Accepted Manuscript Title: Back pain in the elderly: A review Author: Luke D. Jones Hemant Pandit Christopher Lavy PII: DOI: Reference:
S0378-5122(14)00156-X http://dx.doi.org/doi:10.1016/j.maturitas.2014.05.004 MAT 6168
To appear in:
Maturitas
Received date: Accepted date:
1-5-2014 4-5-2014
Please cite this article as: Jones LD, Pandit H, Lavy C, Back pain in the elderly: A review, Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Back Pain in the Elderly: a review.
Luke D Jones DPhil(Oxon) MRCS
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Hemant Pandit DPhil(Oxon) FRCS(T&O)
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Professor Christopher Lavy OBE MD MCh FRCS
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences
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Oxford University Nuffield Orthopaedic Centre
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Windmill Road Oxford, OX3 7LD
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UK
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Luke D Jones
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Corresponding Author
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E: [email protected] Tel +44 1865 223416
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Abstract:
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Low back pain is a common symptom in the older person. Whilst the majority of cases are thought to be mechanical or idiopathic and benign in nature, its multiple potential causes and concerns regarding missed diagnosis of less common but more serious underlying pathological diagnoses mean many physicians find the assessment, investigation and treatment of chronic low back pain in older adults challenging. This narrative review describes the classification of low back pain in older adults, discusses both mechanical and sinister causes of pain, highlights the appropriate use of medical imaging and provides an overview of surgical and non-surgical management of these patients.
Key Words
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Back Pain, Red Flags, Older People
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Introduction. Chronic low back pain (LBP) is recognised as a complex, challenging condition with widespread adverse consequences for patients including physical disability, disturbed sleep, psychosocial disruption and increased use of healthcare resources (1). In young patients,
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low back pain has been shown to be a major problem irrespective of country of origin with a point prevalence of 11.9% +/- 2% and a one month prevalence of 23.2% +/- 2.9% (2). In
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older adults it is recognised as one of the most common, poorly understood and potentially disabling conditions to affect community dwelling elderly persons with 36% percent
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experiencing an episode each year. Of those experiencing an episode of pain, 21% report moderate to severe pain that occurs frequently (3). In the US, it is estimated that up to 6
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million older persons suffer from recurrent low back pain (4). Features that predict the severity of back pain in elderly persons on their first presentation to a physician include female gender, Afro Caribbean origin and low educational status (5) . The prevalence of low
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back pain in the older population mean it is a commonly encountered clinical scenario for all clinicians irrespective of area of speciality.
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Whilst the majority of cases are thought to be mechanical or idiopathic and benign in
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nature, its multiple potential causes and concerns regarding missed diagnosis of less common but more serious underlying pathological diagnoses mean many physicians find the
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assessment, investigation and treatment of chronic low back pain in older adults challenging. As many age related comorbidities commonly exist in these patients independent of their LBP, the unique impact of the back pain itself can be difficult to elucidate. Accurate assessment is important to identify physical and psychosocial factors that contribute to the pain. In addition, factors that contribute an individual’s difficulty in compensating for physical problems should be identified. The aim of this editorial is to discuss the causes, assessment, appropriate investigations and treatment strategies in older persons with low back pain. Methods: A narrative literature review was performed using PubMed and the key search terms “Low back pain”, “Mechanical back pain”, “Red Flags”, “Cauda Equina Syndrome” “Seniors”, “Older Persons” and “The elderly”.
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The classification of low back pain Specific definitive anatomic diagnoses are the exception rather than the rule in those with low back pain. In most patients, symptoms resolve within one week and few have serious persistent symptoms after six to eight weeks (6). In those with persistent symptoms low
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back pain can usefully be thought of as occurring due to
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a) simple mechanical low back pain,
c) serious pathological low back pain
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d) visceral disease masquerading as spine pathology.
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b) low back pain with radiculopathy
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Mechanical low back pain
'Mechanical low back pain' in which the symptoms by definition cannot be ascribed to a
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single pathology (e.g. infection, tumour, fracture) will vary with posture, activity, time and
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treatment. Identifying the pain generator in mechanical low back pain is difficult and can lead to considerable confusion. The important issue is distinguishing the benign mechanical
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causes of low back pain from the more serious pathological causes that do require immediate treatment. A medical diagnosis is imperative to enable the clinician to arrive at a suitable treatment for the pain.
There are many different causes of mechanical low back pain. In the older person, degenerative age related changes can mean potentially multiple pain generators. Low back pain should be considered multifactorial including mechanical, psychological and neurophysiological components and therefore determining a single pain causing structure can be difficult. Often, a single structure cannot be confirmed as the cause of the pain in the face of complex social, emotional and physiological confounders. Within this condition, spondylosis, facet joint degeneration, sacroiliac joint pain and degenerative spondylolisthesis should be considered. Degenerative spondylosis is a term that refers to the degenerative changes that can affect the discs, vertebral bodies and associated joints of
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the lumbar spine (7) (8) (9). Large studies of osteoarthritis have identified the ageing process to be the largest risk factor for osteoarthritis in the spine. An autopsy study of 600 discs by Miller et al (10) noted an increase in disc degeneration from 16% at age 20 to 98% at age 70 years based on macroscopic degeneration. This finding has been reproduced in
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other studies (11) indicating that degenerative change is almost ubiquitous in the older person. Whilst degenerative change is omnipresent in the older person, back pain itself is
not, thus highlighting the confusion from attributing degenerative changes seen on imaging
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as being the primary pain generator. Facet joint degeneration and hypertrophy lead to pain
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increased by extension and homolateral flexion or rotation movements. The pain can be described as sharp and localised, with some deep, ill-defined pain extending into the buttocks or the back of the thighs. There is an absence of neurological deficits and nerve
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root tension signs(12). Degenerative sacroiliac joint pain can present in a similar fashion to facet joint syndrome with localised low back pain that radiates to the posterior thigh
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typically made worse by walking a relieved by lying down (13). Reproduction of symptoms on examination can be difficult which perhaps explains why this diagnosis is commonly overlooked. Spondylolysis refers to a fatigue fracture of the pars interarticularis, and
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spondylolisthesis refers to the forward slippage of a vertebrae on the one below it. Non
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spondylolytic spondylolisthesis is common in older persons and commonly occurs at L4/5 in association with degenerative change in the intervertebral and facet joints. It leads to
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localised low back pain aggravated by extension and relieved by rest. In this situation it is also possible for the older patient to present with radiculopathy secondary to nerve entrapment, and stenotic symptoms due to the forward slippage and narrowing of the central canal (14).
Low back pain with radiculopathy: In lumbar disc herniation the nucleus pulposus presses against the annulus causing the disc to bulge outwards. As this process continues the nucleus can herniate completely through the annulus placing pressure on the spinal meninges and nerve roots as well as releasing chemicals that can irritate the surrounding nerves causing inflammation and pain(15). With ageing, discs gradually dry out, and lose strength and resilience. Despite this, a recent large study indicates that the incidence of lumbar disc herniation decreases with age, particularly in those over the age of 80 and in females (16) with the authors suggesting that the volume
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and inflammatory potential of the nucleus decreases with age. Spinal stenosis can also present with back pain and radiculopathy. It is commonly secondary to degenerative change at multiple levels where the combination of bony overgrowth, hypertrophy of soft tissue structures such as the ligamentum flavum, facet capsule, and a bulging disc can lead to
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classic symptoms of neurogenic claudication with a sensation of numbness and heaviness in the legs with exertion (17) that is relieved by rest or leaning forward on a shopping trolley
or chair. In contrast, stenosis in the lateral recess or in the vertebral foramen itself can lead
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Osteoporotic fractures:
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Pathological conditions affecting the lumbar spine
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to an insidious onset of radicular leg pain (18).
Vertebral compression fractures occur in 25 percent of all postmenopausal women with the prevalence of this condition steadily increases with advancing age, reaching 40 percent in
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women 80 years of age (19). Over 700 000 vertebral compression fractures occur each year in the US outnumbering the combined incidence of hip and wrist fractures combined (6).
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Surprisingly, only one third about one third of vertebral fractures are actually diagnosed (20) because many older persons consider back pain symptoms as “arthritis” or a normal
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part of aging. Therefore, compression fracture should be suspected in any patient older
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than 50 years with acute onset of sudden low back pain. Patients will often complain of focal, deep midline pain. Diffuse paravertebral pain be present secondary to muscle spasm. Although major neurological deficits in these patients are rare, patients may experience a worsening of stenosis or radiculopathy. Lying in the supine position generally relieves some of the discomfort and standing or walking exacerbates the pain. Over time, multiple fractures may result in significant loss of height. Progressive loss of stature results in shortening of paraspinal musculature requiring prolonged active contraction for maintenance of posture, resulting in pain from muscle fatigue (1). The mechanism of such fractures can be separated into two main types. Most commonly, a flexion movement causes anterior part of the vertebral body to crush, forming an anterior wedge fracture. The middle column of the spine remains intact, resulting in loss of anterior height of the vertebra while the posterior height remains unchanged. As the collapsed anterior vertebra heals in situ without regaining previous height, the spine bends forward, leading to a
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kyphotic deformity. The fracture is usually stable and rarely associated with neurologic compromise (18), however it can cause significant sagittal deformity and postural imbalance that accentuates mechanical pain by changing the loading forces through the spine. In the second type, axial force compresses both the anterior and middle column of the vertebrae
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leading to a “burst” fracture, which can lead to retropulsion of fragments into the spinal canal and concomitant neurological impairment.
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Tumours
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The commonest bony site for musculoskeletal tumours is the spine. The overwhelming majority of these tumours are metastatic in nature however a small number are primary benign or primary malignant tumours. Pain whether localised or radicular is the most
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common complaint, present in 85% of cases. Other presenting symptoms include weakness in 41%, and the feeling of a lump in 16% (21). Pain secondary to a spinal tumour is classically
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localised, progressive, unrelenting, worse on movement, bending, twisting and lifting and worse at night. This is in contrast to pain from muscle spasm, degenerative arthritis and other causes which can relent with rest. The commonest metastatic sources are breast,
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prostate, thyroid, lung and kidney. Metastatic spread to the spine is thought to occur
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according to the “seed and soil theory” in which tumour emboli pass into the bloodstream and then embed in natural filters such as the highly vascularised red marrow of the
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vertebrae (14). Thoracic metastases commonly originate from the lung or the breast, via the valve less paravertebral venous plexus, whereas in the lumbar spine metastases commonly originate from the prostate which drains to the pelvic plexus and then to capillaries of the local vertebrae via Batson’s plexus. Primary benign tumours such as osteoid osteoma, osteoblastoma, osteochondroma, aneurysmal bone cyst and eosinophilic granuloma all occur in younger patients and are therefore not seen in older persons with LBP. Primary malignant tumours such as osteosarcoma and Ewing’s sarcoma are also disease of the young. However Lymphoma, Chordoma and solitary plasmacytoma all commonly present in the sixth decade or later (6) and must be considered in the differential diagnosis in older persons with LBP. “Red flags” and their use in the identification of pathological causes for low back pain
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In patients with low back pain presenting to primary care, between 1% and 4 % will have a spinal fracture (22), and in less than 1% malignancy whether this is a primary tumour or a metastasis (23). Most clinical guidelines for back pain recommend the use of red flags in the screening of patients for spinal fractures and malignancy. These are used to identify those
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individuals who are candidates for more extensive diagnostic investigations. The number of red flags endorsed in different guidelines (24)(25) (26) is large and inconsistent making their use somewhat confusing in those who do not frequently manage spinal complaints. In a
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review of eight sets of guidelines on back pain management by Koes et al (27), 26 red flags
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for fracture and 27 for malignancy were identified with none of the eight guidelines endorsing the same red flags for each condition. This understandably leads to considerable confusion over their usefulness. In an attempt to address this problem, Downie et al (28)
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performed a systematic review of red flags to screen for both spinal fracture and malignancy in patients with low back pain. They concluded that a large number of published red flags
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have limited use in distinguishing those with underlying serious pathology. Of the red flags for fracture, only older age, prolonged steroid use, severe trauma and contusion or abrasion over the site of pain increased the probability of fracture. Individual red flags increased to
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risk to between 10% and 33% whilst the presence of multiple red flags in the same
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individual increased the probability of fracture to between 42% and 90%. Of the red flags for tumour only a past medical history of tumour itself was found to have any correlation with
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the likelihood of back pain being of malignant origin. Nonetheless, the pragmatic use of clinical guidelines and red flags should be considered a useful framework by individual physicians attempting to identify those patients at risk of serious disease. Cauda Equina Syndrome (CES)
Cauda equina syndrome results from the compression of multiple sacral and lumbar nerve roots in the lumbar vertebral canal. The compression of these roots can lead to a combination of features but generally the term cauda equina syndrome is only used when these include bladder, bowel or sexual function impairment and perianal numbness (29). Although low back pain with or without sciatic type pains is not essential to the diagnosis of CES, the importance of the condition means that it is considered here. Three patterns of presentations of cauda equine syndrome have been described(30). In type 1 CES is the first symptom of a lumbar disc herniation. In type 2 CES manifests as the end point of a long
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history of chronic back pain with or without sciatica and in type 3 it presents insidiously with a slow progression or urinary and numbness symptoms. The commonest cause of CES is a prolapsed central disc arising from L4/5 or L5/S1 (31). Other, less common causes include spinal injury with subluxation, spinal tumours, and infective causes such as abscess either
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within the spinal canal or impinging upon it. In addition, although rare, iatrogenic causes such as spinal manipulation, spinal anaesthesia and post-operative complications such as
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haematoma must be considered.
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Visceral Disease.
Due to the high presence of co-morbidities in the patient population, consideration of the older person with chronic low back pain must include the possibility that other, non spine
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related pathology may be responsible for the presentation of pain. Whilst non spine causes represents only 2% of those presenting with LBP (32), abdominal aortic aneurysm,
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duodenal ulceration, cholecystolithiasis, nephrolithiasis, prostatitis, urinary tract infection, and fibroids have all been documented to masquerade as chronic low back pain (33) (34).
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Assessment of the older person with low back pain:
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History taking and physical examination of the older person with low back pain should focus on distinguishing pathological serious causes of low back pain from benign mechanical
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disease. The nature and chronicity of the pain, a history of trauma and neurological symptoms including bowel and bladder must be elicited. In addition, a past medical history of neoplasm should be specifically questioned. In older persons, comorbidities such as coexistent hip OA preventing examination of straight leg raise may necessitate adaptation of the normal neurological examination. Key points on examination include the presence of increased thoracic kyphosis in vertebral compression fractures, the presence of a gibbus, evidence of dramatic recent weight loss and neurological findings consistent with compression of the cauda equina.
Imaging in degenerative low back pain
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There is no role for imaging in the initial evaluation of the older patient with back pain in the absence of the signs or symptoms of more serious pathological disease, as in 85% of cases radiographic findings are poorly predictive of clinical symptoms (35). When conservative management of degenerative mechanical back pain fails then imaging should be undertaken
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with due concern for its risks: labelling the patient as suffering from degenerative disease, cost, radiation exposure, and provoking unwarranted minimally invasive or surgical
intervention. If it is suspected that there is sagittal imbalance then standing films that show
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the whole spine should be ordered. Only when imaging is concordant with the patients pain
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pattern or neurological impairment should causation be considered (36). Therefore, in the older person with low back pain, imaging studies are rarely indicated in the first six weeks after symtpoms onset unless back pain is accompanied by signs and symptoms of fracture,
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infection, spinal cord compression or tumour (32). Even in those with pain that lasts for longer than six weeks, radiography is unlikely to lead to any differences in the severity of
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pain, patient functioning or overall health status when compared directly with those who have had no imaging (37).
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Treatment of degenerative low back pain
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Older persons with pathological causes for low back pain should be referred to appropriate orthopaedic, neurosurgical or oncology services depending on local protocols. In those with
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no pathological signs and ongoing pain, treatment rests on physical therapy, pharmacological therapy, and interventional radiology with surgery used with caution in only refractory cases. Physical therapy in the form of “back school” and exercise therapy for mechanical low back pain is well established (38). In a recent systematic review on exercise for the prevention of recurrences of low back pain, Macedo et al concluded that exercise was the most consistent intervention in optimizing recovery from LBP but were unable to draw conclusions regarding the number and frequency of sessions that should be undertaken with a physiotherapist (39). There remains no consensus on the gold standard of pharmacological management of mechanical low back pain (7). In a systematic review of 17 randomised controlled trials, Kuijpers et al (40) concluded that there was no high quality evidence for the use of muscle relaxants, and only low quality evidence for the effects on pain intensity for NSAIDS and opioids compared to placebo. A 2013 Cochrane review on the efficacy of opioids in chronic low back pain drew similar conclusions with some very low or
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moderate quality evidence for their efficacy in reducing pain and improving function when compared to placebo (41). Zambelli et al, in a systematic review of pharmacological treatments of patients with sciatica concluded that due to the poor standard of clinic trials, the evidence for the efficacy of both opioids and non opioids in the treatment of sciatica
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was unclear(42). Injection therapy with epidural injection has become a common interventional strategy with injections usually performed through interlaminar,
transforaminal or caudal approaches. Symptomatic relief is thought to occur via both local
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anaesthetic and long term anti-inflammatory mechanisms associated with corticosteroids.
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In spinal stenosis, transforaminal epidural injection has been demonstrated to show a greater than 50% reduction in pain, improved walking and improved tolerance of standing at one year follow up (43) . Similar prospective studies have demonstrated that in a large
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number of patients these injections result in sufficient functional and symptomatic improvements to allow avoidance of surgical interventions (44). Similarly, radiofrequency
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neurotomy of the medial nerve branch that supplies the facet joint has demonstrated to give significant pain relief to 52% of those over 80 years at one year follow up (45).
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The use surgery in the older persons with mechanical, chronic low back pain is usually
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reserved for those with debilitating pain who have failed conservative options or those with clear evidence of symptomatic sagittal imbalance. In the older person, surgical treatment
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with fusion and instrumentation is a significant procedure with associated risks especially in those with co morbidities. Many surgical techniques have been developed with the aim of either spinal fusion, spinal decompression or both. The evidence for fusion is limited in the older patient population with very few high quality studies available for consideration. In a meta analysis of the evidence, Ibrahim et al concluded that caution should be used in recommending patients for spinal fusion and that further long term studies were required to demonstrate any evidence of the benefit of surgery over conservative measures (46). In contrast, the SPORT study demonstrated superiority of surgical intervention vs non-surgical management of degenerative spondylolisthesis at four years in terms of overall satisfaction, self-rated progress and improvement in back and leg symtpoms (47). Similar findings were reported with surgical vs conservative outcomes for symptomatic lumbar canal stenosis (48). Importantly, in neither of the SPORT studies were patients only those of older years. Conclusions:
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Although back complaints are common among older people, limited information is available in the literature about the clinical course of the back pain and the identification of older persons at risk for the transition from acute back complaints to chronic back pain. Whilst multi centred, international studies have been set up to examine this (49), they are yet to
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report their complete findings. Chronic low back pain in older people should be considered a clinical syndrome with multiple physical contributors. Assessment must focus on identifying those with mechanical low back pain and distinguishing those from individuals with
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pathological disease. The limited role of imaging in those without pathological signs or
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symptoms reflects the complex nature of identifying single pain causing structures in these patients. As always in those with chronic pain, success in managing symtpoms is likely to be achieved using a multidisciplinary approach with surgery reserved only for those with
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refractory symptoms.
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Pearson A, Lurie JD, Tosteson T, Wenyan Z, Abdu W, Weistein J. Who should have surgery for spinal stenosis? Treatment effect predictors in SPORT. Spine (Phila Pa 1976). 2012;37(21):1791–802.
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49.
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40.
Scheele J, Luijsterburg P a J, Ferreira ML, Maher CG, Pereira L, Peul WC, et al. Back complaints in the elders (BACE); design of cohort studies in primary care: an international consortium. BMC Musculoskelet Disord. BioMed Central Ltd; 2011 Jan;12(1):193.
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S0378-5122(14)00156-X http://dx.doi.org/doi:10.1016/j.maturitas.2014.05.004 MAT 6168
To appear in:
Maturitas
Received date: Accepted date:
1-5-2014 4-5-2014
Please cite this article as: Jones LD, Pandit H, Lavy C, Back pain in the elderly: A review, Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Back Pain in the Elderly: a review.
Luke D Jones DPhil(Oxon) MRCS
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Hemant Pandit DPhil(Oxon) FRCS(T&O)
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Professor Christopher Lavy OBE MD MCh FRCS
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences
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Oxford University Nuffield Orthopaedic Centre
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Windmill Road Oxford, OX3 7LD
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UK
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Luke D Jones
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Corresponding Author
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E: [email protected] Tel +44 1865 223416
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Abstract:
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Low back pain is a common symptom in the older person. Whilst the majority of cases are thought to be mechanical or idiopathic and benign in nature, its multiple potential causes and concerns regarding missed diagnosis of less common but more serious underlying pathological diagnoses mean many physicians find the assessment, investigation and treatment of chronic low back pain in older adults challenging. This narrative review describes the classification of low back pain in older adults, discusses both mechanical and sinister causes of pain, highlights the appropriate use of medical imaging and provides an overview of surgical and non-surgical management of these patients.
Key Words
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Back Pain, Red Flags, Older People
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Introduction. Chronic low back pain (LBP) is recognised as a complex, challenging condition with widespread adverse consequences for patients including physical disability, disturbed sleep, psychosocial disruption and increased use of healthcare resources (1). In young patients,
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low back pain has been shown to be a major problem irrespective of country of origin with a point prevalence of 11.9% +/- 2% and a one month prevalence of 23.2% +/- 2.9% (2). In
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older adults it is recognised as one of the most common, poorly understood and potentially disabling conditions to affect community dwelling elderly persons with 36% percent
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experiencing an episode each year. Of those experiencing an episode of pain, 21% report moderate to severe pain that occurs frequently (3). In the US, it is estimated that up to 6
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million older persons suffer from recurrent low back pain (4). Features that predict the severity of back pain in elderly persons on their first presentation to a physician include female gender, Afro Caribbean origin and low educational status (5) . The prevalence of low
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back pain in the older population mean it is a commonly encountered clinical scenario for all clinicians irrespective of area of speciality.
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Whilst the majority of cases are thought to be mechanical or idiopathic and benign in
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nature, its multiple potential causes and concerns regarding missed diagnosis of less common but more serious underlying pathological diagnoses mean many physicians find the
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assessment, investigation and treatment of chronic low back pain in older adults challenging. As many age related comorbidities commonly exist in these patients independent of their LBP, the unique impact of the back pain itself can be difficult to elucidate. Accurate assessment is important to identify physical and psychosocial factors that contribute to the pain. In addition, factors that contribute an individual’s difficulty in compensating for physical problems should be identified. The aim of this editorial is to discuss the causes, assessment, appropriate investigations and treatment strategies in older persons with low back pain. Methods: A narrative literature review was performed using PubMed and the key search terms “Low back pain”, “Mechanical back pain”, “Red Flags”, “Cauda Equina Syndrome” “Seniors”, “Older Persons” and “The elderly”.
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The classification of low back pain Specific definitive anatomic diagnoses are the exception rather than the rule in those with low back pain. In most patients, symptoms resolve within one week and few have serious persistent symptoms after six to eight weeks (6). In those with persistent symptoms low
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back pain can usefully be thought of as occurring due to
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a) simple mechanical low back pain,
c) serious pathological low back pain
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d) visceral disease masquerading as spine pathology.
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b) low back pain with radiculopathy
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Mechanical low back pain
'Mechanical low back pain' in which the symptoms by definition cannot be ascribed to a
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single pathology (e.g. infection, tumour, fracture) will vary with posture, activity, time and
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treatment. Identifying the pain generator in mechanical low back pain is difficult and can lead to considerable confusion. The important issue is distinguishing the benign mechanical
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causes of low back pain from the more serious pathological causes that do require immediate treatment. A medical diagnosis is imperative to enable the clinician to arrive at a suitable treatment for the pain.
There are many different causes of mechanical low back pain. In the older person, degenerative age related changes can mean potentially multiple pain generators. Low back pain should be considered multifactorial including mechanical, psychological and neurophysiological components and therefore determining a single pain causing structure can be difficult. Often, a single structure cannot be confirmed as the cause of the pain in the face of complex social, emotional and physiological confounders. Within this condition, spondylosis, facet joint degeneration, sacroiliac joint pain and degenerative spondylolisthesis should be considered. Degenerative spondylosis is a term that refers to the degenerative changes that can affect the discs, vertebral bodies and associated joints of
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the lumbar spine (7) (8) (9). Large studies of osteoarthritis have identified the ageing process to be the largest risk factor for osteoarthritis in the spine. An autopsy study of 600 discs by Miller et al (10) noted an increase in disc degeneration from 16% at age 20 to 98% at age 70 years based on macroscopic degeneration. This finding has been reproduced in
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other studies (11) indicating that degenerative change is almost ubiquitous in the older person. Whilst degenerative change is omnipresent in the older person, back pain itself is
not, thus highlighting the confusion from attributing degenerative changes seen on imaging
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as being the primary pain generator. Facet joint degeneration and hypertrophy lead to pain
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increased by extension and homolateral flexion or rotation movements. The pain can be described as sharp and localised, with some deep, ill-defined pain extending into the buttocks or the back of the thighs. There is an absence of neurological deficits and nerve
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root tension signs(12). Degenerative sacroiliac joint pain can present in a similar fashion to facet joint syndrome with localised low back pain that radiates to the posterior thigh
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typically made worse by walking a relieved by lying down (13). Reproduction of symptoms on examination can be difficult which perhaps explains why this diagnosis is commonly overlooked. Spondylolysis refers to a fatigue fracture of the pars interarticularis, and
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spondylolisthesis refers to the forward slippage of a vertebrae on the one below it. Non
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spondylolytic spondylolisthesis is common in older persons and commonly occurs at L4/5 in association with degenerative change in the intervertebral and facet joints. It leads to
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localised low back pain aggravated by extension and relieved by rest. In this situation it is also possible for the older patient to present with radiculopathy secondary to nerve entrapment, and stenotic symptoms due to the forward slippage and narrowing of the central canal (14).
Low back pain with radiculopathy: In lumbar disc herniation the nucleus pulposus presses against the annulus causing the disc to bulge outwards. As this process continues the nucleus can herniate completely through the annulus placing pressure on the spinal meninges and nerve roots as well as releasing chemicals that can irritate the surrounding nerves causing inflammation and pain(15). With ageing, discs gradually dry out, and lose strength and resilience. Despite this, a recent large study indicates that the incidence of lumbar disc herniation decreases with age, particularly in those over the age of 80 and in females (16) with the authors suggesting that the volume
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and inflammatory potential of the nucleus decreases with age. Spinal stenosis can also present with back pain and radiculopathy. It is commonly secondary to degenerative change at multiple levels where the combination of bony overgrowth, hypertrophy of soft tissue structures such as the ligamentum flavum, facet capsule, and a bulging disc can lead to
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classic symptoms of neurogenic claudication with a sensation of numbness and heaviness in the legs with exertion (17) that is relieved by rest or leaning forward on a shopping trolley
or chair. In contrast, stenosis in the lateral recess or in the vertebral foramen itself can lead
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Osteoporotic fractures:
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Pathological conditions affecting the lumbar spine
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to an insidious onset of radicular leg pain (18).
Vertebral compression fractures occur in 25 percent of all postmenopausal women with the prevalence of this condition steadily increases with advancing age, reaching 40 percent in
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women 80 years of age (19). Over 700 000 vertebral compression fractures occur each year in the US outnumbering the combined incidence of hip and wrist fractures combined (6).
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Surprisingly, only one third about one third of vertebral fractures are actually diagnosed (20) because many older persons consider back pain symptoms as “arthritis” or a normal
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part of aging. Therefore, compression fracture should be suspected in any patient older
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than 50 years with acute onset of sudden low back pain. Patients will often complain of focal, deep midline pain. Diffuse paravertebral pain be present secondary to muscle spasm. Although major neurological deficits in these patients are rare, patients may experience a worsening of stenosis or radiculopathy. Lying in the supine position generally relieves some of the discomfort and standing or walking exacerbates the pain. Over time, multiple fractures may result in significant loss of height. Progressive loss of stature results in shortening of paraspinal musculature requiring prolonged active contraction for maintenance of posture, resulting in pain from muscle fatigue (1). The mechanism of such fractures can be separated into two main types. Most commonly, a flexion movement causes anterior part of the vertebral body to crush, forming an anterior wedge fracture. The middle column of the spine remains intact, resulting in loss of anterior height of the vertebra while the posterior height remains unchanged. As the collapsed anterior vertebra heals in situ without regaining previous height, the spine bends forward, leading to a
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kyphotic deformity. The fracture is usually stable and rarely associated with neurologic compromise (18), however it can cause significant sagittal deformity and postural imbalance that accentuates mechanical pain by changing the loading forces through the spine. In the second type, axial force compresses both the anterior and middle column of the vertebrae
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leading to a “burst” fracture, which can lead to retropulsion of fragments into the spinal canal and concomitant neurological impairment.
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Tumours
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The commonest bony site for musculoskeletal tumours is the spine. The overwhelming majority of these tumours are metastatic in nature however a small number are primary benign or primary malignant tumours. Pain whether localised or radicular is the most
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common complaint, present in 85% of cases. Other presenting symptoms include weakness in 41%, and the feeling of a lump in 16% (21). Pain secondary to a spinal tumour is classically
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localised, progressive, unrelenting, worse on movement, bending, twisting and lifting and worse at night. This is in contrast to pain from muscle spasm, degenerative arthritis and other causes which can relent with rest. The commonest metastatic sources are breast,
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prostate, thyroid, lung and kidney. Metastatic spread to the spine is thought to occur
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according to the “seed and soil theory” in which tumour emboli pass into the bloodstream and then embed in natural filters such as the highly vascularised red marrow of the
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vertebrae (14). Thoracic metastases commonly originate from the lung or the breast, via the valve less paravertebral venous plexus, whereas in the lumbar spine metastases commonly originate from the prostate which drains to the pelvic plexus and then to capillaries of the local vertebrae via Batson’s plexus. Primary benign tumours such as osteoid osteoma, osteoblastoma, osteochondroma, aneurysmal bone cyst and eosinophilic granuloma all occur in younger patients and are therefore not seen in older persons with LBP. Primary malignant tumours such as osteosarcoma and Ewing’s sarcoma are also disease of the young. However Lymphoma, Chordoma and solitary plasmacytoma all commonly present in the sixth decade or later (6) and must be considered in the differential diagnosis in older persons with LBP. “Red flags” and their use in the identification of pathological causes for low back pain
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In patients with low back pain presenting to primary care, between 1% and 4 % will have a spinal fracture (22), and in less than 1% malignancy whether this is a primary tumour or a metastasis (23). Most clinical guidelines for back pain recommend the use of red flags in the screening of patients for spinal fractures and malignancy. These are used to identify those
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individuals who are candidates for more extensive diagnostic investigations. The number of red flags endorsed in different guidelines (24)(25) (26) is large and inconsistent making their use somewhat confusing in those who do not frequently manage spinal complaints. In a
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review of eight sets of guidelines on back pain management by Koes et al (27), 26 red flags
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for fracture and 27 for malignancy were identified with none of the eight guidelines endorsing the same red flags for each condition. This understandably leads to considerable confusion over their usefulness. In an attempt to address this problem, Downie et al (28)
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performed a systematic review of red flags to screen for both spinal fracture and malignancy in patients with low back pain. They concluded that a large number of published red flags
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have limited use in distinguishing those with underlying serious pathology. Of the red flags for fracture, only older age, prolonged steroid use, severe trauma and contusion or abrasion over the site of pain increased the probability of fracture. Individual red flags increased to
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risk to between 10% and 33% whilst the presence of multiple red flags in the same
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individual increased the probability of fracture to between 42% and 90%. Of the red flags for tumour only a past medical history of tumour itself was found to have any correlation with
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the likelihood of back pain being of malignant origin. Nonetheless, the pragmatic use of clinical guidelines and red flags should be considered a useful framework by individual physicians attempting to identify those patients at risk of serious disease. Cauda Equina Syndrome (CES)
Cauda equina syndrome results from the compression of multiple sacral and lumbar nerve roots in the lumbar vertebral canal. The compression of these roots can lead to a combination of features but generally the term cauda equina syndrome is only used when these include bladder, bowel or sexual function impairment and perianal numbness (29). Although low back pain with or without sciatic type pains is not essential to the diagnosis of CES, the importance of the condition means that it is considered here. Three patterns of presentations of cauda equine syndrome have been described(30). In type 1 CES is the first symptom of a lumbar disc herniation. In type 2 CES manifests as the end point of a long
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history of chronic back pain with or without sciatica and in type 3 it presents insidiously with a slow progression or urinary and numbness symptoms. The commonest cause of CES is a prolapsed central disc arising from L4/5 or L5/S1 (31). Other, less common causes include spinal injury with subluxation, spinal tumours, and infective causes such as abscess either
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within the spinal canal or impinging upon it. In addition, although rare, iatrogenic causes such as spinal manipulation, spinal anaesthesia and post-operative complications such as
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haematoma must be considered.
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Visceral Disease.
Due to the high presence of co-morbidities in the patient population, consideration of the older person with chronic low back pain must include the possibility that other, non spine
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related pathology may be responsible for the presentation of pain. Whilst non spine causes represents only 2% of those presenting with LBP (32), abdominal aortic aneurysm,
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duodenal ulceration, cholecystolithiasis, nephrolithiasis, prostatitis, urinary tract infection, and fibroids have all been documented to masquerade as chronic low back pain (33) (34).
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Assessment of the older person with low back pain:
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History taking and physical examination of the older person with low back pain should focus on distinguishing pathological serious causes of low back pain from benign mechanical
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disease. The nature and chronicity of the pain, a history of trauma and neurological symptoms including bowel and bladder must be elicited. In addition, a past medical history of neoplasm should be specifically questioned. In older persons, comorbidities such as coexistent hip OA preventing examination of straight leg raise may necessitate adaptation of the normal neurological examination. Key points on examination include the presence of increased thoracic kyphosis in vertebral compression fractures, the presence of a gibbus, evidence of dramatic recent weight loss and neurological findings consistent with compression of the cauda equina.
Imaging in degenerative low back pain
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There is no role for imaging in the initial evaluation of the older patient with back pain in the absence of the signs or symptoms of more serious pathological disease, as in 85% of cases radiographic findings are poorly predictive of clinical symptoms (35). When conservative management of degenerative mechanical back pain fails then imaging should be undertaken
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with due concern for its risks: labelling the patient as suffering from degenerative disease, cost, radiation exposure, and provoking unwarranted minimally invasive or surgical
intervention. If it is suspected that there is sagittal imbalance then standing films that show
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the whole spine should be ordered. Only when imaging is concordant with the patients pain
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pattern or neurological impairment should causation be considered (36). Therefore, in the older person with low back pain, imaging studies are rarely indicated in the first six weeks after symtpoms onset unless back pain is accompanied by signs and symptoms of fracture,
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infection, spinal cord compression or tumour (32). Even in those with pain that lasts for longer than six weeks, radiography is unlikely to lead to any differences in the severity of
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pain, patient functioning or overall health status when compared directly with those who have had no imaging (37).
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Treatment of degenerative low back pain
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Older persons with pathological causes for low back pain should be referred to appropriate orthopaedic, neurosurgical or oncology services depending on local protocols. In those with
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no pathological signs and ongoing pain, treatment rests on physical therapy, pharmacological therapy, and interventional radiology with surgery used with caution in only refractory cases. Physical therapy in the form of “back school” and exercise therapy for mechanical low back pain is well established (38). In a recent systematic review on exercise for the prevention of recurrences of low back pain, Macedo et al concluded that exercise was the most consistent intervention in optimizing recovery from LBP but were unable to draw conclusions regarding the number and frequency of sessions that should be undertaken with a physiotherapist (39). There remains no consensus on the gold standard of pharmacological management of mechanical low back pain (7). In a systematic review of 17 randomised controlled trials, Kuijpers et al (40) concluded that there was no high quality evidence for the use of muscle relaxants, and only low quality evidence for the effects on pain intensity for NSAIDS and opioids compared to placebo. A 2013 Cochrane review on the efficacy of opioids in chronic low back pain drew similar conclusions with some very low or
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moderate quality evidence for their efficacy in reducing pain and improving function when compared to placebo (41). Zambelli et al, in a systematic review of pharmacological treatments of patients with sciatica concluded that due to the poor standard of clinic trials, the evidence for the efficacy of both opioids and non opioids in the treatment of sciatica
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was unclear(42). Injection therapy with epidural injection has become a common interventional strategy with injections usually performed through interlaminar,
transforaminal or caudal approaches. Symptomatic relief is thought to occur via both local
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anaesthetic and long term anti-inflammatory mechanisms associated with corticosteroids.
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In spinal stenosis, transforaminal epidural injection has been demonstrated to show a greater than 50% reduction in pain, improved walking and improved tolerance of standing at one year follow up (43) . Similar prospective studies have demonstrated that in a large
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number of patients these injections result in sufficient functional and symptomatic improvements to allow avoidance of surgical interventions (44). Similarly, radiofrequency
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neurotomy of the medial nerve branch that supplies the facet joint has demonstrated to give significant pain relief to 52% of those over 80 years at one year follow up (45).
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The use surgery in the older persons with mechanical, chronic low back pain is usually
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reserved for those with debilitating pain who have failed conservative options or those with clear evidence of symptomatic sagittal imbalance. In the older person, surgical treatment
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with fusion and instrumentation is a significant procedure with associated risks especially in those with co morbidities. Many surgical techniques have been developed with the aim of either spinal fusion, spinal decompression or both. The evidence for fusion is limited in the older patient population with very few high quality studies available for consideration. In a meta analysis of the evidence, Ibrahim et al concluded that caution should be used in recommending patients for spinal fusion and that further long term studies were required to demonstrate any evidence of the benefit of surgery over conservative measures (46). In contrast, the SPORT study demonstrated superiority of surgical intervention vs non-surgical management of degenerative spondylolisthesis at four years in terms of overall satisfaction, self-rated progress and improvement in back and leg symtpoms (47). Similar findings were reported with surgical vs conservative outcomes for symptomatic lumbar canal stenosis (48). Importantly, in neither of the SPORT studies were patients only those of older years. Conclusions:
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Although back complaints are common among older people, limited information is available in the literature about the clinical course of the back pain and the identification of older persons at risk for the transition from acute back complaints to chronic back pain. Whilst multi centred, international studies have been set up to examine this (49), they are yet to
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report their complete findings. Chronic low back pain in older people should be considered a clinical syndrome with multiple physical contributors. Assessment must focus on identifying those with mechanical low back pain and distinguishing those from individuals with
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pathological disease. The limited role of imaging in those without pathological signs or
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symptoms reflects the complex nature of identifying single pain causing structures in these patients. As always in those with chronic pain, success in managing symtpoms is likely to be achieved using a multidisciplinary approach with surgery reserved only for those with
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refractory symptoms.
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