Teenagers with back painBMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h1275 (Published 02 April 2015) Cite this as: BMJ 2015;350:h1275
- Adam D Jakes, academic foundation doctor1,
- Robert Phillips, senior clinical academic2, honorary consultant paediatric and TYA oncologist3,
- Michael Scales, general practitioner4
- 1Leeds 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
- Correspondence to: A D Jakes
- Accepted 29 January 2015
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
A 13 year old boy attends with his mother, complaining of aching lower back pain for two weeks.
What you should cover
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.
Box 1 Red flags—features that may indicate serious spinal pathology1
Age <20 years (especially prepubertal)
Sudden onset of severe back pain
Duration >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
Progressive neurological deficit
Bladder or bowel dysfunction
Disturbed gait or limp
Vertebral tenderness or deformity
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 …
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