What guidelines exist to aid the practitioner in pursuing an effective and systematic approach to the child with back pain

An algorithm has been developed to guide patient assessment on data obtained from clinical history and physical examination (Figure 36-1). The algorithm takes into account three factors:

1. Mechanism of injury: Clear or unclear

2. Nature of symptoms/physical findings: Local vs. systemic vs. neurologic

3. Duration of symptoms: Less than 1 month vs. greater than 1 month

The patient may enter into the algorithm at any stage on findings noted in the history and physical examination. The patient may progress from a lower to a higher level based on the above three factors. The algorithm has four levels:

Figure 36-1. Diagnostic algorithm for back pain in children. BMT, bone mineral testing (DEXA) ; CBC, complete blood count; CRP, C-reactive protein; CT, computed tomography; ESR, erythrocyte sedimentation rate; HNP, herniated nucleus pulposus ; MRI, magnetic resonance imaging; PE, physical examination; Rx, therapy; SPeCt, single-photon emission computed tomography; Sx, symptoms. (Redrawn from Ecker ML. Back pain. Spine State Art Rev 2000;14:236.)

Figure 36-1. Diagnostic algorithm for back pain in children. BMT, bone mineral testing (DEXA) ; CBC, complete blood count; CRP, C-reactive protein; CT, computed tomography; ESR, erythrocyte sedimentation rate; HNP, herniated nucleus pulposus ; MRI, magnetic resonance imaging; PE, physical examination; Rx, therapy; SPeCt, single-photon emission computed tomography; Sx, symptoms. (Redrawn from Ecker ML. Back pain. Spine State Art Rev 2000;14:236.)

LEVEL 1

• Mechanism: Clear history of specific injury

• Nature of symptoms/findings: Symptoms localized to back pain

• Duration of symptoms: Less than 1 month

• Studies/action needed: Symptomatic treatment (activity restriction, nonsteroidal antiinflammatory drugs [NSAIDs]) and follow-up in 1 month. If symptoms persist, advance to Level 2.

LEVEL 2

• Mechanism: History unclear

• Nature of symptoms: Back pain without systemic or neurologic signs, minor physical findings (spinal asymmetry, hamstring spasm), progression from level 1

• Duration of symptoms: Greater than 1 month

• Studies/action needed: PA and lateral radiographs of entire spine (lumbosacral [LS] spine radiographs if spondylolysis/ spondylolisthesis suspected). Positive radiographs (Scheuermann's disease, spondylolysis, significant scoliosis) can be referred to a specialist. Patients with negative radiographs can be observed or advanced to Level 3, depending on clinical judgment

LEVEL 3

• Mechanism: History unclear

• Nature of symptoms: Back pain with systemic symptoms (fever, weight loss)

• Duration of symptoms: Greater than 1 month

• Studies/action needed: CBC, ESR, C-reactive protein, and bone scan in addition to spinal radiographs. Patients with negative findings on these studies require only symptomatic treatment as most serious disorders have been excluded. Patients with positive studies require specialty referral

LEVEL 4

• Mechanism: History unclear

• Nature of symptoms: Back pain with neurologic deficit or patients advanced from Level 3

• Duration of symptoms: Generally greater than 1 month but not always

• Studies/action needed: MRI and/or CT is obtained in addition to Level 3 studies (radiographs, CBC, ESR, C-reactive protein, bone scan). Refer patient to surgeon for assessment for surgical treatment

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