Patterns of Clinical Presentation

Symptom Patterns

Symptom pattern recognition is the key to diagnosis in any age group. Tumors are characterized by nocturnal, constant, and severe pain that often limits activities (Fig. 4). While the pain associated with the benign tumors of osteoid osteoma and osteoblastoma are often dramatically relieved by NSAIDs, pain associated with other tumors is generally not relieved by analgesics. Some mechanical causes such as disk herniation and spinal or sacral fracture usually present acutely or following a significant trauma, while others such as spondylolysis and Scheuermanns disease have a more insidious and chronic onset. Mechanical causes of back pain are typically worse later in the day but not at night, and are aggravated by activities and relieved by rest; spondylolysis and spondylolisthesis are usually worsened by hyperextension and flexion. Some conditions such as spondylolysis, disk herniation, apophyseal ring injuries and fractures often present with very localized pain, others such as Scheuermann present with a broader area of

Dish Syndrome

Figure 4 This 11-year-old girl presented with complaints of severe neck, shoulder, and back pain. On examination, she was found to have significant limitation in movement and diffuse severe tenderness around her shoulder and upper back. X-rays showed generalized osteoporosis of her thoracic spine with collapse of upper thoracic vertebra (asterisk). She had a white blood count of 2.6 K cells/mcl with a normal differential hemoglobin of 9.6gm/dl; platelet count of 117,000/mcl; ESR of 49; and CRP of 1.8 (normal to 0.8). She was found to have acute lymphoblastic leukemia on her bone marrow aspirate.

Figure 4 This 11-year-old girl presented with complaints of severe neck, shoulder, and back pain. On examination, she was found to have significant limitation in movement and diffuse severe tenderness around her shoulder and upper back. X-rays showed generalized osteoporosis of her thoracic spine with collapse of upper thoracic vertebra (asterisk). She had a white blood count of 2.6 K cells/mcl with a normal differential hemoglobin of 9.6gm/dl; platelet count of 117,000/mcl; ESR of 49; and CRP of 1.8 (normal to 0.8). She was found to have acute lymphoblastic leukemia on her bone marrow aspirate.

pain, and still others such as disk herniation with pain that radiates into the buttock or down a leg. In contrast, inflammatory spine pain is usually characterized by stiffness that is improved by moderate activity and worsened by rest and lying supine. The pain is usually relieved by NSAIDs to some degree. Infectious causes can be either acute or insidious in onset, but the pain tends to be constant.

Systemic symptoms such as fever, weight loss, malaise, or night sweats are more likely to be associated with serious conditions such as infection, tumor (usually malignant), IBD, or a major rheumatic disease. Patients that have a history of significant trauma to their back prior to the onset of their pain should be carefully examined for possible spinal fracture or disk her-niation. A change in the bladder or bowel pattern is suspicious for tumor, infection, or a major spinal cord injury. Severe or progressive limitation of activities or limping is also suggestive of infection or tumor, although a severe mechanical or rheumatic disease can also cause these problems.

Adolescents should also be asked about their level of participation in sports to assess their risk for mechanical problems. Underlying medical problems in the patient or the family such as psoriasis, IBD, intravenous drug use, frequent infections, or use of immunosuppressive medications, may indicate potential disease risks. A poor sleep pattern, fatigue, and mood changes are suggestive of fibromyalgia. Excessive school absences might be suggestive of psychogenic pain or school avoidance. These patients will generally have poorly characterized, diffuse, and variable patterns of pain.

Physical Examination Patterns

The spine should be examined for painful scoliosis and a left curve, findings that are often associated with a tumor. Paravertebral muscle spasms, a rigid spine, and spinal point tenderness are seen with tumor and infection, but can also be associated with mechanical etiologies (spondylolysis and disk herniation). A waddling gait with flexed knees indicates spinal nerve root irritation, which can occur with tumors, disk herniation, spondylolisthesis, or intervertebral disk disease. In contrast, a bizarre gait, with prancing steps or other non-organic pattern of walking, is suggestive of a psychogenic problem. If a spinal cord problem is suspected, reflexes, including of the abdomen and anus, and strength and sensory testing should be done. Tenderness of the sacroiliac joints, spine tenderness in a broad area, and decreased lumbar flexibility are findings associated with JIA; patients are also likely to have peripheral joint arthritis and enthesitis or other findings such as dactylitis or nail pitting (psoriatic arthritis), or skin findings (erythema nodosum or oral ulcers in IBD). Occult spinal or sacral anomalies such as a dimple, hair patch, or vascular markings are suggestive of a tethered cord or other congenital spinal canal malformation of spinal canal.

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