The adolescent with back pain in the ED

first read: back pain in the ED

see also: orthopaedics in the ED; paediatric emergency medicine

• traumatic:
  • muscle strain or tendinitis
  • crush fracture Tx vertebrae from compressive injury or hyperflexion injury (eg. fall from pushbike over handlebars onto head or fall from height onto feet)
  • fracture transverse process Lx spine from high impact direct blow or tearing injury from muscle injury
  • renal trauma
  • pyelonephritis
• thoracic kyphosis:
  • Scheuermann's disease - esp. males early adolescence, upper Tx spine resulting in wedging & kyphosis
  • post-traumatic thoracic spine fracture
  • habitual
  • ankylosing spondylitis (10% start before puberty, peak onset 15-25yr olds; always causes sacro-iliitis as well)
• scoliosis:
  • postural - curve disappears when bend to touch toes
  • compensatory - due to pelvic tilt from unequal leg length
  • spasmodic - due to acute muscle spasm as in acute disc prolapse, pyelonephritis or appendicitis
  • structural:
    • congenital - eg. hemivertebrae
    • neuropathic - eg. polio, neurofibromatosis
    • myopathic - eg. muscular dystrophy
    • idiopathic
• hyperlordosis of lumbar spine:
  • racial (eg. negro women)
  • secondary to large abdomen (obesity, pregnancy) which throws centre of gravity forwards & pt compensates by angling upper trunk backwards
  • secondary to thoracic kyphosis
  • spondylolisthesis - posterior elements of L4/5 usually, fail to hold two vertebral levels in place allowing the upper body to slip forward on the lower body & occurs in 3-7% of the population.
  • congenital structural defect (spondylolysis)
  • post-trauma or surgery
  • sports with high shear loads in flexion, esp. in adolescents - gymnastics, rugby, diving, javelin-throwing, wrestling, weightlifting, golf
• uncommonly:
  • gynae. causes such as imperforate hymen, miscarriage, endometriosis
  • lumbar disc prolapse
• rarely:
  • sacro-ileitis:
    • ankylosing spondylitis (10% start before puberty, peak onset 15-25yr olds)
    • psoriasis (5% of pts with psoriasis)
    • Reiter's disease - males mainly; non-specific urethritis, polyarthritis (esp. sacro-iliac, lower limbs), conjunctivitis
    • discitis (loss of disc space on Xray) eg. TB, idiopathic (usually lumbar)
    • osteomyelitis spine
    • tumour

• avoid Xrays unless absolutely necessary as high radiation dose to gonads & then ensure not pregnant, and yield is not high unless major trauma or a compressive trauma such as landing on head or severe hyperflexion such as a MVA lap belt injury or fall from height resulting in an unstable Chance fracture
• urinalysis
• if pubertal amenorrhoeic female, consider imperforate hymen
• if scoliosis:
  • 1. are legs equal length - palpate ASIS whilst standing - if not then compensatory scoliosis
  • 2. is it just postural - ie. it corrects on bending to touch toes
  • 3. otherwise, neuro exam, Xray whole spine & refer to paed. orthopaedics
• if thoracic kyphosis, Xray Tx spine to demonstrate Scheuermann's disease & refer to paed. orthopaedics
• if febrile, unwell with normal urinalysis, and spine tenderness, suspect osteomyelitis of spine.
• if sacro-ileitis, check skin, nails for psoriasis, consider Xray for ankylosing spondylitis features, if male, ask about features of Reiter's