Immediate Questions

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A. Is there evidence of neurologic disability? Back pain in children, as opposed to adults, is more likely to have a serious organic cause. Although "adult-type" low back pain is now recognized in children, a careful evaluation for structural or organic causes is warranted in children. Of utmost importance is a history and physical exam directed toward any potential evidence of spinal cord involvement, which would mandate urgent radiologic and neurosurgical involvement.

B. When and how did pain begin? It is important to recognize acute or more chronic onset. Trauma is a common cause, especially in athletes. Repetitive trauma (eg, in gymnasts) may have a more indolent onset.

C. Are there constitutional symptoms? Fever, weight loss, and malaise may be signs of infectious, inflammatory, or malignant processes. Patients with trauma generally are otherwise well.

D. Is there a history of prior episodes or a congenital problem with the spine? Patients with visible evidence over the spine (hair tufts, vascular malformations) are predisposed to spinal cord entrapment and may have prior or even progressive gait disturbances.

E. Any change in spinal curvature? Chronic juvenile scoliosis is usually not painful, but acute, painful scoliosis is a clue to a new structural cause.

F. Is pain worse at night? Trauma, overuse, spondylolisthesis, and muscle strain disorders usually improve with rest. Worsening of symptoms at night suggests inflammatory, infectious, or malignant processes.

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