Case by Tara Neary & Christopher Sarkis MD 

Patient Presentation

A 7-year-old female presents with back pain and a “wobbly gait".” She has had 2 days of lower back pain, urinary symptoms (urgency and frequency), and unsteady gait. The back pain woke her from sleep and did not improve with ibuprofen. 

VS: T36.7, HR 90, RR 24, BP 120/82, SpO2  97% on room air.

The exam was notable for bilateral patellar hyperreflexia and ankle clonus

Diagnostic Findings

A Head CT showed regional hypoattenuation of the corpus callosum and thalami, concerning for an inflammatory, infectious, or post-infectious demyelinating process. She was admitted to the Neurology service for a lumbar puncture and MRI which revealed the ultimate diagnosis of myeline oligodendrocyte glycoprotein antibody disease (MOGAD) - an autoimmune demyelinating disorder.

MOGAD (MOG Antibody-Associated Disease) is a rare condition that predominantly affects the central nervous system. It is characterized by the presence of antibodies against myelin oligodendrocyte glycoprotein (MOG), which can lead to inflammation and damage to the myelin in the brain and spinal cord. MOGAD can present with a variety of neurological symptoms such as optic neuritis, transverse myelitis, and encephalitis. Diagnosis typically involves a combination of clinical presentation, imaging studies, and detection of MOG antibodies in the blood or cerebrospinal fluid. Treatment usually consists of high-dose corticosteroids during episodes of relapse, along with other immunosuppressive therapies in some cases. Due to the complexity and variability of the disease, management often requires a multidisciplinary approach involving neurologists, ophthalmologists, and other specialists.

Recognizing Red Flags for Back Pain in Children

Back pain in children is commonly attributed to benign causes like muscle strain or poor posture. However, it's crucial to be aware of the red flags that may signal a more serious underlying condition. Some key red flags to watch for include:

• Nighttime pain: Pain that consistently wakes a child from sleep or is worse at night.

• Urologic symptoms: frequency, urgency, and nighttime enuresis can be a symptom of neurologic dysfunction.

• Neurological symptoms: Numbness, weakness, or tingling in the legs, along with back pain, may suggest nerve involvement.

• Change in gait or posture: Any noticeable changes in how a child walks or stands.

• Recent trauma: Back pain following an injury, especially a fall or trauma.

• Fever: Back pain accompanied by fever, which could indicate an infection or inflammatory condition

• Unexplained weight loss: Back pain along with unexplained weight loss or loss of appetite.

If any of these red flags are present, it's essential to consider additional imaging and consults. Remember, early detection of serious conditions can lead to better outcomes for children experiencing back pain. 

Educational Pearls:

• Back pain presenting with any change in gait should prompt concern for pathology involving the spinal cord. Have a low threshold to obtain imaging and consult Neurology.

• Urologic symptoms on frequency and urgency can be a symptom of neurologic retention in the setting of spinal cord pathology.

• Back pain that wakes a patient from sleep should raise concern for oncologic and neurologic conditions needing extensive workup.