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Approach To Pediatric Back Pain

Ilene Claudius , MD, Andrea Marmor, MD, and Mizuho Morrison, DO
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Back pain in kids is most commonly musculoskeletal but the differential diagnosis includes a few “can’t miss” diagnoses. When evaluating children with back pain, having a standardized approach that includes looking for the “red flags” in both the history and physical is important and helps the clinician make appropriate decisions regarding further work up. 

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Mary Ellen P., NP-C -

It has always been my understanding that if I'm obtaining an MR study for back pain with a concern of infectious etiology that I should image the entire spine. Would this be true in the pediatric population as well? Thanks! Great segment and I absolutely love urgent care rap.

Mike W., MD -

Hi Mary, thx for the question and your support of uc rap!!
Here is the respons from Ilene Claudius:
I don't know that there is a universally accepted answer, but my gestalt would be no. For discitis, it is likely focal. There are only 30 reported cases of pediatric epidural abscesses over the last 19 years, so unlikely that, but also usually focal. I suppose if there were a concern for multi-focal osteo, then yes the whole spine. Tough question, and I suppose if I were sedating a kid for an MRI, I'd probably get the whole spine- just to avoid any possibility of having to go back. If I tried without sedation, I'd likely do something faster and more focal- for what that's worth

Ilene

Elizabeth M. -

I had an interesting case of pediatric back pain last week, but the most interesting part is the EKG... can I send that to you?
13yo AA male. PMH asthma. Complaining of upper to mid thoracic back pain x 1 day. Worse with sitting up straight, coughing, sneezing, deep breathing. No injury. No other associated sxs. No pertinent family hx.
He was promptly sent to the ER following the EKG, so we didn't obtain an x-ray.
Mom reported the ER performed another EKG and an x-ray, then discharged pt to f/u with Cardiology the next day. I haven't obtained any records from the ER or Cardiologist, but mom reports the EKG the next day was normal and Cardiology said pt's pain was due to a "growth spurt."
Our team wouldn't do anything different if it happened again, but it was an interesting case because the EKG was so abnormal. I hadn't planned on getting an EKG just given pt's complain, but mom was worried about pt's heart. Have you heard of a growth spurt causing an abnormal EKG?

Mizuho M., DO -

HI Elizabeth, Its not uncommon for kids to have "abnormal looking ECG's" when compared to adults. There are many findings that would be considered "abnormal" in an adult, but can be very common and benign for children. Which is why it is important to know what you are looking for on ECG. This sounds like an interesting case. ..curious to know what you were trying to rule out initially? Back pain is always something to have your antennas up with in kids: Pneumothorax, pericardial effusion, pna, MSK, malignancy etc...so many concerning causes to consider. I've not heard of growth spurt causing ECG changes...it sounds like the Cardiologist was perhaps referring the pain to being MSK related, but the ecg was benign...hence more of a diagnosis of exclusion. But without further detail hard to tell. :) Sounds like you did the right thing regardless referring him to the ED for further workup.

William Keith W. -

A great topic, ECG normal variants. Did the back pain resolve?

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Off The Cuff Full episode audio for MD edition 169:22 min - 79 MB - M4AHippo Urgent Care RAP September 2019 Written Summary 681 KB - PDF

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