Paeds · rheumatology-musculoskeletal-and-sports
Back pain in children and adolescents
Also known as paediatric back pain · low back pain in children · spondylolysis · pars interarticularis stress fracture · Scheuermann kyphosis · Scheuermann disease · juvenile kyphosis · discitis · spondylodiscitis · spondylolisthesis · Adams forward bend test
A fellowship approach to back pain in children and adolescents: back pain is uncommon in the pre-school child and a red flag in its own right, and the age-stratified differential runs from discitis in the toddler through spondylolysis in the school-age athlete to Scheuermann kyphosis and lumbar disc herniation in the adolescent — anchored by the red-flag screen that separates the benign mechanical back from the infection, tumour, or neurological compromise that demands urgent imaging and referral.
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Red flags
- Back pain in a child under five years is itself a red flag — it is uncommon at this age and an organic cause such as discitis, vertebral infection, or tumour must be sought
- Constant night pain that wakes the child from sleep, or pain unrelated to activity, raises malignancy such as osteosarcoma or leukaemia or an infiltrative process until bloods and MRI prove otherwise
- Fever, weight loss, malaise, or systemic illness with back pain demands urgent inflammatory markers, blood culture, and MRI to exclude discitis, vertebral osteomyelitis, or septic sacroiliitis
- Any neurological deficit — leg weakness, gait change, reflex asymmetry, bladder or bowel disturbance, or a positive Babinski — signals spinal cord or nerve root compromise and warrants urgent MRI
- A progressive spinal deformity, a painful rigid kyphosis, or a rapidly worsening scoliosis points to a structural cause such as Scheuermann disease or a tumour eroding the vertebral body
- Persistent back pain lasting longer than four weeks, or any pain that fails to improve with a trial of activity modification, warrants imaging rather than reassurance
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- Musculoskeletal medicine - assess the child with back pain and recognise red flags
- Acute presentations - the febrile child with back pain and the younger child who refuses to walk
- Growth and Development - normal spinal posture and the adolescent growth spurt
- Musculoskeletal medicine - apply the age-stratified differential of paediatric back pain from discitis to spondylolysis to Scheuermann kyphosis
- Orthopaedics and musculoskeletal medicine - choose imaging wisely and recognise the diagnoses needing urgent referral
- Renewed curriculum for first-year trainees from 2027 - Learning goal 6: Clinical management - essential general paediatrics
- Musculoskeletal 10-12
- Acute presentations 10-12
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- 9. Musculoskeletal medicine - back pain in children and the red flag assessment
- 11. Child health and the school-age child and adolescent - spinal deformity and sports-related pain
- 4. Professional skills and knowledge: Patient management
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- Medical Knowledge 2: Conditions common in pediatric primary care
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- Pediatrics: Foundations EPA #5 - Performing a focused physical examination
- Pediatrics: Rheumatology and musculoskeletal applied domain
A four-year-old boy refuses to walk and points to his lower back, he is febrile and irritable, and his inflammatory markers are raised — discitis, the classic cause of back pain in the toddler and pre-school child. A thirteen-year-old female gymnast has three weeks of low back pain that worsens with backbends and eases with rest — spondylolysis, a stress fracture of the pars interarticularis that is the commonest identifiable cause of low back pain in the young athlete. A fifteen-year-old boy has an increasing rounded upper-back deformity with an aching thoracic spine that his mother first noticed a year ago — Scheuermann kyphosis, a structural wedging of the vertebral bodies. The task in each is to screen for the red flag, choose the imaging, and separate the diagnosis that needs urgent referral from the one that needs activity modification and follow-up. [1] [9]
Run the pathway as five moves. Screen for red flags at the first encounter, because a single red flag redirects the whole workup from reassurance to investigation. Localise the pain with a focused spine and neurological examination, asking the child to point with one finger and watching the gait, because the site and the pattern narrow the differential. Image wisely, choosing the modality for the suspected diagnosis — plain films for deformity, MRI for infection and neurological compromise, and a focused lumbar strategy for the athletic extension pain. Treat the underlying cause, because paediatric back pain is managed by the diagnosis, not by blanket analgesia. Follow up at four to six weeks, because a pain that fails to resolve is itself a red flag and demands escalation. [1] [11]
Overview & Definition
Back pain in children and adolescents is the symptom that most reliably separates the careful clinician from the complacent one, because the paediatric back behaves nothing like the adult back. In adults, low back pain is overwhelmingly mechanical and benign, and the default is reassurance. In children, the opposite holds: back pain is comparatively uncommon, and when it is persistent or severe it carries a much higher probability of an identifiable organic cause. The fellowship candidate holds the two truths at once — most back pain in adolescents is mechanical and self-limiting, but back pain in the younger child, or with any red flag, is a diagnosis waiting to be found. [1] [2]
The red flag is the central concept. A red flag is a clinical feature that raises the probability of a serious underlying cause — infection, tumour, inflammatory disease, fracture, or neurological compromise — to a level that demands investigation rather than observation. The recognised red flags for paediatric back pain are constant or night pain, fever and systemic symptoms, weight loss, neurological deficit or a gait change, age under five years, a progressive or painful deformity, and persistence of the pain beyond roughly four weeks. The absence of every red flag allows the conservative management of a presumed mechanical back; the presence of even one redirects the workup. [1] [11]
The clinical importance comes from what an unrecognised spinal tumour or a discitis does to a child. A vertebral osteosarcoma or an Ewing sarcoma presents with night pain that is dismissed as growing pains, and the delay narrows the window for curative treatment. A discitis in the toddler erodes the disc and the adjacent vertebral endplates and, untreated, leaves a residual deformity. A spondylolysis that is loaded through a competitive season progresses from a stress reaction to a complete pars fracture that may not unite. The fellowship task is to apply the red-flag screen, choose the right imaging, and refer the serious cause early. [3] [7]
References12ShowHide
- [1]Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop, 2006.PMID 16670548
- [2]Feldman DS, Hedden DM, Wright JG. The use of bone scan to investigate back pain in children and adolescents. J Pediatr Orthop, 2000.PMID 11097256
- [3]Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am, 1984.PMID 6373773
- [4]Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, Grant WD, Baker D. The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine (Phila Pa 1976), 2003.PMID 12768144
- [5]Lowe TG, Line BG. Evidence based medicine: analysis of Scheuermann kyphosis. Spine (Phila Pa 1976), 2007.PMID 17728677
- [6]O'Donnell JM, Wu W, Youn A, Mann A, Swarup I. Scheuermann Kyphosis: Current Concepts and Management. Curr Rev Musculoskelet Med, 2023.PMID 37615931
- [7]Brown R, Hussain M, McHugh K, Novelli V, Jones D. Discitis in young children. J Bone Joint Surg Br, 2001.PMID 11245515
- [8]Lashkarbolouk N, Mazandarani M, Ilharreborde B, Nabian MH. Understanding the management of pediatric spondylodiscitis based on existing literature; a systematic review. BMC Pediatr, 2023.PMID 37980513
- [9]Choi JH, Ochoa JK, Lubinus A, Timon S, Lee YP, Bhatia NN. Management of lumbar spondylolysis in the adolescent athlete: a review of over 200 cases. Spine J, 2022.PMID 35504566
- [10]Cetik RM, Latalski M, Yazici M. Management of low back pain accompanying sagittal plane pathologies in children: Spondylolysis/spondylolisthesis and Scheuermann's disease. J Child Orthop, 2023.PMID 38050599
- [11]Dahmoush H, Gaddam DS, Ho ML, et al. ACR Appropriateness Criteria® Back Pain-Child: 2024 Update. J Am Coll Radiol, 2025.PMID 40409897
- [12]Rambo AJ, Sheffer BW, Hajek B, Almatari A, Suit P, Rhodes LN. Lumbar Spondylolysis in the Pediatric Population: A Retrospective CT Review With Radiology Rereview. J Am Acad Orthop Surg, 2025.PMID 40233349