Back pain in children and adolescents — branching viva

Branching framework

Open with the red-flag screen and the one-sentence problem representation. This is a pre-school child with back pain and a fever, and back pain under five years is itself a red flag demanding investigation for an organic cause. State the screen aloud — night pain, fever, weight loss, neurological deficit, age under five, progressive deformity, and persistence beyond four weeks — and confirm that this child carries the red flag of the young age and the fever. The examiner is listening for whether you reach for the MRI and the bloods before you reach for the reassurance. ^{[1] [11]}

Branch to the differential and the leading diagnosis. The age-stratified differential is discitis and vertebral infection in the pre-school child, and the refusal to walk with the raised inflammatory markers and the normal plain film points to discitis as the leading diagnosis. Distinguish it from the vertebral osteomyelitis, which has more bone destruction and more systemic illness, and from the tumour, which has constant night pain. The normal plain film does not exclude the discitis, because the early lesion is radiographically occult, and this is probe examiner uses to test your imaging strategy. ^{[7] [1]}

Branch to the single most important investigation. The urgent magnetic resonance imaging of the spine, which reveals the disc-space inflammation and the adjacent endplate oedema that the plain film misses, and which excludes the epidural abscess, the vertebral osteomyelitis, and the tumour. State that the blood culture is drawn before the first antibiotic, and that the inflammatory markers provide the baseline. The ACR Appropriateness Criteria confirm the MRI as the modality for the suspected spinal infection in the child, and the examiner rewards the candidate who names the modality for the diagnosis. ^{[11] [7]}