Idiopathic Pain

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Fibromyalgia and other forms of idiopathic pain are a relatively common diagnosis in new patients presenting with back pain to North American pediatric rheumatology centers (90,91). Fibromyalgia generally develops during late childhood and adolescence, with girls much more commonly

Figure 3 (Continued on next page)

History or risk for: sickle cell disease (SS)? Osteoporosis?


Positive straight-leg raise and/or sciatica?


Increased lumbar curve and tenderness ofL5/S1?


Fixed kyphosis with overlying tenderness?


f NO

History of morning stiffness, with SI tenderness, enthesitis, or peripheral joint arthritis on exam?


History of fatigue, sleeping difficulties; specific tender points but otherwise normal exam?


Bizarre sx and/or neurological findings with "la belle indifference," overreaction in exam, pain on axial loading, or inconsistencies in exam?

Probable nonspecific back pain

Consider vaso-occlusive crisis (SS) or compression fracture (BOTH). Perform X-ray.

Consider disc herniation. Perform MRI.

Consider spondylolysis or spondylolisthesis. Perform X-raya with obliques.

Consider Scheuermann's kyphosis. Per form X-raysa.

Consider enthesitis-related arthritis;

CBC, ESR, CRP, chemistries, HLAB27. Evaluate for sacroileitis (X-ray; consider MRI).

Consider diffuse idiopathic pain/fibromyalgia; CBC, ESR, CRP, chemistries, LDH; consider alternate diagnosis if abnormal.

Figure 3 An algorithmic approach to diagnosis of causes of back pain. aThese are common X-ray findings that may not be causative; therefore continue algorithm to look for other causes. Abbreviations: PE, physical exam; SI, sacroiliac; Sx, symptoms. Source: Reprinted with permission from Ref. 92.

affected than boys (90,91). In addition to back pain, these patients usually complain of widespread musculoskeletal pain, and on examination have significant tenderness at specific soft tissue locations called tender points. The symptoms often have a gradual onset, and patients frequently have associated symptoms such as fatigue, difficulty sleeping, non-restorative sleep, headaches, abdominal pain, dizziness, and mood disturbances (90,91). No evidence for inflammatory, mechanical musculoskeletal, or neurological problems are found on exam, and blood tests should be normal (90,91).

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