Diagnostic Modalities for the Evaluation of Pediatric Back Pain

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Abstract
The commonly taught premise that pediatric back pain frequently has an underlying diagnosis has been recently challenged. Previous studies have suggested that up to 84% of children with low back pain have associated serious diagnoses. Children with back pain, therefore, have frequently undergone exhaustive diagnostic testing. There have been few prospective studies, however, about the diagnosis rate and appropriate diagnostic methods for back pain in children. This study prospectively examines the rate of diagnosis for pediatric back pain and the value of various diagnostic studies for this problem. Methods: All patients presenting to our institution with a chief complaint of back pain were evaluated for the study. Inclusion criteria consisted of age younger than 18 years, no previous back surgery, no previous diagnosis given, and duration of pain longer than 3 months. Seventy-three patients were enrolled in the study, and an algorithm was created for diagnostic evaluation. The algorithm incorporated commonly used diagnostic techniques including radiographs, magnetic resonance imaging, computed tomography, bone scan, and laboratory studies. The end point was considered to be either (1) a definitive diagnosis or (2) no diagnosis and no symptomatic or clinical changes during a 2-year period. Results: Fifty-seven patients (78.1%) ended with no diagnosis. Of the remaining 16, 9 were diagnosed with spondylolysis with or without spondylolisthesis. Three other patients had abnormal laboratory values but no definitive diagnosis. Other diagnoses included Scheuermann disease (n = 2), osteoid osteoma (n = 1), and a herniated disk (n = 1). Conclusions: This investigation is the largest prospective study of diagnostic modalities in pediatric back pain to date. Contrary to most of the previously published data, most of our patients ended the study with no definitive diagnosis. In addition, the most of the diagnoses were made at initial physical examination or via initial plain radiographs. No diagnoses were missed using our algorithm. These results suggest that pediatric back pain frequently does not carry a definitive diagnosis and that exhaustive diagnostic protocols may not be necessary for this problem. Level of Evidence: Prospective study; Level 2 clinical evidence.

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