Diagnosing Low Back Pain in the Elderly

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Diagnosing Low Back Pain in the Elderly

• G. Barry Robbins D.O., FACN
• Associate Professor of Neurobehavioral Sciences
• KCOM
• A College of ATSU

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Risk Factors of LBP

• Repetitive lifting
• Vibration
• Smoking and Alcohol abuse
• Multiple pregnancies
• Inactivity
• Osteoporosis
• Familial Trend
• Anxiety associated with depression

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Prevalence of LBP

• Increases with age
• Reaches 50 in persons 60 yrs.
• 5 of population yearly (900,000 people)
• 80 of population in lifetime
• 10 LBP lasts 6 weeks
• Chronic LBP
• occurs in only 5
• Incurs 87 of cost

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Age Issues in Back Pain

• Osteoid osteoma in teenager
• Inflammatory bowel in 20 year old
• Multiple Myeloma in 70 to 80 year old
• Abdominal Aneurysm in 70 to 80 year old
• Sex Ratios in Low back Pain
• Osteoporotic fractures in women
• Fibromyalgia in women

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Low Back Pain in the Elderly

• Due to a wide range of potential causes of low
  back pain in the elderly makes its diagnosis and
  management more challenging than in younger
  patients.

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4 Important Areas to Assess in the Elderly

• Characteristics of the pain
• Presence of malignancy
• History of non-spinal medical problems
• Psychosocial status

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Causes of lower Back Pain in Older patients

• Acute LBP
• Lumbar strain or sprain
• Vertebral compression fracture due to
  osteoporosis
• Abdominal aortic aneurysm
• Polymyalgia rheumatica

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LBP (cont)

• Chronic LBP
• Aging-related degenerative disk and joint disease
• Malignancy
• Paget disease
• Fibromyalgia
• Diffuse idiopathic skeletal hyperostosis

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LBP (cont)

• Predominant leg pain associated with LBP
• Trochanteric bursitis
• Osteoarthritis of the hip
• Lumbar canal stenosis
• Intervertebral disk herniation

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Key Points of the Medical History

• Careful evaluation is crucial due to the broader
  differential diagnosis in the elderly
• Four important areas
• Characteristics of the pain
• Red flags for cancer
• Non-spinal medical problems
• Psychosocial factors

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1. Characteristics of the Pain

• Location
• leg pain back pain
• Suggests lumbar radiculopathy
• Sensitivity 95 and specificity of 85
• Leg pain aggravated by walking and standing but
  relieved by sitting suggests spinal stenosis
• Anterior thigh pain suggests upper lumbar
  radiculopathy or hip disease
• Onset
• Gradual, slow degenerative mechanical pain
• Sudden and severe osteoporotic compression
  fracture.
• Effect of positional change
• Constant unrelieved with position change cancer
• Mechanical relieved when supine, increased when
  position is changed

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2. Red Flags for Cancer

• Cancer
• 0.5 of all LBP
• 7 of LBP over 50 years of age
• 80 of all LBP patients assoc/w cancer are over
  50 years of age
• Red Flags
• Prior history of cancer (33.3)
• Pain that is usually constant
• Pain at night that disturbs sleep (90)
• Unexplained weight loss 10 in 3 months (15)
• Back pain that progresses despite appropriate
  treatment

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Cancer (Deyo 1988)
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Cancer (cont)
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Cancer

• 2/3 of cancer cases presents as back pain
• Most common Breast, lung, kidney or prostate
• Multiple myeloma is most common
• Non spinal malignant diseases presenting with LBP
• Pancreatic carcinoma
• Renal cell cancer
• Intrapelvic tumors
• Lymphoma with retroperitoneal lymphadeopathy

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Cancer (cont)

• 78 94 LBP due to cancer have Sed Rates 20
  mm/hr
• Plain lumbar radiography is 65 sensitive
• MRI and CT are 95 sensitive in detecting cancer
  ( MRI is preferred)
• Bone scan is 95 sensitive but may be normal in
  multiple myeloma

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Nuclear MedicineMetastatic Bone Disease
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3. Non Spinal Medical Conditions

• Diabetes affects 15 of adults 45 y
• Peripheral vascular disease
• Risk of renal toxicity from NSAIDs
• Ischemic heart disease and CHF
• At risk for renal toxicity from NSAIDs
• Unable to comply with physical therapy program
• Severe comorbidity causing surgical risk

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4. Psychosocial Conditions

• Job dissatisfaction
• Pre-existing psychiatric disorders
• Depression
• Anxiety
• Substance abuse
• Secondary financial gain
• Personal injury litigation
• Workers compensation
• Activities of independent living or caring for
  spouse
• Transportation issues

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Clues to Psychological Component in LBP

• Pain is unrelenting
• Pain and numbness involves entire leg gives way
• If pain level exceeds physical findings
• Nothing helps
• Everything makes the pain worse

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Symptom Magnification Examination

• Waddels Signs Presence of nonorganic signs
  suggesting symptom magnification and
  psychological distress
• Superficial or nonanatomic distribution of
  tenderness
• Nonanatomic or regional disturbance of motor or
  sensory impairment
• Inconsistency on positional SLR
• Inappropriate/excessive verbalization of pain or
  gesturing
• Pain with axial loading or rotation of spine
• Give-Away Weakness - Inconsistent effort on
  manual motor testing with ratcheting rather
  than smooth resistance

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The Physical Examination

• Routine with special observation of
• Spinal posture (kyphosis) due to vertebral
  compression
• Increased muscle tone and stiffness (unrecognized
  Parkinsons disease presenting as bone pain
• Leg pain always check distal pulses (to
  distinguish vascular from neurogenic claudication)

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Causes of Acute LBP in the Elderly

• Lumbar strain or sprain Frequent
• Due to age related changes and deconditioning
• At greater risk for stretch injury
• Pain increased with compression fractures and
  kyphosis
• Pain of a strain is usually acute but if due to
  kyphosis is usually gradual with prolonged
  standing, relieved in supine position

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Vertebral Compression Fracture

• Most commonly due to osteoporosis especially in
  women
• Occur spontaneously or with minimal trauma
• Pain is acute and aggravated by movement, most
  comfortable when motionless
• Plain lateral films, Bone scan, or MRI usually
  distinguishes acute from older Fxs

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Compression fracture
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Radiograph (left) Vertebral compression fracture
(arrow) in an elderly patient. Bone scan (right
shows increased uptake in the acutely compressed
vertebra.
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Abdominal Aortic Aneurysm

• Occur in 4 of persons 50 yr.s
• MenWomen
• More common in persons with Peripheral Vascular
  Disease
• Most are asymptomatic
• 10 15 present with Back pain
• Often associated with abdominal pain
• Radiating to the hips and thighs
• Aneurysm rupture assoc/w a sudden dramatic
  increase in pain
• Pulsatile abdominal mass in 50
• AP and lateral lumbar spine films 70
  curvilinear aortic calcifications
• Abdominal ultrasound or CT 100 sensitive

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Polymyalgia Rheumatica

• Sudden (often overnight) onset of pain and
  stiffness in the neck, upper back, shoulders,
  lower back, buttocks and hips
• Usually in persons 50 yr.s (prevalence
  increases with age)
• Giant cell arteritis found in 40
• Sed rate 40mm/hr.
• Dramatic response to trial of low dose prednisone
  confirms the diagnosis

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Causes of Chronic LBP in the Elderly

• Degenerative disk and joint disease
• Common
• MRI or CT demonstrate disk bulging or protrusion
  and spinal stenosis in persons with no symptoms
• Careful not to attribute LBP symptoms to these
  frequently asymptomatic and near universal
  degenerative changes

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Degenerative Disk and Joint Dx

• Degenerative changes occur in the spinal segment
  (3 components)
• Intervertebral disk - ? water content and thins
• Paired facet joints - ? stress and shear
• Vertebral body - anterior (osteoporotic)
  collapse
• Changes affect the neuro-foramina and ligaments
  (buckle)
• Symptoms are insidious and mechanical in
  character.
• Pain ?s with movement and prolonged activity and
  relieved by rest.

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Diagnostic Imaging Studies

• More cautious interpreting in older patients due
  to false-positive findings increase with age.
• Medical and psychosocial comorbidity increases
  significantly with age.

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George Washington Study - 1990

• 67 patients who never had Lower Back Pain or
  Sciatica
• MRI 20 Herniated Disc
• MRI 50 Bulging Disc
• 60 y o
• MRI 30 Herniated Disc
• MRI 80 Bulging Disc
• MRI 20 Spinal Stenosis

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Sensitivity/Specificity
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Paget Disease

• Common, found in
• 3 of adults 40yr
• 10 of adults 80yr
• 40 have LBP (most are asymptomatic)
• Pain may be
• Bone pain (deep, aching, and constant)
• Arthritic pain
• X-Ray localized bone enlargement vs sclerotic
  changes (prostate cancer)

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Paget Disease

• Diagnosis
• Bone scan more sensitive than X-Rays
• ? Serum alkaline phosphatase (osteoblastic)
• ? Urinary hydroxyproline (osteoclastic)
• More specific indicator of bone reabsorption
• ? Urinary excretion of pyridinoline or
  deoxypyridinoline

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Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• Known as Forestier disease
• Characterized by exuberant ossification of spinal
  ligaments
• Men 50yr
• Seen radiographically in 10 of persons 65yr
• Incidence ? in persons with diabetes
• Stiffness in back is the primary symptom
• Pain (thoracolumbar) in 50 of affected persons

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Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• Diagnosis
• X-Rays reveal flowing anterior calcification
  along at least 4 contiguous vertebrae confirm the
  diagnosis
• Disk height is preserved
• Sacroiliac joints are not involved
• Test for acute-phase reactants are normal

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DISH SYNDROME
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DISH SYNDROME
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Evaluating Non-Radicular, Non-Spinal Causes of
Leg Pain in the Older Patient

• May produce pseudo-sciatica
• Trochanteric Bursitis
• Lateral aspect of hip 40 extends down lateral
  thigh
• Many unable to lie on affected side due to pain
• Direct tenderness over and around the greater
  trochanter.
• Pain provoked by forced hip abduction
• X-Rays occasionally reveal calcifications around
  the trochanter

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Non-Radicular, Non-Spinal Pain

• Osteoarthritis of the Hip
• Pain is felt in the buttocks, groin, or anterior
  thigh, at times radiating to the knee.
• Resembles L2 or L3 radicular pain
• Physical exam indicating hip disease pain with
  internal and external rotation of the hip, often
  with a ? in joint mobility
• X-Ray joint space narrowing and subchondral
  sclerosis with osteophyte formation

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Lumbar Canal Stenosis

• Due to degenerative spinal changes including
• Facet joint hypertrophy
• Bulging or herniation of the intervertebral disk
• Thickening and buckling of the ligamentum flavum
• Most common reason for spinal surgery in persons
  65yr

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CATOsteoarthritis of the SpineSclerotic and
Hypertrophied Facets
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Lumbar Myelogram

• Herniated Nucleus Pulposus with Central Canal
  Stenosis

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Lumbar Canal Stenosis

• Diagnosis primarily based on clinical history
• Classic symptom is pseudoclaudication
• Pain, numbness, weakness, or heaviness in one or
  both legs provoked by walking or standing.
• Pain is relieved by sitting or forward flexion
• The Grocery Cart Syndrome
• Physical exam is unimpressive
• Provocative test is the development of posterior
  thigh symptoms after 30 sec of lumbar extension
• CT or MRI confirms the diagnosis (Critical to
  correlate the findings due to MRI findings of
  spinal stenosis are seen in asymptomatic patients)

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Red Flags of Spinal Stenosis Pseudo-claudication

• Vascular true claudication when walking
• (Diminished pedal pulses, trophic changes of
  skin, etc)
• Neurogenic
• More likely to occur simply with standing
• When walking, more likely to be flexed (e.g.
  pushing a shopping cart)
• Numbness and tingling are common
• Symptoms worsen with coughing or sneezing
• No pain when seated with the spine flexed

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Cauda Equina Syndrome

• A Medical Emergency
• Causes
• Fracture/Dislocation
• Neoplasms
• spinal stenosis
• massive herniated disks
• RED FLAGS
• Recent onset of urinary problems
• Saddle Anesthesia
• Severe or progressive neuro deficits in LEs
• Unexpected laxity of anal sphincter
• Major motor weakness in quadriceps and foot drop
  (Multiple nerve roots)

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Examination

• Pain radiating to lower leg
• Presence of Neurological deficits (M,S, DTRs)
• Progressive neurological deficits
• Pain may stay same but neurological status may
  change ---Recheck in 3 - 7 days if
• severe pain
• progressive symptoms by history
• mild neurological deficits on initial exam
• Inconsistent finding due to guarding or pain on
  motion

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Assessing Functional Capacity in the Older Patient

• LBP may compromise already marginal functional
  status
• May require expanded social service intervention
• Compliance of a therapeutic exercise program may
  not be possible
• Mild cognitive impairments significantly limits
  therapeutic choices