Initial Management at Presentation
- Initial management extrapolated from adult management: Little evidence exists to clearly delineate appropriate management or timing in children; however, some management has been extrapolated from adult cohorts.
- Most episodes self-resolve: In the management of routine back pain in the absence of concerning findings, rest and observation should be initiated with adjuvant oral pain medication. Most initial episodes of back pain in children self-resolve within a week.
- Conservative therapy should be first-line treatment: Persistent pain should be managed with physical therapy, with a focus on core strengthening exercises, avoidance of physical or impact activities, escalation of oral medications (from NSAIDs, muscle relaxants, non-narcotic medications/gabapentin, narcotics).
- Steroids may be beneficial for radicular pain: Patients with radiculopathy can be managed with oral steroids for a short course or epidural steroid injections for refractory pain.
- Lack of evidence to support other modalities: There is insufficient clinical evidence to support the use of the adjuvant modalities mentioned below, but they may be considered for back pain.
- Specific injections may be of benefit: Specific alternative injections may prove useful in appropriate clinical scenarios (trigger point injections for focal myofascial pain, facet blocks for extension pain, sacroiliac joint injections for sacroiliac joint-generated pain).
- Lumbar corset or brace can be trialed for a short period: A brief course of a corset or lumbar support may be helpful but should not be prolonged, as it may contribute to further muscle weakness.
- Acupuncture, chiropractic manipulation, and massage therapy: All lack clinical evidence for management but may be considered.
- Routine follow-up in 6–8 weeks: After initiating a course of therapy, follow-up should be arranged in 6–8 weeks. However, patients should be told to contact their physician immediately or go to the emergency room if they develop new or worsening neurological symptoms.
- If improved after 6–8 weeks: If symptoms are improved or resolved by the follow-up visit, continuation of the conservative course is reasonable. Once symptoms are completely resolved, patients can be advised to gradually increase their level of activity and slowly return to baseline level of activity.
- Failure to improve after 6–8 weeks: Failure of symptoms to adequately resolve by 8–12 weeks may prompt discussion and planning of surgical interventions.
- Longer-term back care: After resolution of symptoms postoperatively or after conservative therapy, management should include aggressive teaching in proper back care, diet, exercise, lifting techniques, posture, core strengthening, and smoking avoidance to try to minimize recurrence.
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