Back pain

Introduction

Back pain is a relatively common presentation to GP’s in the older child/adolescent patient with prevalence varying between 14 and 24%^{1, 2}. It may be related to recognisable physiological variants or pathological entities. In many cases, there is no specific aetiology identified, but appears to arise from the “posterior spinal elements” of the facet joints, paraspinal muscles and associated structures. Back pain in adolescents is often self-limiting.

Common associated findings include biomechanical changes such as hypermobility or altered gait due to pes planus. Other causes may include pars interarticularis defects, Scheuermann’s disease, and less commonly, inflammatory diseases (juvenile idiopathic arthritis, chronic recurrent multifocal arthritis, myositis etc). Sinister pathology needs to be excluded; infection (discitis, osteomyelitis of the vertebrae, muscle abscess, pyelonephritis), malignancy (leukaemia, renal tumours, cancers of the bone, spinal canal, or surrounding structures). Disc prolapse is uncommon in childhood but presents with similar changes as in an adult patient. Significant back pain is rarely due to the isolated finding of elevated body mass index.

Pre-referral investigations

Clinical history including:

• Onset
• Diurnal patterns in the pain
• Aggravating/relieving factors

Physical examination including:

• spine tenderness, movement, facet joint stress manoeuvres
• neurological examination upper and lower limbs, including straight leg raise
• general systems examination, including cardiovascular system, respiratory, abdominal examinations, palpation for lymphadenopathy
• peripheral joint examination to screen for unrecognised arthritis, or hypermobility

Investigations to be guided by history and examination findings and may include:

• Urinalysis, urine MC&S
• Blood tests (ESR, CRP, FBP)
• Imaging:
  • If spinal abnormalities are present, consider spinal x-ray
  • If neurological findings are present, consider MRI.

Pre-referral management

• Short course of oral simple analgesia
  • longer acting NSAIDs such as naproxen can be used
  • Opioid analgesia is not indicated
• Refer to Community Physiotherapist for assessment and management
• Consider Podiatry review, especially if significant pes planus is observed
• Direct family to online information (see useful resources below)

When to refer

If the back pain has been:

• consistently present for >6 weeks
• causing major alteration in function
• causing school absence, loss of social activity
• affecting sleep, altering mood. 

How to refer

• Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
• Routine non-urgent referrals from private hospitals are made via the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au)
• Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 2222 to discuss referral with the on-call Rheumatologist.

Essential information to include in your referral

• Relevant history and examination findings
• Results of investigations
• Current functional level/ impairments
• Response to management to date (including Physiotherapy).

Useful resources

• Pain Health - WA Department of Health
• Back pain in children - Better Health Channel

References

1. King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, MacDonald AJ. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011;152(12):2729–2738.
2. Rathleff MS, Roos EM, Olesen JL, Rasmussen S. High prevalence of daily and multi-site pain–a cross-sectional population-based study among 3000 Danish adolescents. BMC Pediatr. 2013;13:191.

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