Dorsalgia is a set of symptoms that are united by stinging or burning pain of varying intensity in the back area. There are several types of dorsalgia: cervical, thoracic and sacral. The causes of back pain are many different diseases of a vertebral or non-vertebral nature.
Dorsalgia is a group of disorders characterized by mild, moderate or intense pain that occurs in the muscle nerves or joints located in the dorsal region.
The pain can be constant or intermittent, localized to one area or scattered over a wide area. It can be stinging or burning. If the pain is associated with the cervical spine, it can develop into intense pain, accompanied by a feeling of dumbness.
Dorsalgia of the thoracic region
With dorsalgia of the thoracic region, the patient, as a rule, complains of pain in the chest area, aggravated by palpation or movement of the body; there is aching pain under the shoulder blades; pain when moving your arms, bending or turning your body, when you inhale and exhale deeply, between the ribs, there is a feeling of squeezing in the chest. Dorsalgia of the thoracic region occurs as a result of such a common disease as osteochondrosis. But the most common cause of the disorder is a sedentary lifestyle.
Diagnostics
Intense pain at rest for 3 weeks and the presence of “red flag” symptoms usually suggest the presence of a serious illness (tumors or infections). In such cases, it is necessary to conduct instrumental research methods (visualization) using methods such as radiography, MRI, CT (MSCT). If there are signs of progressive neurological deficit, then imaging should be used as quickly as possible and the patient should be transported to a clinic where studies (MRI, CT, radiography) can be performed. X-rays can diagnose fractures, cancer, metabolic changes in bone tissue, infections and inflammatory changes in bone tissue. But it is often necessary to use more informative diagnostic methods, such as MRI or CT, especially when it is necessary to visualize in more detail changes in bone tissue and, especially, in soft tissue. In this regard, MRI is the most informative research method, allowing high-quality visualization of even minor morphological changes in both soft and bone tissues, this is especially necessary if it is necessary to diagnose damage to the nervous tissue of the muscles of the disc ligaments.
If it is necessary to identify focal changes in tissues, scintigraphy can be prescribed, which makes it possible to verify oncological or infectious diseases.
ENMG makes it possible to determine conduction disturbances in nerve fibers and is often used to monitor the dynamics of the disease and the effectiveness of treatment.
Laboratory research methods are used when it is necessary to verify inflammatory oncological and infectious processes.
Dorsalgia of the cervical region
With cervical dorsalgia, compression of the roots, compression of blood vessels, compression of the spinal cord may occur, and may be accompanied by mixed paresis of the arms. The patient complains of pain in the neck, upper shoulder, posterior surface of the shoulder, scapula, and hypotension of the shoulder muscles. The pain can be shooting or chronic. Cervical dorsalgia does not cause sensory impairment. The causes of this type of dorsalgia can be various factors, among them: osteochondrosis, microtrauma of joints and tendons.
Differential diagnosis of back pain in children
I.P. Nikishina
Children's Department (headed by Prof. N.N. Kuzmina) of the Institute of Rheumatology (directed by Corresponding Member of the Russian Academy of Medical Sciences E.L. Nasonov) RAMS, Moscow
Back pain is a problem identified as one of the priorities of the World Decade against Bone and Joint Diseases, carried out under the auspices of WHO in 2000–2010. The high prevalence of this syndrome, the variety of causes leading to it, and, as a consequence, the objective difficulties of differential diagnosis necessitate the closest attention to this problem among doctors of various specialties. The bulk of scientific research and publications are devoted to a comprehensive study (epidemiology, clinical picture, diagnosis, treatment) of this pathological condition in adults, while much less attention is paid to the pediatric aspects of this problem. At the same time, back pain is a striking example of a pathology, the origins of which often lie in childhood, “growing” into a serious medical and social problem as the child grows older. Data on the prevalence of back pain in children and adolescents vary widely, from 20–30 to 83%. A review of the literature data allowed scientists [cit. according to 1] to conclude that low back pain is at least 2–4 times more common in Sweden, Germany and Belgium compared to the countries of the Southeast region (China, Indonesia, Philippines, Nigeria). It is unclear whether these data confirm the role of environmental and genetic factors and whether explanations for this phenomenon can be found in the field of medicine or ethnopsychology. The range of causes causing back pain in childhood is very wide. The following list of the main causes of back pain in children convincingly demonstrates that this problem is at the intersection of the interests of doctors of various specialties. Traditionally, orthopedic surgeons deal with the diagnosis and differential diagnosis of back pain in children. More active participation in this process of physicians of therapeutic specialties, especially rheumatologists, seems justified and useful not only from the standpoint of a wider coverage of differentiated pathology, but also in connection with the need to develop rational approaches to symptomatic pharmacotherapy, taking into account modern trends and requirements for the use of drugs in pediatrics. In this article, the differential diagnosis of back pain in children and adolescents will be considered from the perspective of a pediatric rheumatologist. The main causes of back pain in children • Associated with body position (posture) • Psychogenic • Traumatic • Osteochondropathies and intervertebral hernias • Spondylolysis/spondylolisthesis and dysplastic spondylopathy • Juvenile spondyloarthritis • Discitis • Infection: 1) intervertebral discs; 2) vertebral bodies (osteomyelitis, tuberculosis) • Osteoporosis: 1) idiopathic; 2) for endocrinopathies; 3) iatrogenic • Tumor diseases: 1) spinal cord; 2) osteochondral structures and ligaments; 3) metastatic • Hematological diseases (sickle cell anemia, hereditary spherocytic anemia) • Diseases of internal organs: projection pain in diseases, congenital anomalies and tumors of the gastrointestinal tract (GIT) and urogenital area. Differential diagnosis of back pain (dorsalgia) in children begins with a topical diagnosis of the source of pain impulses. Possible sources of dorsalgia are: 1 – intervertebral joint; 2 – vertebral disc; 3 – costovertebral joint; 4 – ligament; 5 – muscle; 6 – nerve. There is no doubt that destruction of the vertebral bodies can also be a morphological substrate for pain. Pathological conditions in which the source of dorsalgia is projection pain emanating from the internal organs require as early differentiation as possible, since in these clinical situations both the examination tactics and approaches to therapy are fundamentally different. The psychogenic nature of pain can be suspected only after excluding other causes, although it is likely that the psychogenic nature of dorsalgia may be the most common. Apparently, it is no coincidence that from the standpoint of representatives of alternative medicine, parapsychologists and other followers of esoteric knowledge, the condition of the spine is given the most important importance in the origin of various human diseases. From the point of view of scientific medicine, clinical observations are also not uncommon when intense dorsalgia accompanies the course of psychopathological syndromes and severe mental illnesses. Thus, in the observation of the children's department of the Institute of Rheumatology, there is a clinical example of schizophrenia in a teenage girl, whose disease manifested itself for a long time as intense back pain and spinal rigidity, which required a long differential diagnostic search and exclusion of orthopedic and rheumatological diseases. The differential diagnosis of dorsalgia is based on a clinical assessment that takes into account: • pain intensity; • duration; • localization; • irradiation; • circadian rhythm; • provoking factors; • presence and topical diagnosis of functional disorders; • the presence of other clinical signs: neurological disorders, symptoms of systemic damage to the musculoskeletal system and other organs and systems, fever, signs of intoxication, hematological changes, lesions of the skin and mucous membranes, etc. The following paraclinical methods are a necessary addition to clinical research methods, allowing to clarify the topical and nosological diagnosis for back pain in children: • radiography of the spine in 2 projections, if necessary (suspicion of diseases of the range of spondyloarthritis) radiography of the pelvis; • Magnetic resonance imaging; • CT scan; • electromyography (for symptoms of unspecified radiculopathy); • densitometry; • radioisotope osteoscintigraphy; • myelography (performed according to indications based on the conclusion of neurosurgeons). Among the most significant (although not the most common) causes of back pain in children and adolescents, diseases of the range of seronegative/juvenile spondyloarthritis (JSA) should be taken into account. The JSA group includes juvenile ankylosing spondylitis (JAS) as a prototype for the entire JSA group, as well as a number of clinically and pathogenetically similar diseases: psoriatic arthritis (spondyloarthritic variant), reactive (postenterocolitic and urogenic) arthritis associated with the HLA-B27 antigen, Reiter's syndrome, enteropathic arthritis (associated with inflammatory bowel diseases - regional enteritis, ulcerative colitis). Many authors consider it appropriate to also distinguish undifferentiated spondyloarthritis to designate those clinical situations in which the patient has only individual manifestations characteristic of JSA and does not have the entire symptom complex of the disease, which is essentially a stage in the formation of the disease and, with natural evolution, usually leads to the development of JSA . JAS is a condition in which damage to the axial skeletal structures is a pathognomonic symptom, since JAS is actually the equivalent of adult ankylosing spondylitis (AS). There are no precise data on the prevalence of JAS. According to official statistics from the Ministry of Health of the Russian Federation, the incidence of JAS in children and adolescents in 2002 was 1.7 per 100,000 children [2], i.e. Until now, JAS is considered a rare disease in children, although today it has become obvious that JAS is not as rare as it is rarely diagnosed. If we take into account that among adults of the white race, manifest AS occurs with a frequency of 2:1000 and higher, and among all cases of AS, 15–30% occur in juvenile onset, then the prevalence of JAS should be from 0.03 to 0.06% . The results of long-term follow-up observations when assessing the nosological outcomes of juvenile arthritis in patients who left the care of pediatricians and are observed by rheumatologists-internists indicate that every third or fourth patient with juvenile chronic arthritis develops a clinical picture of JAS as the disease progresses. The most important feature of JAS, which causes difficulties in early diagnosis, is the presence of a “prespondylic” stage, when the clinical picture of the disease has nonspecific features that are indistinguishable from the symptoms of other inflammatory diseases of the joints in children. The duration of this prespondylic stage before the appearance of the first symptoms of spinal lesions can be several (sometimes more than 10) years and is inversely related to the age of onset of the disease (Fig. 1). This pattern of the course of JAS dictates the need for a thorough assessment and interpretation of other clinical manifestations of the disease in order to make a diagnosis or predict the development of JAS in the future. The clinical symptom complex of JAS consists of 4 main syndromes: a) articular syndrome: more often oligoarthritis with predominant damage to the lower extremities, usually asymmetrical, predominantly non-destructive (with the exception of tarsitis and coxitis), a relatively benign course with the possibility of complete reverse development and a tendency to develop long-term, in including long-term remissions; b) enthesopathies - inflammatory changes in the places of attachment of tendons and ligaments to the bones; c) extra-articular manifestations with typical damage to the eyes, heart, mucous membranes, skin; possible involvement of internal organs in the process (for example, IgA-associated nephropathy); d) damage to the axial skeleton.
Damage to the axial skeleton develops in almost half of the patients during the first year, and in 20–30% already at the onset of JAS. For the first time, symptoms of involvement of the iliosacral joints and spine in the process can be detected at the age of 11–14 years, regardless of the age of onset of JAS (see Fig. 1). The first clinical sign of an axial lesion is usually pain in the projection of the sacroiliac joints, which manifests itself both as active complaints and during physical examination. It is important to emphasize that the Kushelevsky symptoms used for the clinical diagnosis of sacroiliitis in adults have virtually no diagnostic significance for children, probably due to the high plasticity of tissues in childhood, which prevents the creation of hyperextension in the area of the sacroiliac joints, which is necessary to identify inflammation in this area . The assessment of the patient’s complaints, as well as the identification of palpation pain in the projection of the sacroiliac joints, is more informative. Symptoms of sacroiliitis are often, from the moment of their first appearance, combined with damage to the lumbar and lower thoracic or cervical spine. Intense, predominantly nocturnal, back pain characteristic of adults is atypical in childhood and develops after a significant period of time, providing grounds for formal compliance with the generally accepted diagnostic criteria (Modified New York Criteria) for AS (see Fig. 1). Most often in children one can observe intermittent complaints of a feeling of fatigue and tension in the back muscles with an inflammatory rhythm, i.e. occurring in the early morning hours and decreasing after exercise. Sometimes local pain, limited range of motion, smoothness of the physiological curves of the spine, especially lumbar lordosis, and regional muscle wasting are detected (Fig. 2). In some patients, these symptoms significantly decrease or disappear completely after adequate treatment, and repeated relapses may occur only after several years. The Thomayer, Ott, and Schober functional tests used in adults are of little information for JAS due to the rare development of significant functional disorders in the spine. The modified Schober test (as modified by Macrae and Wright) is more informative, when performing it, not 10, but 20–25 cm are measured upward from the last lumbar vertebra (depending on the age of the child). Thus, the modified Schober test reveals changes localized not only in the lumbar, but also in the lower thoracic spine. Practical assistance in studying the condition of the spine is provided by a visual assessment of the curve formed by the spinal column with a maximum forward tilt of the torso. Normally, when viewed from the side, this curve looks like a smooth arc without sharp bends and local flattening. The study of chest excursion in children can be used only for an approximate assessment of the degree of involvement of the costovertebral joints, as a rule, with a significant severity of pain, which is rare. X-ray assessment of lesions of the axial skeleton in children and adolescents presents significant difficulties due to the incompleteness of the skeletal ossification processes. It is known that on radiographs of the pelvis in childhood, the articular surfaces of intact sacroiliac joints may not look smooth and clear enough, often their gaps have an uneven width, which can be erroneously interpreted as manifestations of sacroiliitis. However, even with significant severity of the growth zones, indisputable radiological changes in the sacroiliac joints can be detected, for example, pronounced osteosclerosis with the so-called phenomenon of pseudo-expansion of the joint space (Fig. 3) or pronounced erosions with elements of ankylosis, corresponding to stages III–IV (Fig. 4 ).
Rice. 1. Comparison of the age of onset of JAS and the timing of involvement of the axial skeleton in the process.
Rice. 2. Muscle hypotrophy and smoothness of the physiological curves of the spine in a patient with JSA.
Rice. 3. Stage II sacroiliitis in a patient with JAS: osteosclerosis, erosion of adjacent articular surfaces and “pseudo-expansion” of the joint space (indicated by the arrow).
Rice. 4. Bilateral sacroiliitis stage III–IV in a patient with JSA: erosion of adjacent articular surfaces with signs of ankylosis.
Rice. 5. Computed tomographic image of the early stage of sacroiliitis: erosion of adjacent articular surfaces (indicated by an arrow) in a patient with JAS.
Rice. 6. X-ray picture of anterior spondylitis and calcification of the anterior longitudinal ligament of the lumbar spine in a patient with JAS.
Rice. 7. Forming “posterior” and “anterior” syndesmophytes in the cervical spine in a patient with JAS.
Rice. 8. Ankylosis of the facet joints in the cervical spine in a patient with JAS.
Rice. 9. Anomaly in the structure of the lumbosacral junction: bilateral (incomplete on the left) sacralization of the last lumbar vertebra with symptoms of neoarthrosis on the right (indicated by the arrow) in an 11-year-old boy.
Rice. 10. Degenerative changes and disc protrusion in the lumbar spine in a teenager.
Rice. 11. Focus of calcification at level LII–LIII (osteochondroma): on the left – densitometry; on the right is an x-ray of the spine in an oblique projection.
To identify sacroiliitis in children in recent years, many authors have actively recommended the use of computed tomography and nuclear magnetic resonance (Fig. 5), the advantage of which is the sagittal plane of the image, which gives a more complete picture of the joint space of the sacroiliac joints. However, so far these methods have not found widespread use in clinical practice due to their low availability and are performed mainly for differential diagnostic purposes (excluding a local process, such as a tumor). In contrast to the radiological manifestations of sacroiliitis, the degree of damage to the overlying parts of the spine differs qualitatively in JSA and AS in adults. In JSA, syndesmophytes develop much less frequently and at a much later date; they are reliably detected only in a few pediatric patients (Fig. 6). X-ray may reveal compaction of the anterior longitudinal ligament, which becomes more and more evident as the skeleton grows and develops, as well as spondylitis progresses. It is important to emphasize the presence of a certain stage in the development of compaction of the spinal ligaments, which is, apparently, a reflection of the physiological characteristics of the mobility of the spine in everyday life. For example, in the lower thoracic and lumbar segments of the spine, compaction of the lateral sections of the anterior longitudinal ligament primarily develops, while in the cervical spine, simultaneous or sequential calcification of the posterior and anterior ligaments develops (Fig. 7). Intervertebral and costovertebral joints are affected with equal frequency in both JAS and AS in adults, but, as a rule, at later stages of disease development. Sometimes the radiological severity of arthritis of the intervertebral joints, for example with ankylosis of the facet joints in the cervical spine (Fig. 8), exceeds the clinical manifestations. Spondylodiscitis can also act as one of the clinical and radiological signs of spinal damage characteristic of JAS. In some patients, it occurs quite early and is sometimes the leading symptom of the disease, but it is necessary to emphasize the imperative need to exclude other causes of spondylodiscitis (infection, including tuberculous lesions, “aseptic” juvenile discitis). As a condition that requires differentiation from JSA, it should be emphasized that adolescent girls may develop a peculiar “JSA-like” syndrome , characterized by a very benign (in the form of arthralgia and/or short-term episodes of synovitis) peripheral articular syndrome, enthesopathies of multiple localization without exudative symptoms and persistent back pain. Long-term observations accumulated and summarized in the children's department of the Institute of Rheumatology of the Russian Academy of Medical Sciences allowed us to conclude that this symptom complex is a transient condition, apparently resulting from pronounced neurohumoral changes, it is completely reversible, although it is often mistakenly interpreted as JAS. On the contrary, it seems that in true JAS, damage to the axial skeleton in girls develops even later than in boys. It is not uncommon to observe that in girls, persistent, sometimes destructive arthritis of the lower extremities for many years is the only manifestation of JAS, and involvement of the spine in the process is observed after 18–20 years of age and even later. The most common pathological condition accompanied by back pain in children and adolescents is juvenile osteochondrosis of the spine (juvenile kyphosis, Scheuermann-Mau disease) . The cause of this condition is a genetically determined disorder in the formation of the apophyses of the vertebral bodies, gradually leading to their deformation and early degenerative changes. The clinical and radiological picture of juvenile osteochondrosis includes: • pain of a “mechanical” nature in the back, localized mainly in the thoracic region, arising and intensifying after physical activity, observed mainly in the daytime and evening hours; • palpation pain in the projection of the spinous processes and vertebral bodies; • kyphosis of the upper thoracic region; • wedge-shaped deformities (anterior, lateral), deformities such as platyspondyly of the vertebral bodies (single or multiple); • subchondral sclerosis, osteophytes. Dysplastic spondylopathy can also cause intense pain in the spine, especially in the case of an abnormality in the structure of the lumbosacral junction. Partial and complete bilateral or unilateral sacralization of the last lumbar vertebra or lumbarization of the first sacral vertebra is not always detected due to insufficient awareness of doctors, and is also not diagnosed due to poor-quality X-ray examination. The pain syndrome is especially pronounced in the case of the formation of a pathological articulating surface - neoarthrosis (Fig. 9). The pathology of the intervertebral discs: discitis and degenerative changes in the disc, protrusion and disc herniation (Fig. 10) should also be taken into account during the differential diagnosis of dorsalgia in children, paying attention to the appearance of neurological disorders, their localization, irradiation, and the presence of “tension symptoms.” Spondylolysis, usually accompanied by spondylolisthesis , is one of the relatively common conditions characteristic of childhood and adolescence, well known to orthopedic surgeons. The cause of this disease is dystrophic changes leading to a defect in the bone tissue of the vertebral arches and, as a consequence, “slipping” of 1–2 or a block of vertebrae, causing severe pain and neurological disorders. Pathologies of the vertebral bodies are also characterized by the presence of back pain. These conditions include: • spondylitis: infectious (tuberculosis, brucellosis, osteomyelitis), or “aseptic”; • traumatic injuries, including those resulting from osteoporetic spondylopathy; • destruction of vertebral bodies as a result of tumor infiltration (in leukemia, neuroblastoma, lymphoma, some solid tumors, sickle cell anemia). The diagnosis of a tumor process is extremely difficult, the need for the earliest possible detection of which imposes great responsibility on the doctor. Difficulties in the differential diagnosis of dorsalgia caused by neoplasms in benign tumors are due to the atypical localization, which requires more advanced additional research methods. For example, in the children's department of the Institute of Rheumatology, 2 observations of osteoid osteoma of the transverse process of the vertebral body, identified only by computed tomography, presented an exceptional difficulty for diagnosis. Of particular interest is the clinical observation of osteochondroma in a teenage boy, in whom a standard X-ray examination did not find an explanation for persistent pain in the back, and a densitometric study performed to exclude osteoporetic spondylopathy discovered a focus of calcification (Fig. 11) and allowed further verify the diagnosis.
Tumors that can cause dorsalgia in children: Benign • aneurysmal bone cyst • hemangioma • osteoid osteoma • osteogenic fibroma • eosinophilic granuloma • osteochondroma • osteoblastoclastoma • giant cell tumors of the vertebrae Malignant • Ewing's sarcoma • osteogenic sarcoma • metastatic lesions: – leukemia – neuroblastoma – lymphoma
It should be noted that severe pain and spinal rigidity in a child are not a typical manifestation of juvenile osteochondrosis or JSA, and the presence of such symptoms requires the exclusion of a wide range of diseases of a non-rheumatic nature, including neoplasms. Thus, in our department, 2 cases of acute leukemia, Ewing's sarcoma, 4 cases of neuroblastoma, melanoma, and non-Hodgkin's lymphoma were identified. The paradox of the situation is that it was in these patients that the diagnosis of JAS appeared as a guide or suspicion of JAS was expressed. In conclusion, it must be emphasized that the range of diseases, the clinical symptom of which is back pain, is extremely wide and diverse. Correct and timely interpretation of dorsalgia in children and adolescents requires high professionalism from the doctor, since the price of diagnostic errors can be severe disability and even the life of the child.
References 1. Cassidy JT, Petty RE. Textbook of pediatric rheumatology. New York, Edinburgh, Melbourne, Tokyo, 2001. 2. Sharapova O.V., Korsunsky A.A. Question modern pediatrician. 2004; 3 (1): 12–5.
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