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 the probe the 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]

Branch to the immediate management. The empirical intravenous antibiotics targeting Staphylococcus aureus, the commonest organism, after the blood culture is drawn, with immobilisation for comfort and a step-down to oral guided by the clinical and the inflammatory-marker response. The infectious-diseases team is involved for the antibiotic guidance, and the orthopaedic team is involved if a complication demands surgery. The family is counselled on the diagnosis, the duration, and the safety-net, and the outcome is excellent with prompt treatment. [7] [11]

Branch to the adolescent gymnast with the extension-related back. The school-age or adolescent athlete in an extension-loading sport — gymnastics, cricket fast bowling, dance — with a low back pain that worsens with hyperextension has a spondylolysis until imaging excludes it. The one-legged lumbar hyperextension test reproduces the pain, and the management is activity cessation, an anti-lordotic brace, and a core-stabilisation programme to achieve pars union. The imaging strategy progresses from the initial films to the modality that reveals the early pars lesion, and the bilateral defect with a progressive spondylolisthesis is monitored and fixed when it progresses. [9] [11]

Close with the Scheuermann kyphosis and the tumour. The adolescent with a rigid thoracic kyphosis that does not correct on extension has Scheuermann kyphosis, confirmed by the vertebral wedging on the lateral radiograph, and managed with a brace in the skeletally immature and surgery for the severe rigid curve. And the child with constant night pain that wakes them from sleep has a tumour until the MRI and the biopsy prove otherwise — osteosarcoma, Ewing sarcoma, or leukaemia — and the red-flag screen is the safeguard that catches it. The examiner rewards the candidate who frames the back-pain assessment as a clinical reasoning exercise with the safety-net review. [1] [9]