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Evidence In Practice |
Julie M Fritz, PT, PhD, ATC, is Assistant Professor, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pa
M Kathleen Kelly, PT, MS, is Assistant Professor, Department of Physical Therapy, University of Pittsburgh
A12-year-old girl with no previous history of back pain was referred to our outpatient physical therapy department after developing an insidious onset of back pain, bilateral thigh pain, and difficulty walking. Her symptoms began approximately 3 months prior to her referral to therapy. The initial symptoms were pain and tightness in the right posterior thigh, which progressed to pain in the lumbar region and the left posterior thigh and buttock. She had radiographs of the right hip that were reported by the radiologist to be negative for a fracture or any developmental abnormality. She reported her pain to be mild (2/10 on a pain rating scale) and mostly unaffected by activity. Her chief complaint was the inability to play soccer due to changes in her walking and running. She had received physical therapy 6 months before. At that time, she reported only pain and tightness in the right posterior thigh, and her primary care physician referred her to our department with a diagnosis of "hamstring strain." These symptoms resolved with 2 weeks of therapy that focused on stretching exercises. She returned to the same physician for the current episode, and the physician again made the diagnosis of "hamstring strain." She had not received any further imaging studies since the initial episode.
The initial examination of the patient revealed an abnormal gait pattern with reduced stride length bilaterally, which was worse on the right side than on the left. Observation showed a scoliotic curve in the lumbar region with the convexity on the right and what appeared to be visible muscle spasm in the lumbar paraspinal musculature. Active range of motion in the lumbar spine revealed 10 degrees of lumbar extension, 85 degrees of flexion, 5 degrees of right side bending, and 20 degrees of left side bending. Extension caused a mild increase in low back pain, whereas flexion did not increase pain; however, the patient deviated toward the right during the movement. Lower-extremity reflexes, muscle strength, and sensation to light touch and sharp/dull discrimination were intact bilaterally. The straight-leg-raise test was positive bilaterally, reproducing leg symptoms at approximately 20 degrees on the right side and 45 degrees on the left. Palpation of the lumbar spine, buttock, and posterior thigh regions did not reveal any areas of tenderness.
The signs and symptoms in this patient could have a musculoskeletal origin, such as a lumbar disk herniation, spondylolithesis, or other musculoskeletal impairment. However, the presentation of this patient at initial examination raised some concerns about the possibility of a non-musculoskeletal cause of her symptoms. We were particularly suspicious because she had been seen 6 months ago and had no gait abnormalities or visible scoliosis at that time. Because of the rather dramatic change in her presentation, we were concerned that this patient may require referral for further diagnostic evaluation to rule out a nonmusculoskeletal cause, such as a tumor somewhere in her spinal column. We decided to search the literature to determine which signs and symptoms in the clinical examination may be most useful in distinguishing a musculoskeletal from a non-musculoskeletal cause of low back pain in a child.
 | Database used for search: MEDLINE |
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| Initial keywords: child, non-musculoskeletal |
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 TopDatabase used for search:... Initial keywords: child, non... Limits: English, human, last...Selection of articles for...Clinical decision:References |
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The primary non-musculoskeletal condition that we thought might present as low back pain was a neoplasm; therefore, we decided to try using the keyword neoplasm. According to Ovid's Help feature, selecting the Map Term checkbox "usually results in higher-quality retrieval." Therefore, we checked this box throughout the remainder of our search. When we typed in this keyword, MEDLINE suggested several more specific subject headings. In this list was the subject heading spinal neoplasms. We decided this term would be more useful for our patient, and we, therefore, used spinal neoplasmsas a keyword. After entering this keyword, MEDLINE suggested several subheadings, including diagnosis, radiography, embryology, and many others. We clicked on the subheading diagnosis because we were concerned about the differential diagnosis of a spinal neoplasm in our patient. This search resulted in 1,763 citations. Next, we combined the keywords child and spinal neoplasms/diagnosis by clicking on the icon labeled Combine. We used an "AND" operator to combine the 2 keywords. This combination narrowed the citation list to 309.
Selected Citations Retrieved by Search Using the Keywords "Child" and "Spinal Neoplams/Diagnosis" With Limits Added*
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A list of 309 was still too large, and we wanted to make the list more specific to this patient with low back pain. We, therefore, entered the keyword low back pain. MEDLINE suggested a number of subject headings, but, to avoid eliminating citations that might be useful by restricting the search too much, we chose the heading low back pain and then selected all subheadings. These actions resulted in 3,956 citations. We combined these with the list of 309 citations using an "AND" operator. This narrowed the list of citations to only 3 references. We felt this was too narrow, and we decided to return to our list of 309 citations. Because we were interested in the diagnostic accuracy of clinical findings for a diagnosis of spinal neoplasm, the most useful articles would be those reporting sensitivity and specificity values. We chose to use the keyword sensitivity. When we typed in this keyword, MEDLINE suggested the subject heading sensitivity and specificity. We chose to use this subject heading, which resulted in 78,279 citations. We combined this list with the 309 citations previously selected using an "AND" operator. This combination yielded 5 articles. We decided to view the titles of these 5 articles. All of the articles dealt with diagnostic imaging procedures such as magnetic resonance imaging (MRI). Because we were interested in the value of clinical findings, we did not believe these articles would be useful for our patient. We, therefore, returned to our list of 309 citations and decided that we would attempt to further narrow our search using MEDLINE's Limits feature.
| Limits: English, human, last 5 years |
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TopDatabase used for search:...Initial keywords: child, non...Limits: English, human, last...Selection of articles for...Clinical decision:References |
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| Selection of articles for review: |
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TopDatabase used for search:...Initial keywords: child, non...Limits: English, human, last...Selection of articles for...Clinical decision:References |
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Unfortunately, most of the articles did not appear to be exactly what we were seeking. Only one article (Martinez-Lage et al) mentioned a comparison between children with low back pain of a non-musculoskeletal origin (spinal neoplasms) and those with back pain of a musculoskeletal origin (lumbar disk herniation). None of the articles mentioned anything about sensitivity or specificity in the title. We decided to select 4 articles and read their abstracts to see if we should obtain the full text version of these articles. We selected the article by Martinez-Lage et al because the title mentioned a comparison group. We selected 3 other articles that we hoped would at least provide descriptive information about children with low back pain due to spinal neoplasms and their clinical presentation. The abstracts are listed and the selected articles are discussed below. We were able to access the abstract for each article by clicking on the Abstract icon.
Grattan-Smith PJ, Ryan MM, Procoopis PG. Persistent or severe back pain and stiffness are ominous symptoms requiring prompt attention. J Paediatr Child Health. 2000;36:208-12.BACKGROUND: Children with severe or persistent back pain and stiffness often have an underlying organic cause but there is a large differential diagnosis, examination may be difficult and the problem is relatively rare in general paediatric practice. These difficulties appeared to lead to delays in diagnosis and management of children with this problem. OBJECTIVES: To provide an approach to the diagnosis and management children with severe or persistent back pain or stiffness based on our clinical experience and the literature. METHODOLOGY: The case histories of 10 children with severe back pain seen by the authors over a 5-year period were reviewed. They were chosen as illustrative examples of the diagnostic and management problems and did not represent a systematic review of all cases seen by the authors over that time. RESULTS: Underlying causes included infection, inflammation, neoplasm, trauma and vascular malformation. Four of the children had spinal cord compression which required urgent decompression. There was one child with a conversion disorder but three children with organic disease were initially felt to have a conversion disorder. Investigations generally proceeded relatively slowly and the problem was not regarded as a semi-urgent situation carrying the risk of permanent paraplegia. Magnetic resonance imaging (MRI) scan of the spine was the investigation of choice. CONCLUSION: Children with severe or persistent back pain and stiffness have a wide variety of underlying causes. The possibility of underlying spinal cord compression should always be considered in children with this presentation. If the diagnosis is not obvious, MRI scan of the spine should be arranged without delay.
[Abstract reprinted with permission of Blackwell Science Asia Pty Ltd.]
The abstract of this article indicated that the study included only 10 children with back pain and not all had spinal neoplasms. The 10 cases were apparently selected by the authors; therefore, this paper is not a systematic or consecutive review of cases and, as a result, may be a biased sample of cases. There is no comparison group of children with back pain of a musculoskeletal origin. Because of the small number of cases and the lack of a comparison group, we did not believe that this article would be helpful in answering our clinical question, so we did not seek out the full text.
Mehlman CT, Crawford AH, McMath JA. Pediatric vertebral and spinal cord tumors: a retrospective study of musculoskeletal aspects of presentation, treatment, and complications. Orthopedics. 1999;22:49-55.Fifty-two pediatric patients with documented vertebral and spinal cord tumors were reviewed to evaluate the musculoskeletal manifestations of presentation, treatment, and management of complications. Diagnoses included 16 malignant and 36 nonmalignant vertebral and spinal cord tumors. Mean age at diagnosis was 8 years 1 month, and the male-to-female ratio was 1.7:1. Overall, there was an average delay in diagnosis of 12 months for this group of patients. Mean clinical follow-up was 5 years. The two most common reasons for presentation were pain (67%) and spinal deformity (46%). Initial plain radiographs were positive in 82% of patients. Postlaminectomy spinal deformity occurred at a rate of 45% in patients undergoing laminectomies, and 60% of those with deformity required spinal fusion. Overall, 67% of the 52 patients underwent spinal fusion, with a 9% asymptomatic pseudarthrosis rate. Complications were common, with 1.9 complications per patient; 59% of complications required surgical management. There were no perioperative deaths. At follow-up, 19% of patients had neurologic deficits ranging from neurogenic bladder to lower extremity weakness and difficulty walking to quadriplegic. Eighty-six percent of patients were ambulating without difficulty at follow-up. The survival rate was 94% and the local recurrence rate was 27% at most recent follow-up.
[Abstract reprinted with permission of Slack Inc.]
This study was a retrospective review of 52 children, all of whom had spinal neoplasms. The abstract indicated that patient characteristics as well as signs and symptoms are given in the article. Because this article involved a larger group of patients, all with spinal neoplasms, we thought that the article might contain some useful information about our patient, so we decided to examine the article more fully. We went to the medical library and copied the full text of the article.
The mean age of the 52 patients with spinal neoplasms reviewed in this article was about 8 years old, and many of the patients were about the age of our patient. The article contained useful tables of the percentage of patients with certain clinical signs and symptoms at the initial presentation. Some interesting descriptive information could be taken from this article. First, of the 52 patients reviewed, the majority (63%) were male. Most patients (67%) reported back pain, and the most common clinical findings were spinal deformity (46%), motor weakness (29%), local tenderness (23%), abnormal reflexes (21%), and abnormal gait (17%). No comparison group of pediatric patients with musculoskeletal low back pain was presented, so it was difficult to determine which of these clinical features would distinguish a spinal neoplasm from musculoskeletal low back pain.
We considered our patient in light of this information. She reported pain and also had a spinal deformity and gait abnormalities on examination. Our patient, however, was female and did not have any local tenderness or motor or reflex abnormalities. Because this article lacked a comparison group, it was interesting, but ultimately of limited usefulness.
Beer SJ, Menezes AH. Primary tumors of the spine in children. Natural history, management and long-term follow-up. Spine. 1997;22:649-58.DESIGN: Patients 16 years of age and younger with primary vertebral neoplasms diagnosed between 1951 and 1996 at The University of Iowa were reviewed retrospectively with specific consideration given to follow-up. OBJECTIVE: Follow-up extending beyond the growth of the axial skeleton was used to establish the natural history, management outcome, and current approach to treatment. SUMMARY OF BACKGROUND DATA: Primary tumors of the spine are uncommon. The treatment of such lesions generally has been based on small series of tumors, or extrapolated from the treatment of tumors in other regions and tumors in adults. Given the unique developing anatomy and dynamic nature of the growing spine in children, delineating appropriate modalities of treatment for these tumors beyond the growth of the axial skeleton is essential. METHODS: Clinical history, radiographs, radiographic reports, and interviews were used to establish this database. Outcome with respect to the various approaches to treatment was then compared in detail. RESULTS: Forty-five patients were identified in which follow-up greater than 10 years was available for 58% of patients. There were 29 histologically benign and 16 malignant tumors. Patients presented most frequently with pain (79%) and neurologic deficits (74%). The duration of symptoms was significantly shorter with malignant tumors (11 weeks) compared with benign tumors (26 weeks). Radiographic abnormalities were demonstrated on plain radiographs in 98% of cases. Tumor excision was achieved in 80%. Follow-up studies were available beyond the growth of the axial skeleton in these patients, with an average follow-up of 14 years. Recurrence was seen in 6 of 45 children, and the overall mortality rate was 6.7%, occurring only with malignant tumors. CONCLUSION: Our current approach to treatment of spinal neoplasms varies from that used in the earlier part of the series and reflects the need for single stage complete resection and stabilization.
[Abstract reprinted with permission from Lippincott Williams & Wilkins.]
This article was another retrospective review of children who had spinal neoplasms. This review included 45 patients. The abstract notes that the most common clinical findings were pain (79%) and neurological deficits (74%). The abstract of this article seems to indicate that the authors were most interested in comparing benign and malignant tumors and in the long-term outcome of these children. Because these issues were not our primary concern, we did not believe that this article would provide much useful information, so we did not seek out the full text.
Martinez-Lage JF, Martinez-Robledo A, Loez F, et al. Disc protrusion in the child. Particular features and comparison with neoplasms. Childs Nerv Sys. 1997;13:201-7.Lumbar intervertebral disc herniation, although common in adults, is infrequent in the young, and especially in patients under 17 years old. In this work we review clinical data pertaining to two pediatric groups of patients whose main complaint was low back pain and/or sciatica, trying to identify factors that might contribute to their earlier referral and to the differential diagnosis of protruded disc and spinal neoplasm in this population. Group A comprises 17 youngsters diagnosed as having lumbar herniated nucleus pulposus and group B, 16 children with neoplasms of the lower thoracic and lumbosacral regions. Both groups were similar in sex distribution and symptoms of pain and numbness. However, there was a striking difference in age at presentation. No patient in group A was younger than 11 years, while most of those in group B were in their first decade of life (P = 0.018). The classic clinical onset in the children with herniated discs started with low back pain and sciatica, as in the children with neoplasms, although in subgroup B leg pain tended to be bilateral. The usual examination findings in both groups were spinal rigidity and sensory loss, but motor weakness and impaired reflexes were found to be more frequent in the group with spinal growths (P = 0.02). Children with lumbosacral neoplasms also tended to present with atypical symptoms (acute onset, intracranial hypertension, subarachnoid hemorrhage and abdominal pain), while this was the exception in the group with herniated discs. Plain radiographs of the pediatric spine showed that X-ray examination is still a good tool for diagnosing spinal growths compared with their scant utility in disc herniations (P = 0.001). During the survey we were impressed by the children's apparent good tolerance to pain, which is probably due to the lack of the emotional component of pain in adults and explains their delayed referral for neurosurgical consultation. However, all modalities of treatment seemed to be effective in children, chemonucleolysis and surgery being extraordinarily effective in this age group. Accordingly, we see no reason for long-term conservative therapy in children with lumbar and sciatic pain; on the contrary, we believe these patients should be offered earlier neurosurgical treatment.
[Abstract reprinted with permission of Springer-Verlag GmbH.]
Based on both the title and the abstract, it appeared that this article could be quite useful in answering our question because 2 groups of patients were included: one group of children with low back pain of a non-musculoskeletal origin (spinal neoplasms), and another group of children with low back pain of a musculoskeletal origin (disk herniation). Unfortunately, other types of musculoskeletal low back pain were not included, but at least a comparison group was used. As noted in the abstract, the authors found that children with musculoskeletal back pain were older than children with neoplasms (average age=14.5 years and 6.8 years, respectively). No child with musculoskeletal back pain was under the age of 11, but most of the children with neoplasms were. Our patient is 12 years of age, which would appear to reduce the likelihood of a spinal neoplasm. The abstract also states that abnormal reflexes and motor weakness were more common in the children with neoplasms. Our patient had neither of these findings. We were interested to know exactly how useful these findings were in distinguishing children with spinal neoplasms from those with musculoskeletal back pain, and we wanted to know if other clinical findings were discussed in the paper but not in the abstract. We decided to retrieve the full text of the article from the library to determine whether any other useful information could be found.
The information in the article proved to be very useful. A table of the number of children with specific clinical findings in each group was presented (Tab. 1). After examining this information, we believed that the most important clinical findings in the diagnosis of a spinal neoplasm appear to be (1) having bilateral versus unilateral leg pain, (2) having motor and reflex impairments, and (3) not having a positive straight-leg-raise test. Of the 17 patients with musculoskeletal back pain, 12 had unilateral leg pain, and only 3 had bilateral leg pain. In the group of children with spinal neoplasms, however, 9 had bilateral leg pain, and no child had unilateral leg pain. Fifteen of the 17 children with musculoskeletal back pain had a positive straight-leg-raise test, but only 1 had a motor deficit and only 4 had impaired reflexes. In contrast, the children with spinal neoplasms were less likely to have a positive straight-leg-raise test (7 of 16) and were more likely to have impaired motor strength (8 of 16) or reflexes (11 of 16).
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Several factors about our patient would appear to help rule out a diagnosis of a spinal neoplasm. Perhaps the most important factor was her age, because most patients with spinal neoplasms seem to be under the age of 10. According to Martinez-Lage et al, our patient's lack of neurological deficits, particularly impaired reflexes, would make a diagnosis of spinal neoplasm less likely. The fact that she has a positive straight-leg-raise test might make a diagnosis of disk herniation more likely.
Because our patient had several signs that were associated with spinal neoplasms and because of the high risk associated with a missed or delayed diagnosis in that case, we decided that the most prudent action to take would be to refer the patient to a pediatric neurology specialist for further diagnostic workup. Our patient had an MRI performed on her spine. Fortunately, no spinal neoplasm was discovered; however, a grade II spondylolisthesis was found that required surgical management. Although the diagnosis we were most concerned about was not present, the decision to refer the patient to a neurology specialist did appear to be justified in the end.
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| Footnotes |
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* Ovid Technologies, 333 Seventh Ave, 4th Floor, New York, NY 10001. 
* English language, Human studies, Publication years between 1996 and 2001.
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