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Virtual Pediatric Hospital: Back Pain in Children: Diagnostic Algorithm Back Pain in Children

Diagnostic Algorithm

Michael P. D'Alessandro, M.D.
Peer Review Status: Internally Peer Reviewed


Diagnostic Algorithm
The diagnostic workup of a child with back pain should always commence with a proper history and physical exam. Seven important warning signs have been identified that if found on history and physical exam should alert the clinician that there is a high probability for an underlying serious cause of back pain. First is if the child is less than four years old. Second is if the back pain causes a functional disability. Children like to play, and if the pain causes them to ask to miss sports, gym, or recess, the pain is serious. Third is a duration of greater than four weeks. Traumatic musculoligamentous injuries should resolve in that time. Fourth is the presence of a fever. Fifth is a postural shift of the trunk caused by the pain with the child chronically splinting to decrease the pain. Sixth is a limitation of motion due to the pain. Seventh is the presence of a neurologic abnormality.

Once a problem list and differential diagnosis have been generated, they should be used to guide the ordering of the proper laboratory tests, if necessary. The presence of an elevated white blood cell count and / or sedimentation rate should suggest the presence of an inflammatory process.

Once the lab test results have been obtained, they should be used to guide the ordering of the proper imaging tests, if necessary. The first imaging test in the child with back pain is a plain film of the spine, including Anterior-Posterior (AP) and lateral views. If the plain film of the spine is positive for a lesion, the lesion should be further investigated with computed tomography (CT) with thin slices. If the plain film of the spine is negative, a bone scan should be performed with tomographic imaging. Tomographic imaging when done with a bone scan increases the sensitivity of the bone scan. If the bone scan demonstrates a lesion, it should be further investigated with computed tomography with thin slices. If the bone scan is negative, a magnetic resonance imaging (MRI) exam of the spine may be done, but it has a low probability of success, unless the lesion is suspected to be a herniated disk. If the MRI demonstrates a lesion, it should be further investigated with computed tomography with thin slices.

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