of adult back pain. Typically, scoliosis is identified during yearly checkups using the Adam forward bend physical examination maneuver (Figure 2).22 During this maneuver, the patient stands with legs straight and feet together. The patient then bends forward at the waist until the back enters the horizontal plane. The clinician looks for a positive rib hump, which indicates spinal curvature. The accuracy of the Adam forward bend maneuver is impaired in overweight and obese patients because of overlying soft tissue and increased double major (right thoracic and left lumbar) curve presentation.22 The clinician may need to adjust or include additional physical examination maneuvers, depending on the patient's body habitus.
Spondylolysis and spondylolisthesis
These conditions manifest clinically as back pain. Criteria for spondylolysis (a bony defect within the pars interarticularis of the vertebral arch and frequent point of fracture) and spondylolisthesis (the forward shift of one vertebra on another) can include:19,23,24
- Radiculopathy or neurogenic pain
- Intermittent claudication
- Difficulty falling asleep or waking up due to pain
- Pain worse with sitting and walking
- Pain with lumbar spinous process palpation.
Adolescent athletes are found to be at higher risk for development of spondylolysis than nonathletes (13.9% compared with 4.4%, respectively), with gymnastics and weightlifting being the most common sports implicated.23 The history and physical examination is up to 81% specific in patients under age 20 years.23 Studies have not yet identified physical examination maneuvers that clearly detect spondylolysis; however, a one-legged hyperextension test (Figure 3) is more often positive in patients with spondylolysis as the cause of low back pain than in those with pain due to other causes.19 Although the maneuver cannot be used definitively to justify diagnostic imaging, a positive one-legged hyperextension test in conjunction with any of the criteria above should prompt further workup.24
Lumbar spinous process palpation has some usefulness in diagnosing lumbar spondylolisthesis, with a 60% sensitivity and 95% specificity.19 It is the optimal physical examination maneuver, but a diagnosis of spondylolisthesis remains challenging because neurogenic and spinal process pain is common in conditions other than spondylolysis and spondylolisthesis.19,23
This form of arthritis primarily affects the spine. Two types affect adolescents: ankylosing spondylitis (in patients age 17 years and older) and juvenile spondyloarthritis (in those age 16 years and younger). Both types are more common in males than females.25 In one study, the presence of four out of these five criteria showed a sensitivity of 77% and specificity of 91.7% in the diagnosis of spondyloarthitis:26
- Insidious onset
- Patient age under 40 years
- Pain present at night
- Pain improving with exercise
- Pain not improving with rest.
Other less-specific symptoms that may be present include:26-28
- Buttock pain
- Morning stiffness
- Shortness of breath
The physical examination should focus on measurement of forward lumbar flexion, lateral lumbar flexion, and chest expansion, as all may be limited in patients with ankylosing spondylitis. Patients may have tenderness to palpation or percussion of the spine as well as pain in the sacroiliac joints with palpation or stress.27 Although not specific to ankylosing spondylitis, two tests have good utility in diagnosing sacroiliac joint dysfunction:29
- PSIS (posterior superior iliac spine) distraction test: sensitivity of 100% and a specificity of 89%.29 (Figure 4)
- Gaenslen test: specificity of more than 90%, but a poor sensitivity (less than 35%).29 (Figure 5)
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.
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