A rare cause of back pain in children: Notalgia paresthetica.

Overview Pediatric and adolescent back pain is a common complaint in the outpatient setting. Recent studies report that 17.8% of 9 to 12-year-old children had at least 1 episode of back pain in a 2-year observation period (14). Recent questionnaire studies have reported at least 1 lifetime episode of low back pain in 39% to 67% of European adolescents (4, 11). While most of these complaints are minor and self-limited, there are subsets of the pediatric and adolescent population that will present with a unique set of differential diagnoses. In special populations, the differential diagnosis will guide evaluation. Patients with sickle cell disease can present with bone pain during a vasoocclusive crisis. Children under 5 years old are much more susceptible to discitis and vertebral osteomyelitis due to their unique anatomy (15). Back pain in children <5 years old is associated with a significant pathological diagnosis in up to 50% of patients, and further extensive work-up is indicated (6). Finally while individually rare, a number of pediatric cancers will present with low back pain, pain radiating to the back, or painful scoliosis (8). In the adolescent sports medicine population, the etiology of low back pain is different from adults and is related in part to the rapid growth associated with adolescence (10). Injuries, both acute and chronic, occur when the spine and its supporting structures cannot accommodate the compression, distraction, or shear forces associated with activity. During growth, the vertebral bodies and neural arch are the weakest parts of the spinal column and are at the greatest risk of injury during force transfer (12). In late childhood, linear growth increases at a greater rate than bone mineral density (BMD), resulting in a relative decrease in bone density (1). This may result in an increased risk for fractures, both acute fractures from trauma, and stress fractures from repetitive activity (9). Following the early adolescent growth spurt, BMD increases more rapidly as vertical growth velocity slows, allowing for progress toward normal adult bone density (1). The lower lumbar pars interarticularis is particularly at risk for stress fractures. Adolescent athletes who engage in sports that involve axial loading of the spine, such as snowboarding, diving, and motor cross, also are at risk for vertebral body compression fractures since the bone density may be diminished transiently during rapid growth (2). Rapid growth also leads to decreased flexibility of the hamstrings and the hip flexors, increasing force demands on the low back muscles and supporting structures. Common causes of back pain in the athletic adolescent population include spondylolysis (up to 47% in pediatric sports medicine clinics) and hyperlordosis (25%) (10). Athletes who participate in repetitive hyperextension activities, such as gymnastics, football, and dance are particularly at risk for each of these conditions. Disc pain (11%) does occur in this population, but unlike adults, disc herniation of the nucleus pulposus often does not occur through the annulus fibrosus. Instead, it herniates through the weaker cartilaginous end plate, resulting in either an apophyseal ring fracture (avulsion of the apophysis with the intact annulus attached) or a disc herniation into the vertebral body (limbus vertebrae) (7). Occasionally the discs can herniate through the inferior border of the vertebral body, creating a Schmorl node as seen in Scheuermann disease. Tumors and infection are very infrequent causes of adolescent back pain. However their presentation often will mimic common back complaints (8). Lesions that involve the posterior column, including osteoid osteoma, osteoblastoma, and aneurysmal bone cysts, may mimic symptoms of spondylolysis. They generally are not associated with systemic symptoms or focal neurological deficits. Osteoid osteomas classically cause nighttime pain relieved by salicylates and some decrease in range of motion secondary to pain. Osteoblastomas usually cause dull pain and are not associated with nighttime pain. Both may cause painful scoliosis. Aneurysmal bone cysts generally cause pain secondary to expansion of the cyst or pathological fracture through the cyst similar to a spondylolytic lesion (8). Malignant lesions of the spine include leukemia, metastatic lesions, and primary malignant tumors such as Ewing sarcoma and osteogenic sarcoma. Metastatic lesions are more common than primary tumors (3). Ewing sarcoma is the most common malignant spine tumor and often involves the pelvis, with sacral involvement being associated with lumbar back pain (3). Spinal cord lesions are rare and usually associated with worsening gait and bowel and bladder symptoms. Isolated back pain is a well-documented but rare presentation of leukemia (13). Case Report History A previously healthy 12-year-old boy who plays recreational baseball is referred to the Department of Orthopedics by his primary care physician for a 2-month history of lumbar and lower thoracic back pain and “muscle spasms.” The pain involves the midline and adjacent paraspinal areas of the lower thoracic and lumbar back. He describes the pain as sharp, episodic, and radiating to the calves bilaterally. Episodes occur sporadically and last only a few minutes. He reports that sometimes the pain is associated with running. It sometimes is relieved with stretching. Initially the pain only occurred about twice a week, but now, the episodes happen daily. Pain can be with activity or at rest. He is pain free and functions normally between the painful episodes. There is no history of trauma or injury. He denies lower extremity numbness, tingling, and weakness. He has no bowel or bladder dysfunction. He has no fevers, painful nocturnal awakenings, or morning stiffness. There is no reported fatigue, pallor, or frequent infections. He has no allergies and takes no medications. Family history is negative for autoimmune arthritis or back problems including disc disease. Of note, his father died from a myocardial infarction at the age of 32 years. Physical Examination Well-developed male in no distress. Vital signs: T, 37°C; Ht, 59 inches (50th percentile); Wt, 56 kg (90th percentile). Pain score: 0. Head eyes ears nose throat: pupils equal round, reactive to light, no icterus, no lymphadenopathy. Spine: full Cervical ROM without pain, normal contour, no cutaneous abnormalities. Adam’s forward bend test: no pain, no rib hump. No pain with side bending, rotation, or hyperextension. The iliac crest is mildly tender to palpation bilaterally. There is full, pain-free range of motion at the hips, including internal or external rotation. Strength is 5/5 and pain free upon resisted testing of the muscles about the hips and pelvis, but he is unable to hold a standard plank. Thomas test is positive bilaterally. Popliteal angle compliment is 45 degrees bilaterally. Straight leg raise is negative. Single-leg hop does not cause pain. Deep tendon reflexes at the patellae and Achilles are normal. He has normal, symmetric strength in the lower extremities with no atrophy. He has normal light touch sensation and no clonus. His gait is normal. Differential Diagnosis Muscle spasm Lumbar musculature strain Iliac crest apophysitis Spondylolysis Spondylolisthesis Infection Neoplasm Spondyloarthropathy Management Plain radiographs of the lumbar spine (Figs. 1, 2) are performed in the office on the day of presentation. Imaging is done to evaluate for possible spondylolisthesis or other conditions that potentially would cause lumbar muscle pain or spasms. These images are normal.FIGURE 1: Anterior-posterior x-rays of lumbar spine.FIGURE 2: Lateral x-rays of lumbar spine.The initial presentation of deficits in core strength and flexibility (tight hamstrings, iliopsoas muscles), along with mild iliac crest tenderness and normal radiographs, is consistent with a muscular etiology of lumbar back pain and associated muscle spasm. There are no red flags of nocturnal pain, unexplained constitutional symptoms (fevers, poor appetite, weight loss, fatigue/lack of energy) or physical examination findings to suggest additional imaging is needed. He is prescribed physical therapy to address the biomechanical deficits found on the examination. The plan is for follow-up after 4 wk of therapy if the pain persists or sooner if symptoms become worse. Three weeks after the initial visit, his mother calls with new concerns. There have been no interim injuries, but the painful episodes are more frequent, now up to three times a day despite physical therapy. The intensity of the pain has increased as well, with pain severe enough to “bring him to his knees.” His mother also reports that he has developed an intermittent rash this week that “looks like hives” and one episode of low-grade fever (100.5°F). He is reevaluated in the office the day his mother calls. The physical examination is unchanged. He is afebrile and has no pain at the time of the examination. His skin appears normal with no rash or bruising. He has no lymphadenopathy or hepatosplenomegaly. Given the new concerns, particularly the dramatic increase in pain, the unexplained rash, and a questionable fever, a new plan is developed. Diagnostic considerations remain similar to the initial differential, but there is a heightened level of concerns for occult infection or neoplasm. Blood work (complete blood count, erythrocyte sedimentation rate, and comprehensive metabolic panel) and magnetic resonance imaging (MRI) of the lumbar spine are ordered. Blood work returns 2 d later with white blood cells 3,400 μL−1 (2% polymorphonuclear leukocytes, 98% lymphocytes, 12 atypical lymphocytes, no blasts, absolute neutrophil count 68), hemoglobin 8.1 mg·dL−1, hematocrit 22.6%, and platelets reported as clumped. His CMP is normal including calcium, alkaline phosphatase, and uric acid. ESR is 22 mm·h−1. He is contacted immediately upon receipt of these results and advised to proceed to the emergency department for urgent evaluation of anemia and neutropenia. He is admitted to the oncology service. Their work-up includes a bone marrow biopsy that reveals hypercellularity with greater than 95% blasts, consistent with leukemia. MRI of the entire spine is performed shortly after admission and revealed diffuse marrow signal abnormality (T1 hypointensity and short TI inversion recovery hyperintensity) throughout the vertebrae and other visualized osseous structures. There is no spinal cord compression or vertebral fractures. Radiologist report notes that “while this may represent red marrow conversion related to underlying anemia, the appearance is concerning for leukemic or other marrow infiltration.” He is diagnosed ultimately with acute myeloid leukemia (AML). Discussion The young adolescent patient in our case presents with low back pain in association with relative core weakness and lower extremity muscle tightness, a common scenario in the sports medicine clinic. Despite a presumably appropriate course of action, he develops atypical features that are worrisome in this setting. Of particular concern are the unexplained increase in pain and the reported fever and rash. Immediate follow-up after this clinical update again demonstrated a pain-free physical examination, but the clinical course was not progressing as expected and his pain seemed out of proportion to the examination. Given this information, the initial differential diagnosis needed to be reprioritized and additional evaluation for occult infection and neoplasm is initiated. Imaging studies remain a cornerstone of the work-up for back pain. Plain radiographs are generally adequate imaging studies for initial diagnostic work-up. If the initial plains films are concerning for potential bony abnormality, then direct consultation with the reading radiologist or with an orthopedic surgeon experienced in treatment of bony tumors may be warranted to elucidate an appropriate differential. Advanced imaging may be indicated if the diagnosis is in question, particularly in patients with worrisome signs and symptoms. MRI, typically without contrast, is the most appropriate approach to the broad work-up of atypical adolescent back pain, especially in the setting of normal plain radiographs. Bone scan is an alternative but has the disadvantage of radiation exposure and less tissue detail. If a specific bony lesion has been identified on plain radiography, contrast MRI or computed tomography (CT) scan may be the preferred imaging modality. CT scans can accurately define osseous lesions and can be completed rapidly in urgent situations. However they may expose children to unnecessary radiation and are less adept at defining soft tissue disorders. Blood work should be directed by the differential diagnosis. The red flags that may alert a clinician to consider blood work are similar to those that guide decisions to obtain advanced imaging. Unexplained constitutional symptoms (fever, chills, weight loss, fatigue, and rash), increasing pain despite follow through with prescribed interventions, nocturnal awakenings due to pain, and pain out of proportion to the suspected etiology should raise clinical suspicion, and blood work needs to be considered. Screening laboratories may include CBC with differential and inflammatory markers (ESR, c reactive protein). Situations more concerning for malignancy may warrant more extensive metabolic panels that include lactate dehydrogenase and uric acid as well as liver function tests. Concern for autoimmune disorders and spondyloarthropathy are evaluated with screening ANA titers, RF and HLA-B27 assessment. This case is a unique presentation of AML presenting as adolescent back pain. It is similar to previously reported presentations of acute lymphoblastic leukemia (ALL). A small percentage of ALL cases (less than 1%) present with extensive skeletal involvement prior to overt symptoms. With this presentation, there is no organomegaly or adenopathy, no blasts in the peripheral blood, and only moderate anemia. Bone metabolic parameters are usually normal, although hypercalcemia may be seen (13). During this process the hypercellular marrow replaces the bony architecture of the spine. This may result in osteopenia and vertebral body compression fractures. While extensive osteopenia and spinal compression fractures may be observed 1 month after induction of chemotherapy, the overall prognosis in ALL is generally favorable with this presentation. In the skeletally immature population, vertebral body remodeling is possible and many regain normal spinal body height (4). This case demonstrates a number of useful points for sports medicine clinicians. In adolescent back pain, an atypical course such as nighttime pain, increasing severity of pain, particularly if out of proportion to the suspected injury or etiology, or pain with subsequent development of unexplained constitutional symptoms should prompt the clinician to look for unusual causes of pain. These atypical causes of pain may mimic spondylolysis and include posterior column lesions such as osteoid osteoma, osteoblastoma, and aneurysmal bone cysts. Unusual causes of pain that mimic functional back pain include spinal compression fractures or bone pain due to infiltration of tumor cells including leukemia and metastatic lesions. Ultimately this case illustrates the need for the sports medicine clinician to maintain a broad differential diagnosis and to be prepared to escalate diagnostic investigation when presented with new clinical information. The authors declare no conflicts of interest and do not have any financial disclosures.

Back pain is a relatively common complaint in children and adolescents. The pediatric patient presenting with back pain can often be challenging, and there are many well-known organic diagnoses that should not be missed. In younger children, an organic cause of back pain can often be found. However, back pain in older children and adolescents is often "non-specific." The differential diagnosis of back pain in children includes neoplasms, developmental, and inflammatory conditions. Basic steps should include an in-depth anamnesis, a systematic physical examination, and standard spine radiographs (anteroposterior and lateral). Nevertheless, advanced diagnostic imaging and laboratory studies should be included when indicated to avoid missing or delaying a serious diagnosis. If other types of imaging tests are necessary (magnetic resonance imaging, computed tomography, bone scan, or single photon emission computed tomography), they should be guided by diagnostic suspicion.

BackgroundThe one-month prevalence of back pain in children and adolescents has been reported at 33, 28 and 48% at ages 9, 13 and 15 respectively. There are many suspected risk factors and triggers of back pain in young people.ObjectiveThe purpose of this scoping review was to identify potential risk factors and potential triggers for back pain in young people. The purpose of part I was to identify potential risk factors for incident and episodic back pain in young people. Part II included all eligible studies with unclear or mixed types of back pain.MethodsDue to the vast number of studies on “risk factors” for back pain, a two-part scoping review of the literature was chosen as the best way to summarise the evidence. We adhered to the PRISMA-ScR guideline for scoping reviews. General potential risk factors and triggers for back pain in children and young adults (≤ 24 years) were included, incorporating physical, environmental, and/or physiological factors. A search was conducted using PubMed and Cochrane databases from inception to September 2018, limited to the English language. Within part I, and because of their importance, only the results of the studies that investigated risk factors of incident back pain and back pain episodes are presented.ResultsThe search identified 7356 articles, of which 91 articles were eligible for this scoping review. The majority of the eligible articles had an unclear definition of back pain (results presented in scoping review part II). There were 7 inception cohort studies included and 1 cohort study that met the criteria for part I. The most consistent risk factors for incident and episodic back pain are female sex and older age.ConclusionDue to inconsistent ways of reporting on the type of back pain, no definitive risk factor for back pain has been identified. In general, females often report more symptoms, also for other diseases, and older age is not a useful risk factor as it merely indicates that the onset may not be in childhood. Clearly, the time has come to study the causes of back pain from different angles.

33 - Low Back Disorders

Low back pain in children and adolescents are usually attributed to mechanical causes and faulty positions. Although most of them are self-limiting, physicians should be aware of the red flag signs that warrant complete evaluation to rule out malignant causes of back pain. As delay in the diagnosis of vertebral lytic lesion may have sequelae in the growing children, pain disproportionate to the signs should have low threshold levels for evaluation. We report a case of 6-year-old boy who presented with worsening back pain. Initially evaluated for tuberculosis spine, he was diagnosed to have Langerhans cell histiocytosis of spine. He improved symptomatically with chemotherapy and spine orthosis and is in complete remission now.

Public press, professional organisations and journals have been sending alarming messages about the rising prevalence of back pain in school age children. Carrying backpacks has been suggested as one of the key factors contributing to back pain in children. The basic assumption based on the biomedical model is that the maturing spine cannot handle the mechanical load of the backpack sufficiently. A review of the evidence in the professional literature, however, revealed very limited evidence to support this assumption. On the contrary, the literature does suggest that psychological and social factors may be of greater importance to explain back pain in children. We conclude this clinical commentary postulating that the public, children and their parents are better served with a more modest and balanced perspective of the professionals, and propose that back pain in children (as it is in adults) should be viewed from a biopsychosocial model.

To determine whether there are significant differences in the causes of back pain in young athletes compared with the general adult population and to review the diagnosis and assessment of young athletic adolescent patients who present with this complaint. Retrospective randomized case comparison study with two cohorts segregated by age and type of activity. The adolescent sports medicine clinic of a children's hospital compared with the acute low back pain clinic of an orthopedic hospital. One hundred adolescent athletes (aged 12 to 18 years; mean age, 15.8 years) with a chief complaint of low back pain were compared with 100 adults (aged 21 to 77 years; mean age, 31.9 years) with acute low back pain. None. Sixty-two percent of the adolescents had derangements of their posterior elements associated with the onset of back pain. Forty-seven percent of the 100 adolescents were ultimately shown to have a spondylolysis stress fracture of the pars interarticularis. By contrast, 5% of adult subjects were found to have spondylolysis associated with low back pain. Similarly, discogenic back pain was the final diagnosis in 48 of the 100 subjects in the adult group, while 11 of the 100 in the adolescent group had back pain attributable to disc abnormalities. Muscle-tendon strain accounted for back pain in 27% of the adults, while only 6% of the adolescents were diagnosed as having muscle-tendon strain. These differences were significant. Spinal stenosis and osteoarthritis as causes of back pain were encountered in 10% of the adults, while these conditions were not encountered in the children. There is a significant differences in the major causes of low back pain in young athletes compared with causes of low back pain in the general adult population. Physicians diagnosing back pain in young athletes must have a specific understanding of these differences to avoid incorrect diagnosis and harmful delays in proper treatment.

Back pain in children

This article describes a quick, straightforward examination for back pain in children. The differential diagnosis is given, along with warning signs of serious causes of back pain. Guidelines are given for handling the more common problem of nonspecific back pain and minimizing unnecessary radiographs and other tests.

Back pain in adults is common and well studied. In contrast, back pain in children has received comparatively little scientific study, despite recent media attention. The purpose of this study is to see what factors influence the prevalence of back pain in middle school children, with particular attention to the weight of children's backpacks and the availability of school lockers. A population-based sample of 1540 children ages 11-14 years in a large metropolitan area was studied. A questionnaire was used to determine presence and severity of back pain, availability of lockers, backpack use, use of 1 or 2 straps to carry backpack, activity limitations due to back pain, and use of pain medication for back pain. Gender, age, weight of the child, and weight of his or her backpack were recorded. Results of scoliosis screening were evaluated with regard to the above information. Data were analyzed using the chi test and univariate or multivariate logistic regression analysis as appropriate. Overall, 37% of the children reported back pain. Backpacks were used by 97% of children, hence there were too few students not using backpacks to treat backpack use as an independent variable. Multivariate analysis found back pain associated with use of a heavier backpack (P=0.001), younger age (P<0.001), female sex (P<0.001), and a positive screening examination for scoliosis (P=0.009). Children with lockers available reported less back pain (P=0.016). The use of 1 or 2 straps to carry the backpack did not have a significant association with back pain (P=0.588). Of the children who reported back pain, 34% limited their activity due to the pain, 14% use medication for pain relief, and 82% believed their backpack either caused or worsened their pain. The incidence of back pain in early adolescence approaches that seen in adults. Recommendations for an "acceptable" weight of backpacks cannot be made from this study, as the weights of students' backpacks seem directly proportional to the likelihood of back pain. This study identifies 2 factors associated with self-reported back pain in early adolescents that are amenable to change: availability of school lockers and lighter backpacks. These findings may be useful in advising families and influencing school policies.

Back pain is reported to occur already in childhood, but its development at that age is not well understood. The aims of this study were to describe BP in children aged 6-12 years, and to investigate any sex and age differences. Data on back pain (defined as pain in the neck, mid back and/or lower back) were collected once a week from parents replying to automated text-messages over 2.5 school years from 2008 till 2011. The prevalence estimates were presented as percentages and 95% confidence intervals. Differences between estimates were considered significant if confidence intervals did not overlap. A test for trend, using a multi-level mixed-effects logistic regression extended to the longitudinal and multilevel setting, was performed to see whether back pain reporting increased with age. Depending on the age group, 13-38% children reported back pain at least once per survey year, and 5-23% at least twice per survey year. The average weekly prevalence estimate ranged between 1% and 5%. In the final survey year more girls than boys reported back pain at least twice. The prevalence estimates did not increase monotonically with age but showed a greater increase in children younger than 9/10, after which they remained relatively stable up to the age of 12 years. We found that back pain was not a common problem in this age group and recommend health professionals be vigilant if a child presents with constant or recurring back pain. Our results need to be supplemented by a better understanding of the severity and consequences of back pain in childhood. It would be productive to study the circumstances surrounding the appearance of back pain in childhood, as well as, how various bio-psycho-social factors affect its onset and later recurrence. Knowledge about the causes of back pain in childhood might allow early prevention.

Back pain in children and adolescents is one of the most frequent reasons for seeing a medical specialist worldwide. Many factors have been incriminated when it comes to influencing the appearance of non-specific back pain in children as well as in adults. For the younger population, some of the culprits seem to be sitting for long periods, us-ing harmful postural patterns, a forward head posture determined by incorrect positioning during prolonged studying hours, and carrying a too-heavy backpack, but do they really influence non-specific back pain in children? These ques-tions are valid for all generations and countries. This paper aimed to review the published literature to determine whether the factors mentioned above, sitting in mismatched school furniture, carrying heavy backpacks, and forward head posture, influence the incidence of non-specific back pain in children and whether there are any data or differences between the general population and Roma-nian students. For this purpose, we conducted database research using the keywords “non-specific back pain in chil-dren, sitting, school furniture, forward head posture, backpack carrying” and various combinations of these terms, which returned 37 eligible articles for this paper in PubMed - Center for Biotechnology Information (NCBI) and Sci-enceDirect. There was no time limit on the researched articles, and they had to refer to the pediatric population, be open-access and in extenso articles, and be written in English, French, or Spanish. After analyzing the results from these articles, the conclusion is that there is no evident or spe-cific connection between non-specific back pain in pediatric populations and harmful posture patterns while sitting or carrying a backpack. Also, more multicentered research using fewer variables and more objective measurement instruments is needed. Keywords: non-specific back pain in children, sitting, bad posture, school furniture, forward head posture, back-pack carrying

BackgroundBack pain is reported to occur already in childhood, but its development at that age is not well understood. The aims of this study were to describe BP in children aged 6–12 years, and to investigate any sex and age differences.MethodsData on back pain (defined as pain in the neck, mid back and/or lower back) were collected once a week from parents replying to automated text-messages over 2.5 school years from 2008 till 2011. The prevalence estimates were presented as percentages and 95% confidence intervals. Differences between estimates were considered significant if confidence intervals did not overlap. A test for trend, using a multi-level mixed-effects logistic regression extended to the longitudinal and multilevel setting, was performed to see whether back pain reporting increased with age.ResultsDepending on the age group, 13-38% children reported back pain at least once per survey year, and 5-23% at least twice per survey year. The average weekly prevalence estimate ranged between 1% and 5%. In the final survey year more girls than boys reported back pain at least twice. The prevalence estimates did not increase monotonically with age but showed a greater increase in children younger than 9/10, after which they remained relatively stable up to the age of 12 years.ConclusionsWe found that back pain was not a common problem in this age group and recommend health professionals be vigilant if a child presents with constant or recurring back pain. Our results need to be supplemented by a better understanding of the severity and consequences of back pain in childhood. It would be productive to study the circumstances surrounding the appearance of back pain in childhood, as well as, how various bio-psycho-social factors affect its onset and later recurrence. Knowledge about the causes of back pain in childhood might allow early prevention.Electronic supplementary materialThe online version of this article (doi:10.1186/s12998-014-0035-6) contains supplementary material, which is available to authorized users.

Imaging of low back pain in children and adolescents

There are numerous etiologies of back pain in the pediatric population. Most of the children experiencing the back pain who are seen in orthopaedic outpatient need careful evaluation of underlying biomechanical and musculoskeletal cause. Nevertheless, other causes like rheumatic, infectious or oncologic etiology need to be considered. This research explores evaluation, differential diagnoses, and diagnosis of back pain in young children. Back pain in children, adolescents and young adults is less common that in mature adults. One of the pertinent issues in the determination of the incidence and prevalence of the lower back pain in ways that, it is defined. Low back pain may be defined as the low back pain with no clinical cause, non-organic and non-specific pain. It is normally used as a descriptive term for different types of back pain. Mechanical pain is also a confusing term that refers to pain without the pathological underlying cause but is conversely used to explain conditions that arise from trauma or overuse such as the intervertebral disc prolapse, muscle pain or spondylolysis. Over the years, back pain has been considered as a sinister presentation within the young age group. Present studies now show that there are many children who experience back pain, but there are very few of them who seek medical intervention mainly because they think it’s normal. When assessing adolescents and children with back pain, it is essential to consider social factors, psychological and lifestyle, because spinal pain does not mean that the child has a spinal disease. Additionally, it is important to consider critical underlying conditions and perform the required investigations to describe these causes without over-investigating the patients with non-specific musculoskeletal pain.