- Email: [email protected]
Back and neck pain in children with cancer
Back and Neck Pain in Children With Cancer Nuno Lobo Antunes, MD Neck and back pain are frequent complaints of patients with pediatric cancer, second only to headaches as a cause of neurologic consultation. The importance of this symptom, however, has not been studied in the pediatric cancer patients. This report is a review of the consultations as a result of neck and back pain in patients with pediatric cancer, with analysis of clinical presentation, etiology, underlying cancer, and neuroradiologic findings. The etiology of the complaint varied with the underlying cancer, although metastatic disease to the spine was frequent in patients with solid tumors, in younger children, and in patients admitted to the hospital. Back or neck pain is a serious complaint in children with systemic cancer, because the incidence of metastatic disease is high. Magnetic resonance imaging of the whole spine should be obtained if metastatic disease can not be excluded clinically, particularly for young patients and in children with advanced disease. © 2002 by Elsevier Science Inc. All rights reserved. Antunes NL. Back and neck pain in children with cancer. Pediatr Neurol 2002;27:46-48.
Introduction Back pain in well children is often not a grave concern, although it may be associated with a serious underlying disorder [1]. In children with cancer, back pain is not rare [2] and always raises the fear of neoplastic involvement of the spine or spinal cord, with resultant paralysis. To determine the significance of this complaint in pediatric patients with cancer, this study reviews the experience of the pediatric department of Memorial Sloan-Kettering Cancer Center regarding children with cancer who complained of back pain of sufficient severity to elicit a neurologic evaluation.
From the Department of Neurology and Pediatrics; Memorial SloanKettering Cancer Center; New York, New York.
46
PEDIATRIC NEUROLOGY
Vol. 27 No. 1
Methods A computer database that includes all the neurologic consultations requested by the pediatric department of Memorial Sloan-Kettering Cancer Center was created in October 1997. Information regarding the patients’ age, sex, and underlying malignancy or malignancies was collected. Main complaints (up to three), diagnosis (up to three), neuroradiologic investigations, etiologic factors, patient’s location (outpatient clinic or hospital ward), and cancer status (active tumor or no evidence of disease) were also recorded. Follow-up consultations were not included unless the patient presented with a different primary complaint. Almost all of the consultations were provided by the author, a pediatric neurologist with special training in neuro-oncology. Neurologic diagnoses were recorded at the initial evaluation and amended if the diagnosis changed as a result of ensuing investigations or clinical evolution. The consultations as a result of neck or back pain were selected and analyzed for the features mentioned above.
Results During the period October 1, 1997 to March 1, 2001, 546 consultations were provided for 384 patients (304 [55.7%] for boys and 242 [44.3%] for girls). The frequency of symptoms is presented in Table 1. Back and neck pain represented 9% of the consultations and was the most common complaint after headache. The age distribution is depicted in Table 2; neck pain was more common in older patients. Most consultations were provided in the outpatient setting (44/63 [69.8%]) and generally involved patients undergoing active treatment for cancer (52/63 [82.5%]). Solid tumors were more frequent than hematologic cancers, as shown in Table 3. Metastatic disease was the most frequent cause of back and neck pain (Table 4) and was responsible for almost one half of the consultations, and for an even higher percentage if the child was an inpatient (14/19 [73.7%]), or was younger than 10 years of age (9/14 [64.3%]). Back pain was caused by metastases in 63% of patients with solid tumors. Infections causing back pain included herpes zoster, Candida albicans osteomyelitis, and bacterial meningitis. Nine children had iatrogenic back or neck pain. One patient with bilateral avascular necrosis of the femur complained of low back pain, whereas a survivor of
Communications should be addressed to: Dr. Antunes; Department of Pediatrics; Memorial Sloan-Kettering Cancer Center; 1275 York Avenue; New York, NY 10021. Received October 2, 2001; accepted January 11, 2002.
© 2002 by Elsevier Science Inc. All rights reserved. PII S0887-8994(02)00389-2 ● 0887-8994/02/$—see front matter
Table 1. Reason for neurologic consultation in children with cancer (n ⴝ 700)
Complaints
No.
% Complaints
Pain Headache Back pain Limb pain Neck pain Other Other neurologic complaints Altered mental status Seizure Visual disturbances or diplopia Leg weakness Sensory disturbance Baseline neurologic status Movement disorder Sphincter disturbance Dizziness/vertigo Nausea/vomiting Cord compression? Other
248 130 51 48 12 7 452 60 47 45 42 38 29 22 17 16 10 9 117
35.4% 18.6% 7.3% 6.9% 1.7% 1.0% 64.6% 8.6% 6.7% 6.4% 6.0% 5.4% 4.1% 3.1% 2.4% 2.3% 1.4% 1.3% 16.7%
Hodgkin’s disease presented with neck pain as a consequence of weakness and marked atrophy of the neck muscles after mantle irradiation. Another patient developed a meningioma of the cervical spine after radiotherapy for Hodgkin’s lymphoma. Bone marrow expansion induced by colony-stimulating factors was the cause of severe back pain in two patients. A similar mechanism explained the back pain as the first sign of recurrence in patients with leukemia. Several children complained of severe back pain after lumbar puncture. Magnetic resonance imaging of the spine was ordered after 48 of 63 (76.2%) of the consultations and was abnormal in 29 of 48 (60.4%). The majority of patients with metastatic disease to the spine had multilevel, discontinuous disease (19/29 [65.5%]). Discussion The significance of back pain in general pediatric patients is controversial. Anttila et al. [3] found that 14% of school children who complained of headaches also had back pain. The prevalence of back pain in adolescents is approximately 30% [4], and is moderate to severe in 20% [5]. Most have no serious underlying pathology. Warning signs of a serious problem include constant pain in a child younger than 11 years of age that lasts for several weeks Table 2.
Age distribution
Age
Back Pain
Neck Pain
0–5 ⬎5–10 ⬎10–15 ⬎15–20 ⬎20
5 9 7 18 12
0 0 2 4 6
Table 3.
Underlying cancer
Leukemia Hodgkin’s lymphoma Non-Hodgkin’s lymphoma Neuroblastoma Ewing’s sarcoma Osteosarcoma Rhabdomyosarcoma Other
Back Pain (n ⴝ 51)
Neck Pain (n ⴝ 12)
9 (17.6%) 4 (7.8%) 3 (5.9%) 11 (21.6%) 11 (21.6%) 3 (5.9%) 3 (5.9%) 7 (13.7%)
0 (0.0%) 3 (25%) 2 (16.7%) 1 (8.3%) 4 (33.3%) 2 (16.7%) 0 (0.0%) 0 (0.0%)
or occurs spontaneously at night, repeatedly interferes with school, play or sports, or is associated with stiffness and limitation of motion, fever, or neurologic abnormalities [6]. The significance of neck and back pain in children with cancer is not known. In adults with cancer, back pain is the most common symptom leading to a neurologic consultation [7]. Tumors such as breast, prostate, and lung cancer often metastasize to the spine, causing first neck or back pain and then, if untreated, paralysis. The biology of pediatric cancer is different, with spine metastases being less common. Thus in children with cancer, consultations because of back pain are not as common. Since October of 1977, all neurologic consultations requested by the pediatric department of Memorial SloanKettering Cancer Center were registered in a computerized database. Our patients do not consist exclusively of children. Approximately one third of our patients are young adults. These patients have cancers that characteristically affect pediatric patients, preserving the homogeneity of the sample. A few children with hematologic disorders that, although not neoplastic in nature, were treated with chemotherapy and were included in our study. By not excluding them, we believe we present a more accurate picture of the patients being treated at a large tertiary pediatric cancer department. Back and neck pain were the second most common complaint after headache. This likely results from the awareness by the pediatric oncologists that, even in children, metastatic disease to the spine frequently presents with back pain, and that to preserve function, Table 4.
Etiology
Trauma Musculoskeletal Infectious Metastatic: Spine Epidural space Spinal cord compression Other Unclear
Back Pain (n ⴝ 51)
Neck Pain (n ⴝ 12)
4 (7.8%) 13 (25.5%) 3 (5.6%) 24 (47.1%) 11 6 7 3 (5.6%) 4 (7.8%)
1 (8.3%) 2 (16.7%) 1 (8.3%) 5 (41.7%) 3 1 1 3 (25.0%) 0 (0.0%)
Antunes: Back Pain in Pediatric Cancer 47
treatment should be instituted before the development of severe neurologic deficits. The majority of patients complaining of back and neck pain were adolescents or young adults. Although less frequent in young children, back pain in this age group is particularly worrisome because it was associated with a high incidence of metastatic disease. Patients admitted to the hospital also had an increased incidence of metastases, likely reflecting the advanced stages of their cancer. In children with leukemia, back pain was caused by trauma (including lumbar puncture), by bone marrow expansion from disease, or induced by colony-stimulating factors. Uncommon etiologies were present in some patients with Hodgkin’s disease. Cranial meningiomas are well known complications of radiotherapy to the scalp or brain [8], but they are unusual in the spine after mantle radiation. Significant atrophy of the muscles of the neck often follows mantle radiation in Hodgkin’s disease, and can be a cause of neck pain. Although not strictly a pain syndrome, Lhermitte sign [9], characterized by an uncomfortable sudden electric shocklike sensation, traveling down the spine to the arms and legs on flexion of the neck, may also be observed as a consequence of radiation to the spine. Several patients with non-Hodgkin’s lymphoma had neck or back pain as a consequence of infection, including meningitis, vertebral fungal osteomyelitis, and herpes zoster. In some patients, zoster may be difficult to identify as a cause of back pain if a rash is absent [10]. Solid cancers were overrepresented in these patients with pediatric tumors and back pain. The presence of back or neck pain in a child with a solid tumor is caused by metastatic disease in more than one half of the patients and spinal cord compression is present in approximately one third. The approach to the treatment of pediatric cord compression is controversial [11]. At Memorial Hospital, chemotherapy is used as the first-line treatment for patients with lymphoma, disseminated neuroblastoma, and Ewing’s sarcoma. Surgery is reserved for patients who progress despite chemotherapy and for patients with locoregional neuroblastoma. Contrary to the findings of other researchers [12], full motor recovery has been observed in a patient with complete paraplegia, and I
48
PEDIATRIC NEUROLOGY
Vol. 27 No. 1
believe that aggressive treatment should be pursued even in those circumstances, especially when there is residual sensory function or the paraplegia evolved slowly. The findings of this review indicate that magnetic resonance imaging of the spine should be performed in any child with neck or back pain when the etiology is not immediately apparent. If disease is evident, the whole spine should be imaged because multilevel disease is the rule. In summary, back or neck pain is a serious complaint in children with systemic cancer, because the incidence of metastatic disease is high. Magnetic resonance imaging of the whole spine should be obtained if metastatic disease cannot be excluded clinically, particularly for young patients and in children with advanced disease. References [1] Cabral DA, Tucker LB. Malignancies in children that initially present with rheumatic complaints. J Pediatr 1999;134:53-7. [2] Antunes NL, De Angelis LM. Neurologic consultations in children with systemic cancer. Pediatr Neurol 1999;20:121-4. [3] Anttila P, Metsabonkala L, Mikkelson M, Helenius H, Sillanppa M. Comorbidity of other pains in schoolchildren with migraine or nonmigrainous headache. J Pediatr 2001;138:176-80. [4] Feldman DE, Rossignol M, Shrier I, Abenhaim L. Smoking. A risk factor for development of low back pain in adolescents. Spine 1999;24:2492-6. [5] Harreby M, Nygaard B, Jessen T, et al. Risk factors for low back pain in a cohort of 1389 Danish school children: An epidemiologic study. Eur Spine J 1999;8:444-50. [6] Sponseller PD. Evaluating the child with back pain. Am Fam Phys 1996;54:1933-41. [7] Clouston PD, De Angelis LM, Posner JB. The spectrum of neurologic disease in patients with systemic cancer. Ann Neurol 1992; 31:268-73. [8] Neglia JP, Meadows AT, Robison LL, et al. Second neoplasms after acute lymphoblastic leukemia in childhood. N Engl J Med 1991; 325:1330-6. [9] Lossos A, Siegal T. Electric shock-like sensations in 42 cancer patients: Clinical characteristics and distinct etiologies. J Neurooncol 1996;29:175-81. [10] Flamholc L. Neurological complications in herpes zoster. Scand J Infect Dis Suppl 1996;100:35-40. [11] Hoover M, Bowman LC, Crawford SE, et al. Long-term outcome of patients with intraspinal neuroblastoma. Med Pediatr Oncol 1999;32:353-9. [12] De Bernardi B, Pianca C, Pistamiglio P, et al. Neuroblastoma with symptomatic spinal cord compression at diagnosis: Treatment and results with 76 cases. J Clin Oncol 2001;19:183-90.
Introduction Back pain in well children is often not a grave concern, although it may be associated with a serious underlying disorder [1]. In children with cancer, back pain is not rare [2] and always raises the fear of neoplastic involvement of the spine or spinal cord, with resultant paralysis. To determine the significance of this complaint in pediatric patients with cancer, this study reviews the experience of the pediatric department of Memorial Sloan-Kettering Cancer Center regarding children with cancer who complained of back pain of sufficient severity to elicit a neurologic evaluation.
From the Department of Neurology and Pediatrics; Memorial SloanKettering Cancer Center; New York, New York.
46
PEDIATRIC NEUROLOGY
Vol. 27 No. 1
Methods A computer database that includes all the neurologic consultations requested by the pediatric department of Memorial Sloan-Kettering Cancer Center was created in October 1997. Information regarding the patients’ age, sex, and underlying malignancy or malignancies was collected. Main complaints (up to three), diagnosis (up to three), neuroradiologic investigations, etiologic factors, patient’s location (outpatient clinic or hospital ward), and cancer status (active tumor or no evidence of disease) were also recorded. Follow-up consultations were not included unless the patient presented with a different primary complaint. Almost all of the consultations were provided by the author, a pediatric neurologist with special training in neuro-oncology. Neurologic diagnoses were recorded at the initial evaluation and amended if the diagnosis changed as a result of ensuing investigations or clinical evolution. The consultations as a result of neck or back pain were selected and analyzed for the features mentioned above.
Results During the period October 1, 1997 to March 1, 2001, 546 consultations were provided for 384 patients (304 [55.7%] for boys and 242 [44.3%] for girls). The frequency of symptoms is presented in Table 1. Back and neck pain represented 9% of the consultations and was the most common complaint after headache. The age distribution is depicted in Table 2; neck pain was more common in older patients. Most consultations were provided in the outpatient setting (44/63 [69.8%]) and generally involved patients undergoing active treatment for cancer (52/63 [82.5%]). Solid tumors were more frequent than hematologic cancers, as shown in Table 3. Metastatic disease was the most frequent cause of back and neck pain (Table 4) and was responsible for almost one half of the consultations, and for an even higher percentage if the child was an inpatient (14/19 [73.7%]), or was younger than 10 years of age (9/14 [64.3%]). Back pain was caused by metastases in 63% of patients with solid tumors. Infections causing back pain included herpes zoster, Candida albicans osteomyelitis, and bacterial meningitis. Nine children had iatrogenic back or neck pain. One patient with bilateral avascular necrosis of the femur complained of low back pain, whereas a survivor of
Communications should be addressed to: Dr. Antunes; Department of Pediatrics; Memorial Sloan-Kettering Cancer Center; 1275 York Avenue; New York, NY 10021. Received October 2, 2001; accepted January 11, 2002.
© 2002 by Elsevier Science Inc. All rights reserved. PII S0887-8994(02)00389-2 ● 0887-8994/02/$—see front matter
Table 1. Reason for neurologic consultation in children with cancer (n ⴝ 700)
Complaints
No.
% Complaints
Pain Headache Back pain Limb pain Neck pain Other Other neurologic complaints Altered mental status Seizure Visual disturbances or diplopia Leg weakness Sensory disturbance Baseline neurologic status Movement disorder Sphincter disturbance Dizziness/vertigo Nausea/vomiting Cord compression? Other
248 130 51 48 12 7 452 60 47 45 42 38 29 22 17 16 10 9 117
35.4% 18.6% 7.3% 6.9% 1.7% 1.0% 64.6% 8.6% 6.7% 6.4% 6.0% 5.4% 4.1% 3.1% 2.4% 2.3% 1.4% 1.3% 16.7%
Hodgkin’s disease presented with neck pain as a consequence of weakness and marked atrophy of the neck muscles after mantle irradiation. Another patient developed a meningioma of the cervical spine after radiotherapy for Hodgkin’s lymphoma. Bone marrow expansion induced by colony-stimulating factors was the cause of severe back pain in two patients. A similar mechanism explained the back pain as the first sign of recurrence in patients with leukemia. Several children complained of severe back pain after lumbar puncture. Magnetic resonance imaging of the spine was ordered after 48 of 63 (76.2%) of the consultations and was abnormal in 29 of 48 (60.4%). The majority of patients with metastatic disease to the spine had multilevel, discontinuous disease (19/29 [65.5%]). Discussion The significance of back pain in general pediatric patients is controversial. Anttila et al. [3] found that 14% of school children who complained of headaches also had back pain. The prevalence of back pain in adolescents is approximately 30% [4], and is moderate to severe in 20% [5]. Most have no serious underlying pathology. Warning signs of a serious problem include constant pain in a child younger than 11 years of age that lasts for several weeks Table 2.
Age distribution
Age
Back Pain
Neck Pain
0–5 ⬎5–10 ⬎10–15 ⬎15–20 ⬎20
5 9 7 18 12
0 0 2 4 6
Table 3.
Underlying cancer
Leukemia Hodgkin’s lymphoma Non-Hodgkin’s lymphoma Neuroblastoma Ewing’s sarcoma Osteosarcoma Rhabdomyosarcoma Other
Back Pain (n ⴝ 51)
Neck Pain (n ⴝ 12)
9 (17.6%) 4 (7.8%) 3 (5.9%) 11 (21.6%) 11 (21.6%) 3 (5.9%) 3 (5.9%) 7 (13.7%)
0 (0.0%) 3 (25%) 2 (16.7%) 1 (8.3%) 4 (33.3%) 2 (16.7%) 0 (0.0%) 0 (0.0%)
or occurs spontaneously at night, repeatedly interferes with school, play or sports, or is associated with stiffness and limitation of motion, fever, or neurologic abnormalities [6]. The significance of neck and back pain in children with cancer is not known. In adults with cancer, back pain is the most common symptom leading to a neurologic consultation [7]. Tumors such as breast, prostate, and lung cancer often metastasize to the spine, causing first neck or back pain and then, if untreated, paralysis. The biology of pediatric cancer is different, with spine metastases being less common. Thus in children with cancer, consultations because of back pain are not as common. Since October of 1977, all neurologic consultations requested by the pediatric department of Memorial SloanKettering Cancer Center were registered in a computerized database. Our patients do not consist exclusively of children. Approximately one third of our patients are young adults. These patients have cancers that characteristically affect pediatric patients, preserving the homogeneity of the sample. A few children with hematologic disorders that, although not neoplastic in nature, were treated with chemotherapy and were included in our study. By not excluding them, we believe we present a more accurate picture of the patients being treated at a large tertiary pediatric cancer department. Back and neck pain were the second most common complaint after headache. This likely results from the awareness by the pediatric oncologists that, even in children, metastatic disease to the spine frequently presents with back pain, and that to preserve function, Table 4.
Etiology
Trauma Musculoskeletal Infectious Metastatic: Spine Epidural space Spinal cord compression Other Unclear
Back Pain (n ⴝ 51)
Neck Pain (n ⴝ 12)
4 (7.8%) 13 (25.5%) 3 (5.6%) 24 (47.1%) 11 6 7 3 (5.6%) 4 (7.8%)
1 (8.3%) 2 (16.7%) 1 (8.3%) 5 (41.7%) 3 1 1 3 (25.0%) 0 (0.0%)
Antunes: Back Pain in Pediatric Cancer 47
treatment should be instituted before the development of severe neurologic deficits. The majority of patients complaining of back and neck pain were adolescents or young adults. Although less frequent in young children, back pain in this age group is particularly worrisome because it was associated with a high incidence of metastatic disease. Patients admitted to the hospital also had an increased incidence of metastases, likely reflecting the advanced stages of their cancer. In children with leukemia, back pain was caused by trauma (including lumbar puncture), by bone marrow expansion from disease, or induced by colony-stimulating factors. Uncommon etiologies were present in some patients with Hodgkin’s disease. Cranial meningiomas are well known complications of radiotherapy to the scalp or brain [8], but they are unusual in the spine after mantle radiation. Significant atrophy of the muscles of the neck often follows mantle radiation in Hodgkin’s disease, and can be a cause of neck pain. Although not strictly a pain syndrome, Lhermitte sign [9], characterized by an uncomfortable sudden electric shocklike sensation, traveling down the spine to the arms and legs on flexion of the neck, may also be observed as a consequence of radiation to the spine. Several patients with non-Hodgkin’s lymphoma had neck or back pain as a consequence of infection, including meningitis, vertebral fungal osteomyelitis, and herpes zoster. In some patients, zoster may be difficult to identify as a cause of back pain if a rash is absent [10]. Solid cancers were overrepresented in these patients with pediatric tumors and back pain. The presence of back or neck pain in a child with a solid tumor is caused by metastatic disease in more than one half of the patients and spinal cord compression is present in approximately one third. The approach to the treatment of pediatric cord compression is controversial [11]. At Memorial Hospital, chemotherapy is used as the first-line treatment for patients with lymphoma, disseminated neuroblastoma, and Ewing’s sarcoma. Surgery is reserved for patients who progress despite chemotherapy and for patients with locoregional neuroblastoma. Contrary to the findings of other researchers [12], full motor recovery has been observed in a patient with complete paraplegia, and I
48
PEDIATRIC NEUROLOGY
Vol. 27 No. 1
believe that aggressive treatment should be pursued even in those circumstances, especially when there is residual sensory function or the paraplegia evolved slowly. The findings of this review indicate that magnetic resonance imaging of the spine should be performed in any child with neck or back pain when the etiology is not immediately apparent. If disease is evident, the whole spine should be imaged because multilevel disease is the rule. In summary, back or neck pain is a serious complaint in children with systemic cancer, because the incidence of metastatic disease is high. Magnetic resonance imaging of the whole spine should be obtained if metastatic disease cannot be excluded clinically, particularly for young patients and in children with advanced disease. References [1] Cabral DA, Tucker LB. Malignancies in children that initially present with rheumatic complaints. J Pediatr 1999;134:53-7. [2] Antunes NL, De Angelis LM. Neurologic consultations in children with systemic cancer. Pediatr Neurol 1999;20:121-4. [3] Anttila P, Metsabonkala L, Mikkelson M, Helenius H, Sillanppa M. Comorbidity of other pains in schoolchildren with migraine or nonmigrainous headache. J Pediatr 2001;138:176-80. [4] Feldman DE, Rossignol M, Shrier I, Abenhaim L. Smoking. A risk factor for development of low back pain in adolescents. Spine 1999;24:2492-6. [5] Harreby M, Nygaard B, Jessen T, et al. Risk factors for low back pain in a cohort of 1389 Danish school children: An epidemiologic study. Eur Spine J 1999;8:444-50. [6] Sponseller PD. Evaluating the child with back pain. Am Fam Phys 1996;54:1933-41. [7] Clouston PD, De Angelis LM, Posner JB. The spectrum of neurologic disease in patients with systemic cancer. Ann Neurol 1992; 31:268-73. [8] Neglia JP, Meadows AT, Robison LL, et al. Second neoplasms after acute lymphoblastic leukemia in childhood. N Engl J Med 1991; 325:1330-6. [9] Lossos A, Siegal T. Electric shock-like sensations in 42 cancer patients: Clinical characteristics and distinct etiologies. J Neurooncol 1996;29:175-81. [10] Flamholc L. Neurological complications in herpes zoster. Scand J Infect Dis Suppl 1996;100:35-40. [11] Hoover M, Bowman LC, Crawford SE, et al. Long-term outcome of patients with intraspinal neuroblastoma. Med Pediatr Oncol 1999;32:353-9. [12] De Bernardi B, Pianca C, Pistamiglio P, et al. Neuroblastoma with symptomatic spinal cord compression at diagnosis: Treatment and results with 76 cases. J Clin Oncol 2001;19:183-90.