Fritz, J. M., & Kelley, M. K. (2002). Clinical Question: What signs and symptoms can be used to differentiate low back pain of a musculoskeletal origin from a potentially more serious non-musculoskeletal condition in a 12-year-old girl? Physical Therapy, 82(5).

BACKGROUND

Back pain is a frequent problem and finding the exact cause of back pain is clinically challenging. This is a report on a case of a 12-year-old girl with an episode of back pain that illustrates some of the common clinical challenges in identifying whether back pain is from a musculoskeletal cause or one that may be from some other more serious pathology. While this case study took place in a physical therapy clinic it is reflective of the very same issues that may crop up in clinical practice for massage practitioners.

The young girl came to the physical therapy clinic after developing an episode of back pain, bilateral thigh pain, and difficulty in walking. Her symptoms had begun approximately 3 months prior to her coming to the physical therapy clinic. Initially the symptoms were pain and tightness in the right posterior thigh that progressed to the lumbar region and then the left posterior thigh and buttock. When she came into the physical therapy clinic her main complaint was not pain, but an inability to play soccer due to changes in her walking and running.

Her initial examination revealed an abnormal gait pattern that also included a reduced stride length that was worse on the right. There was also a scoliotic curve to her lumbar spine with a convexity on the right. Visible muscle spasm was also apparent in the paraspinal muscles. The straight leg raise test (which most commonly investigates for the presence of intervertebral disc herniation, but may be positive with a few other problems) was positive with the right side being much more sensitive than the left side. Palpation did not reveal any specific tenderness and range of motion evaluations showed a mild increase in pain during extension, but none in flexion.

The signs and symptoms that were evident with this patient could be of musculoskeletal origin. Conditions that fit into her clinical picture include lumbar disc herniation, spondylolisthesis, myofascial trigger point problems or some other muscular impairment. Yet other conditions that are not musculoskeletal could also produce similar symptoms. A spinal neoplasm (tumor) is also likely to produce many of these symptoms and a condition such as this would certainly warrant referral to another specialist.

RESULTS AND DISCUSSION

The pattern of onset of her symptoms did not clearly point to either a musculoskeletal problem or to a non-musculoskeletal problem like a neoplasm. There were characteristics of both in her complaint. Therefore the clinicians chose to consult the available research literature to see if there were any studies that elaborated on how to distinguish between musculoskeletal and non-musculoskeletal complaints in a young child.

A comprehensive search of the available medical literature revealed a number of studies on musculoskeletal and non-musculoskeletal low back pain in children. However, none of them were specifically what the clinicians were looking for so pulling partial information from multiple studies seemed the best approach. Each of the studies contributed valuable information that helped paint a better picture for them to make an appropriate decision. Valuable information they derived from the studies included:

• Lumbar disc herniation is not common in the young person and especially in patients under 17 years of age.
   
• Motor weakness and impaired reflexes were more frequent in patients with spinal tumors than in those with musculoskeletal low back pain.
   
• Leg pain from a neoplasm is frequently bilateral whereas it is not as common for musculoskeletal back pain to produce bilateral lower extremity pain.
   
• Motor and reflex impairments are more common with spinal neoplasm.
   
• If an intervertebral disc is pressing on a nerve root then a straight leg raise test is likely to be positive. However, children with a spinal neoplasm are less likely to have a positive straight leg raise.

When using any orthopedic testing procedure it is important to consider two factors: the sensitivity of the test and the specificity of the test. In a nutshell, sensitivity relates to how accurate the testing procedure is at identifying every person in a group that has a particular condition. Specificity refers to only including those individuals who actually have the condition so a high degree of specificity will rule out or screen for false positives. In the procedures evaluated with this young patient the clinicians considered the sensitivity and specificity of each test when determining what additional information they might gain from the procedure.

After evaluating all the available information they still felt like this young girl’s back pain could fall into either category, the pain of musculoskeletal origin or the pain of non-musculoskeletal origin. There were some symptoms of each category present. However, a spinal neoplasm that is missed in the diagnostic evaluation can cause significant problems later. Therefore they felt it was important to refer the client to a pediatric neurology practice

Eventually the patient had an MRI performed on her spine and found that no neoplasms were present. Unfortunately what did become evident was that the client had a grade II spondylolisthesis that required surgical intervention at a later date.
The process of evaluating the pain and discomfort affecting this young girl was an excellent exercise in research and clinical problem solving. Being able to follow the steps used by these clinicians was a great example of how research can help support giving the most effective care with each individual person.

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