title: Persistent or severe back pain and stiffness are ominous symptoms requiring prompt attention.
abstract: BACKGROUND
  Children with severe or persistent back pain and stiffness often have an underlying organic cause but there is a large differential diagnosis, examination may be difficult and the problem is relatively rare in general paediatric practice. These difficulties appeared to lead to delays in diagnosis and management of children with this problem.
  
  
  OBJECTIVE
  To provide an approach to the diagnosis and management children with severe or persistent back pain or stiffness based on our clinical experience and the literature.
  
  
  METHODS
  The case histories of 10 children with severe back pain seen by the authors over a 5-year period were reviewed. They were chosen as illustrative examples of the diagnostic and management problems and did not represent a systematic review of all cases seen by the authors over that time.
  
  
  RESULTS
  Underlying causes included infection, inflammation, neoplasm, trauma and vascular malformation. Four of the children had spinal cord compression which required urgent decompression. There was one child with a conversion disorder but three children with organic disease were initially felt to have a conversion disorder. Investigations generally proceeded relatively slowly and the problem was not regarded as a semi-urgent situation carrying the risk of permanent paraplegia. Magnetic resonance imaging (MRI) scan of the spine was the investigation of choice.
  
  
  CONCLUSIONS
  Children with severe or persistent back pain and stiffness have a wide variety of underlying causes. The possibility of underlying spinal cord compression should always be considered in children with this presentation. If the diagnosis is not obvious, MRI scan of the spine should be arranged without delay.
authors.affiliation: Department of Paediatrics, Westmead Hospital, Department of Neurology, Royal Alexandra Hospital for Children, Sydney, New South Wales, Australia. addyG@nch.edu.au
authors.forename: P J
authors.initials: PJ
authors.lastname: Grattan-Smith
authors.forename: M M
authors.initials: MM
authors.lastname: Ryan
authors.forename: P G
authors.initials: PG
authors.lastname: Procopis
mesh_terms: D001416:Back Pain / Q000175:diagnosis* / Q000503:physiopathology; D002574:Cervical Vertebrae; D002648:Child; D002675:Child, Preschool; D003291:Conversion Disorder / Q000175:diagnosis* / Q000503:physiopathology; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008228:Lymphoma, Non-Hodgkin / Q000175:diagnosis* / Q000503:physiopathology; D008297:Male; D011379:Prognosis; D013119:Spinal Cord Injuries / Q000175:diagnosis* / Q000503:physiopathology; D013125:Spinal Neoplasms / Q000175:diagnosis* / Q000503:physiopathology