Pediatric back pain and diagnostic strategies

Size: px

Start display at page:

Download "Pediatric back pain and diagnostic strategies"

Allyson Gregory
6 years ago
Views:

1 ANDREA ROSSI, MD Department of Pediatric Neuroradiology G. Gaslini Children s Research Hospital Genoa Italy Pediatric back pain and diagnostic strategies

pain in prepubertal children almost always heralds a serious underlying disorder However, in adolescent children,

2 Pediatric back pain: an underestimated problem In a younger child, refusal to crawl, sit, or walk may indicate back pain Families, or even physicians, overlooking the problem may cause a significant delay in the diagnosis Presence of back pain in prepubertal children almost always heralds a serious underlying disorder However, in adolescent children, chronic back pain may be found in up to 13%, and the underlying cause is often a sports induced injury F 3 y pilocytic astrocytoma

The diagnostic workup of a child with back pain should always commence with a proper history and physical exam 1. The child is less than four years old 2.

3 The diagnostic workup of a child with back pain should always commence with a proper history and physical exam 1. The child is less than four years old 2. Back pain causes a functional disability 3. Duration of greater than four weeks 4. Presence of a fever 5. Postural shift of the trunk caused by the pain 6. Limitation of motion due to the pain 7. Presence of a neurologic abnormality

4 Historic symptoms: 1) Nighttime pain 2) Pain with generalized symptoms 3) Acute pain 4) Chronic pain 5) Pain associated with neurological symptoms 6) Painful scoliosis I will not deal with torticollis

5 1) Nighttime pain Regular pain that occurs at night and awakens the child: consider tumor or infection Nighttime pain warrants immediate medical evaluation

6 Pediatric spinal tumors CLASSIFICATION Intramedullary Intraduralextramedullary Extradural

7 Pediatric intramedullary tumors pilocytic astrocytoma ganglioglioma oligodendroglioma Pilocytic astrocytoma: 50% of cases

8 Pediatric intramedullary tumors often cause significant enlargement of the spinal canal pilocytic astrocytoma M 6 y ganglioglioma F 2 y E E E E T T T T E E E E

9 Aneurysmal bone cyst (ABC) 42% of benign bone tumors Typical of older children (at least 10 yrs) Prevailingly involve posterior elements Prevailingly involve thoracolumbar spine May be reactive lesions M 12 y

10 M 12 y MRI hallmark: Multiple dependent fluid-fluid levels (Better seen on T2WI)

11 Ewing s sarcoma Most common spinal primary bone malignancy in children (50% of cases) Often multifocal bone involvement Mid- to late infancy (62% older than 9 yrs, none younger than 3 yrs) F 9 y

12 2) Pain with generalized symptoms Fever and other generalized symptoms occurring with back pain: consider tumor or infection Complete blood count and ESR should be ordered; if elevated, infection is likely Routine blood work for children < 10 yrs can be normal in patients with leukemia

13 Bacterial spondylodiscitis Staphylococci, streptococci from septic emboli (arterial and venous) Traditionally believed to begin into the hypervascular pediatric disc

Bacterial spondylodiscitis Staphylococci, streptococci from septic emboli (arterial and venous) Traditionally believed to begin into the hypervascular pediatric disc Probably infection starts in the

14 Bacterial spondylodiscitis Staphylococci, streptococci from septic emboli (arterial and venous) Traditionally believed to begin into the hypervascular pediatric disc Probably infection starts in the vertebral body adjacent to the endplate, then proceeds to the disc, and eventually spreads to both adjacent bodies Clinical features: acute onset with back pain, refusal to walk, irritability, fever, anorexia, local tenderness Abdominal pain may be present

15 T2 GdT1 Discitis Narrowing of disc space Swelling and T2 hyperintensity of the posterior anulus Mild T2 hyperintensity of vertebral endplates Enhancement of the posterior anulus

16 Acute lymphoblastic leukemia, onset F,6y back pain, fever, malaise

17 3) Acute pain Acute pain with or without radiation, pain with Valsalva maneuver, stiffness: consider spondylolysis/listhesis, muscle strain, disc herniation, or trauma

$repetitive activity (stress fracture) 4-5% of$ children > 6 yrs, especially those active in

18 Spondylolysis / spondylolisthesis Spondylolysis: Fracture of the pars interarticularis or pedicle(s) >> L5 Injury, repetitive activity (stress fracture) 4-5% of children > 6 yrs, especially those active in sports Boys: girls = 3:1 Extension (bending backwards) and rotation Sports at risk: ballet, gymnastics, football, high jumping, diving, rowing, and weight lifting

19 45 oblique views of the patient 20 cephalad angulation of the central x ray beam

20 13 y 15 y Spondylolisthesis: an intrinsically unstable condition corset for 8 mos.

21 Disc herniation in children Repeated trauma may be an important etiological factor The history and physical findings are not fundamentally different from those in the adult However, abnormal neurological findings are not common 6y 9y 8y

22 Disc space calcification

Disc space calcification Typically involves the

Cause uncertain (trauma, inflammation advocated)

complaint: local pain Herniation of calcified disc

23 Disc space calcification Typically involves the cervical spine Possible multilevel involvement Cause uncertain (trauma, inflammation advocated) Most patients are boys, 6-10 yrs Principal complaint: local pain Herniation of calcified disc fragment may cause neurologic signs Conservative treatment is advocated

24 Acute pain: Contemplate history of recent trauma! T8 Trauma + acute neurological signs: emergent MRI SCIWORA M10y M6y Whiplash

4) Chronic pain Duration of greater than 4 weeks in the absence of associated findings: in older children & adolescents, consider developmental problems, poor posture, or psychological problems

25 4) Chronic pain Duration of greater than 4 weeks in the absence of associated findings: in older children & adolescents, consider developmental problems, poor posture, or psychological problems 60-75% of children reporting back pain will have non-specific back pain. Their physical exam and X-rays will be normal. It is usually considered a muscle strain or from poor posture. Do notforgetlong-standing, benign bone tumors

on three adjacent vertebral bodies, end-plate changes, disk-space narrowing Onset occurs in

26 F 15y, chronic pain, kyphosis Scheuermann s disease Osteochondrosis that presents as an abnormality of the vertebral epiphyseal growth plates Radiographic findings: vertebral wedging of 5 degrees or more on three adjacent vertebral bodies, end-plate changes, disk-space narrowing Onset occurs in adolescence Rigid kyphosis Pain is generally gradual, located over the deformity, and worst at the end of the day

27 Histiocytosis M 7 y Most common benign anterior lesion Most common cause of vertebral collapse >> Cervical/thoracic spine

28 M 6y long-standing back pain T10 20 days 2 months 1 year

29 5) Pain associated with neurological symptoms 1 st priority: Rule out compressive etiologies Everything from benign to malignant conditions

Red flags that suggest spinal compression: Insidious

weak hands, or loss of sexual, bladder, or bowel function

causes an electric shock-type sensation that radiates down the

limbs (atrophy, hyporeflexia) Sensory changes are variable,

30 Red flags that suggest spinal compression: Insidious progression Neurological symptoms: gait disturbance, clumsy or weak hands, or loss of sexual, bladder, or bowel function Neurological signs: Lhermitte's sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs Upper motor neuron signs in the lower limbs (Babinski's sign up-going plantar reflex, hyperreflexia, clonus, spasticity) Lower motor neuron signs in the upper limbs (atrophy, hyporeflexia) Sensory changes are variable, with loss of vibration and joint position sense more evident in the hands than in the feet

31 Acute transverse myelopathy (ATM): a clinical syndrome CLINICAL FEATURES: Pain Paresthesias Leg weakness Sphincterial dysfunction CAUSES: Idiopathic ( Acute transverse myelitis ) ADEM Post-infectious Post-vaccination Devic s, MS Ischemic Metabolic Paraneoplastic Autoimmune (i.e., SLE) Post-irradiation

32 Τ1 Τ2 ΓδΤ1 MRI criteria for myelitis : Normal or slightly expanded spinal cord Diffuse or patchy hyperintensity on T2W Possible (~40%) patchy Gd enhancement Laboratory findings: CSF inflammatory signs (pleiocytosis, elevated IgG) ATM F 14 y

6) Painful scoliosis Pain occurring with recent-onset scoliosis: consider tumor or HSM Controversial association between idiopathic scoliosis and pain: General belief that idiopathic scoliosis does

33 6) Painful scoliosis Pain occurring with recent-onset scoliosis: consider tumor or HSM Controversial association between idiopathic scoliosis and pain: General belief that idiopathic scoliosis does not cause pain However, pain is present in 32% of cases, of which 9% have underlying pathologies (Behli et al, Spine 2006) Pain does not occur < 5 yrs, is rare between 6 and 10 yrs, and is much more common > 15 yrs

34 Osteoid osteoma Painful scoliosis Nighttime pain that recedes with salicylates (not always!) Target sign on CT Enhancing reactive tissue on MRI

35 Osteoid osteoma Hot spot on bone scan

36 Spinal cord astrocytoma In young children, pain is the most common symptom, but kyphoscoliosis is also a significant manifestation Deformities may increase following laminectomy

37 Extraspinal tumors that invade the spine Nerve sheath tumors No significant scoliosis Neuroblastoma

38 Back pain MRI

39 MRI

A Patient s Guide to Back Pain in Children

A Patient s Guide to Back Pain in Children 2350 Royal Boulevard Suite 200 Elgin, IL 60123 Phone: 847.931.5300 Fax: 847.931.9072 DISCLAIMER: The information in this booklet is compiled from a variety of