| Condition | Typical age group/risk groups | Clinical features |
| Thoracic or lumbar spine pain |
| Osteoid osteoma (common) | - Second decade of life
- More common in males than females
| - Nocturnal pain
- Pain unrelated to activity
- Prompt relief with NSAIDs
- May be associated with scoliosis
|
| Malignant tumors of the spine: - Malignant primary tumors (eg, Ewing sarcoma, osteochondroma)
- Secondary malignancy (eg, leukemia, lymphoma, neuroblastoma, metastatic disease)
| - All ages
- May have history of malignancy
| - Nocturnal pain
- Constant pain (unchanged by activity)
- Systemic symptoms (eg, fever, weight loss, malaise)
- Pain <3 months duration
- May be associated with recent onset scoliosis
|
| Tumors of the spinal cord: - Intramedullary (eg, ependymoma)
- Extradural (eg, neuroblastoma, lymphoma, PNET)
- Intradural-extramedullary (eg, neurofibroma, schwannoma)
| - Varies with type of tumor
| - Nocturnal pain
- Abnormal neurologic findings (eg, difficulty walking, sphincter dysfunction)
|
| Vertebral osteomyelitis (including tuberculous spondylitis [Pott disease]) | | - Nocturnal pain
- Constant pain (unchanged by activity)
- Localized pain, worse with percussion or palpation
- Systemic symptoms (eg, fever, malaise)
- Ill appearance
- May be associated with recent-onset scoliosis
- Exposure to tuberculosis (for tuberculous spondylitis)
|
| Tethered cord | | - Neurologic abnormalities (eg, bladder dysfunction, leg weakness, calf muscle atrophy, diminished/absent DTRs, dermatomal sensory loss, foot drop)
- Recent onset of scoliosis with severe pain
- Older children: Back pain exacerbated by exercise
- Younger children: Refusal to perform certain activities
|
| Syringomyelia | - All ages
- Associated with:
- Congenital anomalies (eg, Arnold-Chiari type I malformation)
- History of spinal infection, inflammation, tumor, or trauma
| - Recent onset scoliosis with severe pain
|
| Transverse myelitis | - All ages
- May be associated with:
- Infection
- Systemic inflammatory autoimmune disorders (eg, SLE, ankylosing spondylitis)
| - Abnormal neurologic findings (motor, sensor, and/or autonomic)
|
| Vaso-occlusive pain in a child with sickle cell disease | - History of sickle cell disease
- Pain in other bones
- Abnormal urinalysis (concentrating defect, hematuria, proteinuria)
| |
| Chronic nonbacterial osteomyelitis/chronic multifocal osteomyelitis affecting the vertebrae (rare) | - All ages with a peak onset between age 7 and 12 years
- More common in females than males
- Associated with:
- Psoriasis
- Palmoplantar pustulosis
- Acne
- IBD
- Spondyloarthropathy
| - Nocturnal pain
- May have constant pain
- May have systemic symptoms (eg, fever)
|
| Spinal epidural abscess (rare) | - Any age
- Associated with:
- Bacteremia
- Epidural catheter placement
| - Fever
- Localized pain, worse with percussion or palpation
- Radicular pain
- Neurologic deficit
|
| Lumbar, lumbosacral, or sacroiliac joint pain |
| Spondylolysis (common) | - Early adolescence
- More common in males than females
- Associated with:
- Scheuermann kyphosis
- Repetitive trauma, particularly lumbar extension (eg, gymnastics, dance, weightlifting)
| - Pain may extend into buttocks and posterior thighs
- Pain worse with extension/improved with rest
- Hamstring tightness
- Positive SLR
- Limited forward bending
|
| Spondylolisthesis | - Early adolescence
- More common in males than females
- Associated with:
- Scheuermann kyphosis
- Repetitive trauma, particularly lumbar extension (eg, gymnastics, dance, weightlifting)
| - Pain may extend into buttocks and posterior thighs
- Pain with extension
- Hamstring tightness
- Prominent spinous process
- Flattening of normal lumbar lordosis
- Knee-flexed, hip-flexed gait (Phalen-Dickson sign)
|
| Intervertebral disc herniation | - Adolescents
- Acute trauma and axial load
- Scheuermann kyphosis
- Family history of intervertebral disc herniation
- Obesity/overweight
- Associated with:
- Weightlifting
- Wrestling
- Gymnastics
- Collision sports
| - Pain radiating to buttocks or lower extremities
- Pain worse with flexion
- Limited spinal flexibility
- Positive SLR test
- Leg pain is often worse than back pain
|
| Apophyseal ring fracture (slipped vertebral apophysis) | - Adolescents
- More common in males than females
- Associated with:
- Gymnastics
| - Pain radiating to buttocks or lower extremities
- Pain worse with flexion
- Positive SLR test
- Leg pain is often worse than back pain
|
| Sacroiliac joint infection | | - Fever
- Sacral pain
- Pain with maneuvers that twist the pelvis (eg, the FABERE test)
|
Inflammatory arthritis: - Enthesitis-related arthritis
- Ankylosing spondylitis
- Psoriatic arthritis, psoriatic JIA
- Reactive arthritis
- IBD-associated arthritis
| - Family history of inflammatory spondylitis
| - Nocturnal pain
- Morning stiffness
- Chronic pain
- Sacroiliac joint tenderness (eg, positive FABERE test)
- Flattening of the lumbar curve on forward flexion
- Involvement of other joints
|
| Discitis (rare) | | - Nocturnal pain
- Generally affects lower lumbar spine
- Gradual onset of back pain, irritability, or refusal to walk or crawl
- Minimal systemic toxicity
|
| Paraspinal muscle pain |
| Pyomyositis | - Children age 2 to 5 years
- Adults age 20 to 45 years
- Associated with:
- Immunodeficiency
- Injection drug use
- Concurrent infection
- Malnutrition
| - Fever
- Pain usually localized to single muscle group, but multiple muscle groups may be involved
- Systemic toxicity with progression
|
| Viral myalgia (common) | | - Fever
- Signs/symptoms of viral illness (eg, rhinitis, pharyngitis, cough)
|
| Non-midline (referred) back pain |
| Pyelonephritis (common) | | - Dysuria
- Fever
- Abnormal urinalysis (pyuria, bacteriuria)
|
| Pneumonia | | |
| Pelvic inflammatory disease | - Sexually active female adolescent
| - Fever
- Abdominal/pelvic pain
|
| Nephrolithiasis | | - Severe pain
- Abnormal urinalysis (hematuria)
|
| Pancreatitis | - Associated with:
- Trauma
- Infection
- Structural anomalies
- Certain medications
| - Fever
- Acute steady upper abdominal pain that may radiate to back
- Nausea and vomiting
- Relief with bending forward
|
