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myalgias due to influenza), infections with referred pain to the back (e.g.,
pneumonia, pelvic inflammatory disease, cholecystitis, and pancreatitis), and
herpes zoster.
Neoplasms, both benign and malignant, may present with back pain. Osteoid
osteoma, the most common tumor that presents with back pain, is benign and can
present with nocturnal pain that is relieved with anti-inflammatory medications.
Localized back pain can also result from primary bony malignancies (e.g., Ewing
sarcoma, osteosarcoma, and osteoblastoma), as well as bony metastases from
other sites. Other nonbony solid tumors (e.g., neuroblastoma, Wilms tumor) can
lead to regional pain. Leukemia, lymphoma, and other marrow infiltrative
processes can also cause back pain.
Inflammatory arthritides may present with back pain in children. These include
ankylosing spondylitis, inflammatory bowel disease–associated arthritis, reactive
sacroiliitis, and psoriatic arthritis. Arthritides typically have pain that is worse in
the morning and improves as the day progresses.
Finally, there are other causes of back pain that present in children. Children
with sickle cell disease can have vaso-occlusive crises of the spine and are also at
increased risk of infectious causes of back pain, especially osteomyelitis.
Nephrolithiasis and urinary tract obstruction, can cause severe back pain. Aortic
dissection is exceedingly rare in children but should be considered in patients
with Marfan syndrome or other connective tissue disorders. An imperforate
hymen can lead to recurrent back pain in an adolescent female. Chronic pain
syndromes also present with back pain, though they are unlikely to have isolated
back pain. Psychogenic back pain is a diagnosis of exclusion. Table 54.1 lists the
differential diagnosis for back pain.

EVALUATION AND DECISION
History. Evaluation of back pain begins with further characterization of the pain.
Where exactly is the pain? Localization of pain to a specific vertebra is more
suggestive of pathology at that location, such as a fracture or infection, as
opposed to the more generalized musculoskeletal lower back pain. What was the

onset of the pain like? Did it occur after trauma, raising suspicion for fracture, or
was it more insidious in onset? Does the pain radiate down the buttock and the
back of the leg suggesting a radiculopathy from a herniated lumbar disc? What
does it feel like? Is it dull and achy like muscular pain? How severe is the pain?
Does anything make the pain better or worse? Pain that improves as the day
progresses may be suggestive of a rheumatologic etiology, pain that worsens with
activity is typically musculoskeletal, and pain at night may be indicative of more