Back pain is a relatively common presenting symptom in children and adolescents. Typical causes include muscle strain or spasm, spinal deformities (e.g., Scheuermann kyphosis, adolescent idiopathic scoliosis), spondylolysis, bulging or herniated intervertebral disks, apophysitis of the iliac crest, and functional pain syndromes such as fibromyalgia. Spondyloarthropathies such as ankylosing spondylitis may present with low back pain and stiffness, which are often worse in the morning. Less common but more serious causes include malignancy and infections. The physical examination should include postural inspection, evaluation for tenderness, range of motion, strength testing, and testing for fractures and nerve impingement. Treatment for patients with muscle strain include relative rest, home-based exercises, physical therapy, and limited use of nonsteroidal anti-inflammatory drugs. If findings from the history and physical examination suggest underlying pathology, radiography and laboratory studies are indicated initially; magnetic resonance imaging, computed tomography, or a bone scan may be needed for further evaluation. It is generally accepted that the following factors warrant immediate evaluation: patient age younger than five years, symptoms persisting beyond four weeks, systemic symptoms, nighttime pain, bowel incontinence/urinary retention, or other neurologic symptoms.
