Evaluation of a systematic approach to pediatric back pain: the utility of magnetic resonance imaging.

BACKGROUND: Several studies have suggested that back pain in the majority of pediatric patients does not have an identifiable cause. Many children undergo extensive diagnostic workup that ultimately results in a nonconfirmative diagnosis. The purpose of this study was to (1) describe the prevalence of back pain seen in a pediatric orthopaedic clinic; (2) evaluate the efficacy of a systematic approach dependent on magnetic resonance imaging (MRI) in the diagnosis of pediatric back pain; and (3) analyze sensitivity, specificity, positive predictive value, and negative predictive value of various clinical signs and symptoms. METHODS: For a 24-month period, all patients that presented with a chief complaint of back pain were prospectively enrolled in this study and evaluated in a systematic approach which utilized MRI for patients with constant pain, night pain, radicular pain, or abnormal neurological examination after an initial history, physical examination, and negative radiographic examination. RESULTS: The prevalence of chief complaint of back pain was 8.6% (261/3042 patients). Of the 261 patients, 34% had an identifiable pathology following the systematic approach. In 8.8% of patients, the diagnosis was established with the history, physical examination, and plain radiographs. MRI yielded a definitive diagnosis in another 25% of patients. It is noteworthy that of the 89 patients with a confirmed pathology, 26% were identified with plain radiographs and 74% with MRI. CONCLUSIONS: A systematic approach to diagnose pediatric back pain demonstrated that 34% of pediatric patients that present to an outpatient orthopaedic clinic complaining of back pain will have identifiable pathology. The diagnostic yield increased from 8.8% with the history, physical examination, and plain radiographs to 22% with the TCN Bone Scan to 36% with the use of the MRI. The clinician should be aware that the presences of lumbar pain or constant pain are red flags for the presence of underlying pathology. LEVEL OF EVIDENCE: Level III.

Peripheral Nerve Radiofrequency Neurotomy: Hip and Knee Joints.

Intra-articular hip and knee pain is a common cause of physical and psychosocial disability. Many conservative treatment options provide only short-term relief. Recent research studies have shown improvement in pain and function with minimal complications after radiofrequency neurotomy of the hip and the knee, especially in patients who have failed conservative treatment or are not surgical candidates. More quality research studies are needed to establish the efficacy and safety of these procedures in patients with refractory hip and knee pain.

An unusual complication in a 9-year-old patient with hereditary multiple osteochondromatosis.

This case report describes the presentation of a 9-year-old boy with a history of hereditary multiple osteochondromatosis who presented to the outpatient setting with progressive difficulty in ambulation. Magnetic resonance imaging of the spine revealed a thoracic spinal tumor, which was surgically removed. After surgery, the boy's ambulation and spasticity/contractures improved. This case is unique because this complication of hereditary multiple osteochondromatosis was identified at an age and in a region that are not typical. From a clinical standpoint, early identification of this complication is important because surgical treatment typically leads to good outcomes.