After a thorough neurologic examination, anteroposterior and lateral radiographs should be obtained. The goal isto rule out a nonmuscular etiology. A computed tomography (CT) scan or MRI of the head and neck is necessary forpersistent neck pain, neurologic symptoms, and persistentdeformity.
Treatment of muscular torticollis is aimed at increasing the range of motion of the neck and correcting the cosmetic deformity. Stretching exercises of the neck can be very beneficial for infants. Surgical management is indicated if patients do not improve with adequate stretching exercises in physical therapy. Postoperative physical therapy is needed to decrease the risk of recurrence. Treatment in patients with underlying disorders should target the disorder.
Back pain in the pediatric population should always be approached with concern. In contrast to adults, in whom back pain is frequently mechanical or psychological, back pain in children may be the result of organic causes, especially in preadolescents. Back pain lasting longer than a week requires a detailed investigation. In the pediatric population, approximately 85% of children with back pain for greater than 2 months have a specific lesion: 33% are posttraumatic (spondylolysis, occult fracture), 33% are developmental (kyphosis, scoliosis), and 18% have an infection or tumor. In the remaining 15%, the diagnosis is undetermined.
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The history must include the onset and duration of symptoms. The location, character, and radiation of pain are important. Neurologic symptoms (muscle weakness, sensory changes, and bowel or bladder dysfunction) must be reviewed. Medical history and family history should be obtained, with a focus on back pain, rheumatologic disorders, and neoplastic processes. The review of systems should include detailed questions on overall health, fever, chills, recent weight loss, and recent illnesses. Physical examination should include a complete musculoskeletal and neurologic evaluation. Spinal alignment, range of motion, areas of tenderness, and muscle spasm should be noted. Red flags for childhood back pain include persistent or increasing pain, systemic findings (e.g., fever, weight loss), neurologic deficits, bowel or bladder dysfunction, young age (under 4 is strongly associated with tumor), night waking, pain that restricts activity, and a painful left thoracic spinal curvature.
Anteroposterior and lateral standing films of the entire spine with bilateral oblique views of the affected area should be obtained. Secondary imaging with bone scan, CT scan, or MRI may be necessary for diagnosis. MRI is very useful for suspected intraspinal pathology. Laboratory studies, such as a complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and specialized testing for juvenile idiopathic arthritis and ankylosing spondylitis, may be indicated.
The differential diagnosis of pediatric back pain is extensive (Table 202-2). Treatment depends on the specific diagnosis. If serious pathology has been ruled out and no definitediagnosis has been established, an initial trial of physicaltherapy with close follow-up for reevaluation is recommended.
Diskitis (most common before the age of 6 years) Vertebral osteomyelitis (pyogenic or tuberculous) Spinal epidural abscess Pyelonephritis Pancreatitis
Hip and pelvic abnormalities (sacroiliac joint dysfunction) Herniated nucleus pulposus (intervertebral disk) Overuse injuries (facet syndrome) Vertebral stress fractures (spondylolysis, spondylolisthesis) Vertebral compression fracture (steroid, sickle cell anemia) Upper cervical spine instability (atlantoaxial instability)