Practice 10-Minute Consultation

Teenagers with back pain

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1275 (Published 02 April 2015) Cite this as: BMJ 2015;350:h1275
  1. Adam D Jakes, academic foundation doctor1,
  2. Robert Phillips, senior clinical academic2, honorary consultant paediatric and TYA oncologist3,
  3. Michael Scales, general practitioner4
  1. 1Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds LS9 7TF, UK
  2. 2Centre for Reviews and Dissemination, University of York, York, UK
  3. 3Leeds General Infirmary, Leeds, UK
  4. 4Clinical Lecturer Academic Unit of Primary Care, University of Leeds, Leeds, UK
  1. Correspondence to: A D Jakes adam.jakes{at}hyms.ac.uk
  • 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

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.

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

  • Previous malignancy

  • Corticosteroid use

  • Recent trauma

  • Progressive neurological deficit

  • Bladder or bowel dysfunction

  • Saddle anaesthesia

  • 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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