BMJ 2015;350:h1275 doi: 10.1136/bmj.h1275 (Published 2 April 2015)
Page 1 of 3
Practice
PRACTICE 10-MINUTE CONSULTATION
Teenagers with back pain 1
2
Adam D Jakes academic foundation doctor , Robert Phillips senior clinical academic honorary 3 4 consultant paediatric and TYA oncologist , Michael Scales general practitioner Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds LS9 7TF, UK; 2Centre for Reviews and Dissemination, University of York, York, UK; 3Leeds General Infirmary, Leeds, UK; 4Clinical Lecturer Academic Unit of Primary Care, University of Leeds, Leeds, UK 1
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
A 13 year old boy attends with his mother, complaining of aching lower back pain for two weeks.
What you should cover History
The onset, duration, and nature of the pain will help to differentiate non-specific (that is, unexplained, non-pathological) back pain from potentially serious conditions: • Pain of acute onset (within seconds) is likely to indicate injury such as a herniated vertebral disc, fracture, or muscle strain. • Pain of more than four weeks’ duration highlights an ongoing process that warrants further assessment.
Focused questions to illicit “red flags” are essential (box 1). By definition, teenagers with back pain fulfil one of these red flags as they are under 20 years old, requiring a high index of suspicion.
Pain at night, constant unremitting pain, or pain that spreads into the buttocks/legs may be manifestations of infection, arthritis, fracture, or malignancy. Morning stiffness (>30 minutes) or stiffness with rest or inactivity suggests an inflammatory cause, and the presence of uveitis, enthesitis, or family history of HLA-B27 warrants investigation for juvenile arthritis and ankylosing spondylitis. A personal or family history of psoriasis, nail changes, or inflammatory bowel disease increases the likelihood of a spondyloarthropathy. Systemic symptoms such as fever, significant weight loss (>10% within six months), and/or night sweats suggest potentially serious pathology such as malignancy (for example, lymphoma) or infection (discitis, vertebral osteomyelitis, tuberculosis). Limb weakness, sensation loss, or neuropathic pain may indicate nerve or spinal cord compression. If bowel/bladder dysfunction or saddle anaesthesia is present, cauda equina compression must be suspected.
Enquire about effects on activities of daily life and recreation: • Ask about the duration of backpack, television, and computer use, along with any history of injury.
• Pain during specific activities such as swimming (breast and butterfly stroke), weight lifting, or gymnastics, which require lumbar spine extension, may indicate spondylolysis (pars interarticularis fracture) or spondylolisthesis (forward displacement of vertebra).
Overweight children are at higher risk of back pain. Intermittent lower back pain affects 10-15% of young athletes,2 but it may be more common in gymnasts and contact sport participants. Observe the interaction and relationship dynamics between parent and child: • Teenagers can imitate illness behaviour, so enquire about parental back pain or chronic illness.
• Establish what has brought the patient to this consultation with this problem at this time. • Be aware of the parent’s agenda, which may be based on family history, media concerns, or internet searches. Take note of parental insight and knowledge when considering urgent referral.
Psychological problems can manifest as back pain. Consider whether this is an attempt to avoid school sports. Sensitively enquiring about friends, social activities, and home life may unearth concerns; however, this may become apparent only without a parent present. In addition, identify risk factors for development of long term back pain—for instance, with the Keele STarT Back Screening Tool (box 2)—which can guide management.
Examination Observe the patient as he walks in (for example, for evidence of a limp) and sits down. Observe the patient at rest—is he a “sloucher,” indicating a postural element? Look for abnormal curvature of the spine. A marked kyphosis may indicate
Correspondence to: A D Jakes [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1275 doi: 10.1136/bmj.h1275 (Published 2 April 2015)
Page 2 of 3
PRACTICE
The bottom line • Back pain in teenagers is common; characterising the pain and identifying the presence of red flags are vital to ensuring that potentially serious conditions are identified • Enquiring about life at home, activities of daily life, and recreation may unearth precipitating factors, as well as risk factors for chronicity
Box 1 Red flags—features that may indicate serious spinal pathology1 • Age 4 weeks • Thoracic spine pain • Night pain or wakes patient from sleep • Unremitting pain, even when supine • Fever, chills, night sweats • Unexplained weight loss • Immunocompromise or HIV • Previous malignancy • Corticosteroid use • Recent trauma • Progressive neurological deficit • Bladder or bowel dysfunction • Saddle anaesthesia • Disturbed gait or limp • Vertebral tenderness or deformity
Box 2 The Keele STarT Back Screening Tool In the past two weeks (yes=1 point; no=0 points): 1. My back pain has spread down my leg(s) at some time in the past 2 weeks 2. I have had pain in the shoulder or neck at some time in the past 2 weeks 3. I have only walked short distances because of my back pain 4. I have dressed more slowly than usual because of back pain 5. I feel that it’s not really safe for a person with a condition like mine to be physically active 6. Worrying thoughts have been going through my mind a lot of the time 7. I feel that my back pain is terrible and it’s never going to get any better 8. In general I have not enjoyed all the things I used to enjoy Overall (not at all (0 points), slightly (0 points), moderately (0 points), very much (1 point), or extremely (1 point)): 9. How bothersome has your back pain been in the past 2 weeks?
Total of 9 points: 1 point for each “yes” response to questions 1 to 8; question 9 scores 1 point for the responses “very much” or “extremely.” The scores are broken down as: 4=medium/high risk; supervised exercise programme with or without psychological counselling Use sub-score from questions 5-8 to differentiate medium and high risk: ≤3=medium risk; supervised exercise programme ≥4=high risk; augmented supervised exercise programme and psychological counselling
Scheuermann’s disease (osteochondrosis leading to wedge shaped deformities of the vertebrae). Examine the range of movement of the neck and spine, also looking for deformity and bony tenderness, including the sacroiliac joints. Do a modified Schober’s test. Measuring a point on the back 5 cm below and another 10 cm above the level of the posterior iliac spines (dimples of Venus), ask the patient to bend forward at the hip. An increase of less than 5 cm on forward flexion indicates limitation of lumbar flexion.
Examine both hips (for referred pain) and note any leg length discrepancy. A straight leg raise may produce dermatomal pain, which can identify nerve impingement from a herniated disc. Posterior thigh pain in a non-dermatomal distribution due to tight hamstrings does not constitute a “true positive” result. If you are concerned about possible neurological deficits, do a full neurological examination. If malignancy is suspected, palpate For personal use only: See rights and reprints http://www.bmj.com/permissions
for an enlarged liver, spleen, and lymph nodes. Absence of hepatosplenomegaly or lymphadenopathy does not exclude malignancies.
What you should do More than 75% of cases will have non-specific back pain and do not need further investigation3: • Careful explanation (box 3) and reassurance are crucial, together with correct posture and backpack advice,4 if warranted.
• If risk factors for chronicity or slow resolution are present, supervised exercise programmes (stretching and strengthening exercises for abdominal and trunk muscles) are the only evidence based conservative intervention for lower back pain in teenagers.5 Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1275 doi: 10.1136/bmj.h1275 (Published 2 April 2015)
Page 3 of 3
PRACTICE
• Analgesia is usually not needed.
If an inflammatory condition is suspected (for instance, owing to morning stiffness or a personal or family history of such a condition): • Request a full blood count and inflammatory markers (erythrocyte sedimentation rate/C reactive protein). • Refer to rheumatology if the above are positive or the diagnosis remains likely despite normal inflammatory markers.
• HLA B27 is associated with seronegative spondyloarthropathies but is not useful in initial assessment, being common in the UK general population (9.5%)8; most HLA B27 positive teenagers will have other causes of back pain. Systemic symptoms of fever, weight loss, and night sweats warrant a full blood count/film. Results suggesting infection will require further investigation for a potential source, with results indicative of a malignant process prompting an urgent referral to haematology. Vertebral deformities or suspicion of bone tumours require radiographs, best performed by paediatric, spinal, or orthopaedic specialists.
When to refer Evidence of cord or cauda equina compression requires immediate neurosurgical referral, and other neurological deficits necessitate urgent referral. Refer as discussed above if an inflammatory condition is suspected or systemic symptoms are present. Additional red flag features (box 1) also warrant urgent
For personal use only: See rights and reprints http://www.bmj.com/permissions
referral. Multiple presentations with the same problem, but with no clear diagnosis, may necessitate referral to a paediatrician for further assessment.1 Contributors: ADJ and MS developed the concept for the paper. All three authors contributed to the design and writing of the paper and its subsequent revisions. All the authors approved the final version to be published. MS is the guarantor. Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3 4 5 6 7 8
Davis PJ, Williams HJ. The investigation and management of back pain in children. Arch Dis Child Educ Pract Ed 2008;93:73-83. D’Hemecourt P, Gerbino PG 2nd, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 2000;19:663-79. Bhatia NN, Chow G, Timon SJ, et al. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop 2008;28:230-3. American Academy of Pediatrics, HealthyChildren.org. Backpack safety. 2013. www. healthychildren.org/English/safety-prevention/at-play/Pages/Backpack-Safety.aspx. Michaleff ZA, Kamper SJ, Maher CG, et al. Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. Eur Spine J 2014;23:2046-58. National Institute of Health and Clinical Excellence. Referral guidelines for suspected cancer: cancer in children and young people. NICE, 2005. Arthritis Research UK. Back pain. 2011. www.arthritisresearchuk.org/shop/products/ publications/patient-information/conditions/back-pain.aspx. Brown MA, Pile KD, Kennedy LG, et al. HLA class I associations of ankylosing spondylitis in the white population in the United Kingdom. Ann Rheum Dis 1996;55:268-70.
Accepted: 29 January 2015 Cite this as: BMJ 2015;350:h1275 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1275 doi: 10.1136/bmj.h1275 (Published 2 April 2015)
Page 4 of 3
PRACTICE
Box 3 Advice to patients • Back pain is common, is usually not serious, and usually gets better after a few weeks • This “non-specific” back pain is associated with the structures of the lower back rather than a disease process • It is best to continue with everyday activities, including physical activities at school6 • Always use both straps of a backpack and tighten the straps so that it is close to the body. Keep the weight carried to a minimum4 • Sit well back into a chair with feet flat on the floor and area of attention at eye level • Take regular breaks from TV and computer use • Patient information leaflets are available from Arthritis Research UK7
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Practice
PRACTICE 10-MINUTE CONSULTATION
Teenagers with back pain 1
2
Adam D Jakes academic foundation doctor , Robert Phillips senior clinical academic honorary 3 4 consultant paediatric and TYA oncologist , Michael Scales general practitioner Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds LS9 7TF, UK; 2Centre for Reviews and Dissemination, University of York, York, UK; 3Leeds General Infirmary, Leeds, UK; 4Clinical Lecturer Academic Unit of Primary Care, University of Leeds, Leeds, UK 1
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
A 13 year old boy attends with his mother, complaining of aching lower back pain for two weeks.
What you should cover History
The onset, duration, and nature of the pain will help to differentiate non-specific (that is, unexplained, non-pathological) back pain from potentially serious conditions: • Pain of acute onset (within seconds) is likely to indicate injury such as a herniated vertebral disc, fracture, or muscle strain. • Pain of more than four weeks’ duration highlights an ongoing process that warrants further assessment.
Focused questions to illicit “red flags” are essential (box 1). By definition, teenagers with back pain fulfil one of these red flags as they are under 20 years old, requiring a high index of suspicion.
Pain at night, constant unremitting pain, or pain that spreads into the buttocks/legs may be manifestations of infection, arthritis, fracture, or malignancy. Morning stiffness (>30 minutes) or stiffness with rest or inactivity suggests an inflammatory cause, and the presence of uveitis, enthesitis, or family history of HLA-B27 warrants investigation for juvenile arthritis and ankylosing spondylitis. A personal or family history of psoriasis, nail changes, or inflammatory bowel disease increases the likelihood of a spondyloarthropathy. Systemic symptoms such as fever, significant weight loss (>10% within six months), and/or night sweats suggest potentially serious pathology such as malignancy (for example, lymphoma) or infection (discitis, vertebral osteomyelitis, tuberculosis). Limb weakness, sensation loss, or neuropathic pain may indicate nerve or spinal cord compression. If bowel/bladder dysfunction or saddle anaesthesia is present, cauda equina compression must be suspected.
Enquire about effects on activities of daily life and recreation: • Ask about the duration of backpack, television, and computer use, along with any history of injury.
• Pain during specific activities such as swimming (breast and butterfly stroke), weight lifting, or gymnastics, which require lumbar spine extension, may indicate spondylolysis (pars interarticularis fracture) or spondylolisthesis (forward displacement of vertebra).
Overweight children are at higher risk of back pain. Intermittent lower back pain affects 10-15% of young athletes,2 but it may be more common in gymnasts and contact sport participants. Observe the interaction and relationship dynamics between parent and child: • Teenagers can imitate illness behaviour, so enquire about parental back pain or chronic illness.
• Establish what has brought the patient to this consultation with this problem at this time. • Be aware of the parent’s agenda, which may be based on family history, media concerns, or internet searches. Take note of parental insight and knowledge when considering urgent referral.
Psychological problems can manifest as back pain. Consider whether this is an attempt to avoid school sports. Sensitively enquiring about friends, social activities, and home life may unearth concerns; however, this may become apparent only without a parent present. In addition, identify risk factors for development of long term back pain—for instance, with the Keele STarT Back Screening Tool (box 2)—which can guide management.
Examination Observe the patient as he walks in (for example, for evidence of a limp) and sits down. Observe the patient at rest—is he a “sloucher,” indicating a postural element? Look for abnormal curvature of the spine. A marked kyphosis may indicate
Correspondence to: A D Jakes [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1275 doi: 10.1136/bmj.h1275 (Published 2 April 2015)
Page 2 of 3
PRACTICE
The bottom line • Back pain in teenagers is common; characterising the pain and identifying the presence of red flags are vital to ensuring that potentially serious conditions are identified • Enquiring about life at home, activities of daily life, and recreation may unearth precipitating factors, as well as risk factors for chronicity
Box 1 Red flags—features that may indicate serious spinal pathology1 • Age 4 weeks • Thoracic spine pain • Night pain or wakes patient from sleep • Unremitting pain, even when supine • Fever, chills, night sweats • Unexplained weight loss • Immunocompromise or HIV • Previous malignancy • Corticosteroid use • Recent trauma • Progressive neurological deficit • Bladder or bowel dysfunction • Saddle anaesthesia • Disturbed gait or limp • Vertebral tenderness or deformity
Box 2 The Keele STarT Back Screening Tool In the past two weeks (yes=1 point; no=0 points): 1. My back pain has spread down my leg(s) at some time in the past 2 weeks 2. I have had pain in the shoulder or neck at some time in the past 2 weeks 3. I have only walked short distances because of my back pain 4. I have dressed more slowly than usual because of back pain 5. I feel that it’s not really safe for a person with a condition like mine to be physically active 6. Worrying thoughts have been going through my mind a lot of the time 7. I feel that my back pain is terrible and it’s never going to get any better 8. In general I have not enjoyed all the things I used to enjoy Overall (not at all (0 points), slightly (0 points), moderately (0 points), very much (1 point), or extremely (1 point)): 9. How bothersome has your back pain been in the past 2 weeks?
Total of 9 points: 1 point for each “yes” response to questions 1 to 8; question 9 scores 1 point for the responses “very much” or “extremely.” The scores are broken down as: 4=medium/high risk; supervised exercise programme with or without psychological counselling Use sub-score from questions 5-8 to differentiate medium and high risk: ≤3=medium risk; supervised exercise programme ≥4=high risk; augmented supervised exercise programme and psychological counselling
Scheuermann’s disease (osteochondrosis leading to wedge shaped deformities of the vertebrae). Examine the range of movement of the neck and spine, also looking for deformity and bony tenderness, including the sacroiliac joints. Do a modified Schober’s test. Measuring a point on the back 5 cm below and another 10 cm above the level of the posterior iliac spines (dimples of Venus), ask the patient to bend forward at the hip. An increase of less than 5 cm on forward flexion indicates limitation of lumbar flexion.
Examine both hips (for referred pain) and note any leg length discrepancy. A straight leg raise may produce dermatomal pain, which can identify nerve impingement from a herniated disc. Posterior thigh pain in a non-dermatomal distribution due to tight hamstrings does not constitute a “true positive” result. If you are concerned about possible neurological deficits, do a full neurological examination. If malignancy is suspected, palpate For personal use only: See rights and reprints http://www.bmj.com/permissions
for an enlarged liver, spleen, and lymph nodes. Absence of hepatosplenomegaly or lymphadenopathy does not exclude malignancies.
What you should do More than 75% of cases will have non-specific back pain and do not need further investigation3: • Careful explanation (box 3) and reassurance are crucial, together with correct posture and backpack advice,4 if warranted.
• If risk factors for chronicity or slow resolution are present, supervised exercise programmes (stretching and strengthening exercises for abdominal and trunk muscles) are the only evidence based conservative intervention for lower back pain in teenagers.5 Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1275 doi: 10.1136/bmj.h1275 (Published 2 April 2015)
Page 3 of 3
PRACTICE
• Analgesia is usually not needed.
If an inflammatory condition is suspected (for instance, owing to morning stiffness or a personal or family history of such a condition): • Request a full blood count and inflammatory markers (erythrocyte sedimentation rate/C reactive protein). • Refer to rheumatology if the above are positive or the diagnosis remains likely despite normal inflammatory markers.
• HLA B27 is associated with seronegative spondyloarthropathies but is not useful in initial assessment, being common in the UK general population (9.5%)8; most HLA B27 positive teenagers will have other causes of back pain. Systemic symptoms of fever, weight loss, and night sweats warrant a full blood count/film. Results suggesting infection will require further investigation for a potential source, with results indicative of a malignant process prompting an urgent referral to haematology. Vertebral deformities or suspicion of bone tumours require radiographs, best performed by paediatric, spinal, or orthopaedic specialists.
When to refer Evidence of cord or cauda equina compression requires immediate neurosurgical referral, and other neurological deficits necessitate urgent referral. Refer as discussed above if an inflammatory condition is suspected or systemic symptoms are present. Additional red flag features (box 1) also warrant urgent
For personal use only: See rights and reprints http://www.bmj.com/permissions
referral. Multiple presentations with the same problem, but with no clear diagnosis, may necessitate referral to a paediatrician for further assessment.1 Contributors: ADJ and MS developed the concept for the paper. All three authors contributed to the design and writing of the paper and its subsequent revisions. All the authors approved the final version to be published. MS is the guarantor. Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3 4 5 6 7 8
Davis PJ, Williams HJ. The investigation and management of back pain in children. Arch Dis Child Educ Pract Ed 2008;93:73-83. D’Hemecourt P, Gerbino PG 2nd, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 2000;19:663-79. Bhatia NN, Chow G, Timon SJ, et al. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop 2008;28:230-3. American Academy of Pediatrics, HealthyChildren.org. Backpack safety. 2013. www. healthychildren.org/English/safety-prevention/at-play/Pages/Backpack-Safety.aspx. Michaleff ZA, Kamper SJ, Maher CG, et al. Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. Eur Spine J 2014;23:2046-58. National Institute of Health and Clinical Excellence. Referral guidelines for suspected cancer: cancer in children and young people. NICE, 2005. Arthritis Research UK. Back pain. 2011. www.arthritisresearchuk.org/shop/products/ publications/patient-information/conditions/back-pain.aspx. Brown MA, Pile KD, Kennedy LG, et al. HLA class I associations of ankylosing spondylitis in the white population in the United Kingdom. Ann Rheum Dis 1996;55:268-70.
Accepted: 29 January 2015 Cite this as: BMJ 2015;350:h1275 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1275 doi: 10.1136/bmj.h1275 (Published 2 April 2015)
Page 4 of 3
PRACTICE
Box 3 Advice to patients • Back pain is common, is usually not serious, and usually gets better after a few weeks • This “non-specific” back pain is associated with the structures of the lower back rather than a disease process • It is best to continue with everyday activities, including physical activities at school6 • Always use both straps of a backpack and tighten the straps so that it is close to the body. Keep the weight carried to a minimum4 • Sit well back into a chair with feet flat on the floor and area of attention at eye level • Take regular breaks from TV and computer use • Patient information leaflets are available from Arthritis Research UK7
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
