Back Pain in Kids and Teens

While back pain is very common for adults, kids are much more resilient and flexible and do not suffer the same types of back injuries to which adults are subject. In fact, medically significant back pain in children and teens is infrequently encountered, with even fewer cases in younger children.

Because children rarely suffer from back pain, any complaint by a child or teenager about acute or chronic back pain is taken very seriously by Pediatricians, and usually will result in a detailed consultation that will include a review of the child’s medical history and a physical exam.

Suspicious episodes of pain, or any concerning features of the pain, will result in radiological studies (such as an x-ray or MRI scan) and possibly a referral to a specialist for further examination and diagnostic tests.

The most common causes of back pain in children and teens tend to be somewhat age-dependent:

Younger children are less likely to be putting their spine under the same severe stresses as older children and adults. Thus, for the most part younger children do not have medically significant back pain and their discomfort tends to be short-lived. Also, younger children tend to self-limit their activity, choosing not to repeat painful activities, which aids in their recovery if an episode of back pain does occur.

At a young age, if a child has back pain there is greater concern for the possibility of a serious condition, such as a spinal tumor, growth, or an infection of the spine.

Therefore, if the pain persists in a younger child despite a lack of re-injury, or if there are other symptoms suggestive of a more insidious process (infection or tumor), the child’s condition will most likely be considered atypical, and therefore, further work-up and medical examination will be indicated.

Older children tend to be more aggressive in their activities and sports, thereby increasing the risk of injury to the bones, nerves and soft tissues in the spine. Teenagers are also more likely to test the limits of their bodies, often being exhorted by commercial advertising and/or peer pressure to push the envelope.

At this point, compression fractures are more commonplace, and we begin to see occasional disc injuries. Older pediatric patients also can injure the joints between vertebral bones, causing painful stress injuries. Only very rarely do the nerve roots become compromised.

Slightly older children can be convinced to minimize their activity to speed up healing times, but then they frequently return to the same injurious behavior that caused the initial damage. Here, older kids may also find themselves the victims of their own intermittent inactivity and suffer overuse injuries, similar to an adult who is a “weekend warrior”. For most injuries, the treatment of choice is usually a short period of rest with an eye towards developing and maintaining physical conditioning.

Tumors and infection of the spine may occur in teens, but it is more common for back pain to be caused by sports injuries or overuse syndromes.

Scoliosis
While scoliosis (curvature of the spine) is not an uncommon diagnosis among teenagers, it is very rare that scoliosis will cause back pain. Teens with scoliosis may develop back pain, just as other teenagers, but it has not been found that people with adolescent idiopathic scoliosis are any more likely to develop back pain than the rest of the population.

Potential causes of back pain in children and teens
While adults can have vertebral disc injuries involving rupture, protrusion or slipping, and compression, these problems are uncommon in children. However, as kids age and their bodies mature, it becomes more likely that an injury to the spinal discs may occur and cause pain.

Causes of back pain that tends to occur older children

Spondylolysis
As kids’ sporting events become more competitive and the activities more specialized, certain types of injuries tend to arise. Spondylosis, a defect of the joint between vertebral bones, is commonly found in those who tend to hyperextend their backs (bend backwards), such as gymnasts. This injury may actually represent a stress fracture and the period of rest and recuperation may be extensive – up to 4 to 6 weeks.

Spondylolisthesis
Occasionally, further injury can be found as spondylolisthesis, a “slipping” of one vertebra upon another. This condition can progress through adolescence, and if it results in instability and pain it may require spinal fusion surgery at a later point.

Disc Injuries and vertebral fractures
Teens who tend to punish their spines through gymnastics or extreme sports (such as skateboarding, in-line skating, and vert biking) will frequently land very hard on their feet or buttocks. Either way, the force is transmitted to their vertebrae, which can result in a vertebral fracture and/or damage to the intervertebral discs.

If the disc material is extruded out or herniated, the spinal cord nerve roots leaving the cord can be compressed. This causes the sensation of pain along the path of that nerve. A well-known version of this is sciatica, which presents as buttock pain radiating down the back of a leg. Conservative measures are usually the first line of treatment for this type of pain (such as physical therapy, medications, osteopathic or chiropractic manipulation). If these treatments do not provide sufficient pain relief, patients may require surgery (e.g. a microdiscectomy or discectomy) to relieve pressure on the nerve.

Causes of back pain that may occur in younger or older children:

Infection
Of constant concern to physicians is the diagnosis of infection of the spine (discitis) in children. An infection of the spine is of great consequence and requires prompt diagnosis. Diagnosis of an infection is usually made with the assistance of a good physical exam and laboratory data. Signs of inflammation may be present (e.g. redness, swelling) even to the level of the skin. Radiographic studies are frequently normal. Treatment may consist of antibiotics if bacteria are found to be the cause of the infection. Again, prolonged rest is the primary treatment.

Tumor
Another major concern for pediatricians is potential for a tumor in the spine in children. Luckily, this is a very rare occurrence. As with infection of the spine, the diagnosis hinges on obtaining a good medical history, physical exam, and the suspicious nature of physicians when they cannot get an otherwise satisfactory diagnosis to explain the child’s symptoms. Treatment once again depends upon the final diagnosis and the skills of several subspecialties.

Backpacks
Importantly, pediatricians are starting to see a new form of injury in school-age children and teens become more common: overuse injuries and back strain caused by carrying back packs that are too heavy.

Often, backpacks may equal 20% to 40% of the child’s own body weight (equivalent to a 150-pound adult carrying a 30 to 60-pound back pack around 5 days a week). This amount of weight understandably creates a great deal of strain on the child’s spine. Additional strain is caused when children and teens carry the backpack over one shoulder, causing an uneven load on the spine.

Summary
As you may have noted, rest and careful monitoring of symptoms seems to be the answer for most diagnoses. This is because the vast majority of back pain problems in children are related to soft tissue damage (such as muscles, ligaments and tendons), which is often caused by overuse or strain.

Surgery for back pain in children is very rare, and is usually only considered for the more severe cases. If the child’s pain is severe, and he or she is having difficulty functioning, then surgery may be considered.

Most importantly, a careful process of elimination of medically more significant causes of back pain (such as tumor, infection, fracture) should always precede any therapeutic plan.

Julian Huang, MD
July 10, 2002