In 2018, a previously healthy 4-year-old girl sought care multiple times for recurrent back and hip pain. Prior evaluations, including radiographs and orthopedic assessment, failed to identify a cause.

On December 16, 2018, she presented to the emergency department (ED) with recurrent atraumatic back pain, currently rated as 2 out of 10 but up to a 9 out of 10. The physician’s note documented “4-year-old female with sudden onset last evening of lower back pain … she awoke crying and asking for a heating pad. Mom states she provided Tylenol for pain control … pain worse when lying down and walking … this is third episode of same complaint in the past year.” Physical exam showed normal vital signs, a well-appearing child with normal gait, strength, sensation, range of motion, ability to jump, and no focal spinal tenderness. Urinalysis showed 1+ leukocyte esterase, 5 to 10 white blood cells and red blood cells. Lumbar spine X-rays were interpreted as negative. The emergency physician concluded that the etiology of the pain was unclear, did not believe the urinalysis explained the symptoms, and discharged the patient.

Over the next two weeks, she developed persistent pain, insomnia, lower-extremity weakness, bowel and bladder dysfunction, and ultimately paralysis. On January 8, 2019, an MRI revealed a T7-L1 epidural and paraspinal Ewing sarcoma with cord compression requiring emergent decompression followed by chemotherapy and radiation. She regained the ability to walk but continues to experience residual weakness and chronic physical and psychological sequelae.

The lawsuit, which named the emergency physician, radiology, and the hospital, focused primarily on the December 16, 2018, lumbar spine X-ray. Subsequent review of these radiographs identified vertebra plana at T10, and the interpreting radiologist later acknowledged that the abnormality had been present but was not recognized. The plaintiffs contended that earlier recognition would have led to earlier diagnosis and intervention before the development of spinal cord compression and neurologic deficits.

Learning Points for Emergency Physicians

• Recurrent atraumatic back pain and night pain are red flags in a young child. Unlike adults, children rarely develop repeated episodes of unexplained back pain. Malignancy should be considered when symptoms are recurrent, progressive, nocturnal, or involve bone pain.
• The history should drive the differential diagnosis.Although this was documented as the third episode in a year, the record contains little exploration of prior episodes, prior evaluations, progression, response to treatment, or the factors prompting emergency evaluation.
• A normal radiograph does not normalize an abnormal history. Recurrent, worsening, atraumatic back pain in a young child remains concerning even when the initial evaluation is unrevealing. A broader differential may prompt or advanced imaging.

Dr. Cohen is a dual board-certified expert in pediatric emergency medicine and emergency medicine with extensive experience in clinical practice, peer review, and medicolegal consultation.