Terry Pulliam Burd wrote:
Surgery is a last resort. Old people are at high risk for complications,
but mainly those with cormorbid conditions. Healthy old people, usually
tolerate surgeries almost as good as a middle aged person; again,
depending on the surgery.
Certain people here have offered good advice, alas mixed in with the
obligatory BS.
However, there is hope for humanity ; )
INTRODUCTION ? While the prevalence of low back pain is essentially
constant throughout adulthood [1], the sources of low back pain vary
with age. Regional low back pain between the ages of 20 and 40 generally
arises from strain of one or another soft tissue element in the back or
from sciatica. The latter condition is characterized by pain radiating
in a dermatomal distribution that is often due to compression of a lower
lumbar nerve root by a protruding intervertebral disc. (See "Approach to
the diagnosis and evaluation of low back pain in adults"). Other causes,
such as congenital abnormalities, tumors and infections, are rare,
except in specific circumstances (eg, epidural abscess in a patient with
intravenous drug use).
In contrast, the differential diagnosis of low back pain in older
patients is broader, and often includes infection, cancer, and
osteoporotic fracture as well as the sprains, strains, and herniated
discs seen in younger subjects. Most important, degeneration of the
spinal elements is ubiquitous in older patients. The extent of
degenerative disease has a weak but positive association with symptoms,
and several pain syndromes may be seen, including neurogenic
claudication due to lumbar spinal stenosis.
INITIAL EVALUATION ? For purposes of this discussion, we shall consider
"older" patients to be those over sixty years of age. The initial
consideration in evaluating older patients with back pain should be to
exclude ominous conditions such as malignancy, infection, and neurologic
emergencies [2].
Malignancy ? Cancer is an important but uncommon cause of low back pain.
One study, for example, evaluated 1975 patients who presented to a
walk-in clinic with a complaint of low back pain; 13 (0.7 percent) had a
malignancy [3]. The major risk factors for cancer included age above 50,
previous history of cancer, unexplained weight loss, and failure to
improve within one month of conservative therapy (show table 1) [3]. A
history of preexisting cancer is particularly important, since most
spinal malignancies are metastatic from other sites.
Infection ? Risk factors for spinal osteomyelitis or epidural abscess
include known infection elsewhere (eg, urinary tract infection, skin
infection, intravenous drug use) and immunosuppression due to associated
illness or drug use [2,4]. Fever and local tenderness are also useful
findings on the physical examination.
Neurologic emergency ? The next critical issue in the evaluation of an
older patient with back pain is to exclude two uncommon emergent
conditions: the cauda equina syndrome; or a rapidly progressive
neurologic deficit that may arise from a benign or serious condition.
The cauda equina syndrome arises from compression of the lumbosacral
nerve roots by a central herniated disc, central lumbar spinal stenosis,
or a tumor or infection invading the spinal canal. Affected patients
usually present with urinary retention or overflow incontinence. The
physical examination in this disorder may reveal loss of anal sphincter
tone or saddle anesthesia about the anus, perineum, and genitals.
Vertebral fracture ? Older patients, particularly women, are at risk for
vertebral compression fractures due to osteoporosis. Back pain following
trauma should alert the clinician to this possibility of a fracture,
although compression often occurs in the absence of trauma. In one
study, for example, new vertebral fractures that were not recognized
clinically were associated with substantial increases in back pain and
functional limitation due to back pain in women ages 65 years and older
[5]. (See "Clinical manifestations and treatment of thoracolumbar
vertebral compression fractures").
The major risk factors for osteoporotic fracture are the same as those
for osteoporosis including (in addition to estrogen deficiency) a family
history of osteoporosis, cigarette use, prolonged steroid use, advanced
age, excessive thyroid hormone replacement, white race, and thin body
habitus [6]. (See "Epidemiology and causes of osteoporosis"). Older
patients are also at increased risk for falls due, for example, to
psychoactive drug use, impaired visual and vestibular function, and
weakness and gait abnormalities arising from musculoskeletal,
neurologic, or other disorders [7].
DEGENERATIVE SPINAL DISEASE ? Once cancer, infection, and compression
fracture have been excluded, the differential becomes limited primarily
to manifestations of degenerative disease of the lumbar spine.
Unfortunately, radiographic evaluation of the degenerative lumbar spine
is nonspecific [8-10]. MR imaging in asymptomatic subjects over age 60
reveals disc protrusions in 80 percent [11] and degenerative spinal
stenosis in 20 percent [8]. Thus, the evaluation of low back pain in the
older patient must rely heavily on the history and physical examination,
with radiographic tests being used only to confirm the clinical impression.
Four types of pain syndromes can be seen: lumbago; osteoarthritis; a
herniated disc; and lumbar spinal stenosis.
Lumbago ? Probably the most common low back syndromes seen in older
patients are simple strains and sprains. These generally present as
"lumbago," or nonspecific pain in the lower back, sometimes with
radiation into one or both buttocks, and muscle spasm. These episodes
are generally self-limited, usually lasting less than two months.
Osteoarthritis ? Older patients with degenerative spine disease may
develop osteoarthritic pain arising from the facet joints [12]. Patients
with this syndrome generally have exacerbation of pain upon lumbar
extension, which tends to load the facet joints, and relief of pain with
lumbar flexion. The pain is typically most severe in the central low
back area; it may radiate into the buttocks or thighs, and is often
bilateral. This pattern of radiation does not necessarily imply nerve
root involvement; but reflects a sclerotomal pattern of pain radiation.
Herniated disc ? The herniated disc syndrome occurs infrequently in
persons over sixty. At times, a symptomatic disc herniation can occur in
the setting of spinal stenosis, producing manifestations of both
disorders. Both syndromes produce sciatic pain, but the pain in spinal
stenosis tends to be more diffuse in distribution and is often
bilateral. Pain from a herniated disc is typically worse with lumbar
flexion, while pain from spinal stenosis is typically worse with lumbar
extension (similar to that in osteoarthritis) (show table 2). (See
"Approach to the diagnosis and evaluation of low back pain in adults").
LUMBAR SPINAL STENOSIS ? Spinal stenosis refers to a narrowing of the
spinal canal with compression of the nerve roots in the central spinal
canal or in the neural foramina. Spinal stenosis may be due to acquired
or degenerative processes, or to congenital stenosis [13].
Degenerative disease causing canal or lateral recess stenosis is
most often seen in patients in the sixth or seventh decade of life.
Recurrence of stenosis following surgery is common, and often due to
bone regrowth or fibrosis at the operated vertebral level, or worsening
of lesions at an adjacent level.
Congenital spinal stenosis is due to inadequate development of the
canal or foramina. It may present in the third or fourth decade due to
degenerative changes occurring in the setting of a small spinal canal.
Pathophysiology of degenerative disease ? The pathophysiology of
degenerative spinal stenosis is reasonably well understood [14-16]. The
process begins with progressive disc degeneration. There are many
factors that underlie this initial event, including trauma, aging, and
inherited traits. Twin studies, for example, suggest that genes may
contribute approximately 75 percent to the risk of developing disc
degeneration [17]. One genetic risk factor for lumbar disk degeneration
has been identified, an Arg103->Trp substitution in the alpha 3 chain of
collagen IX [18].
Progressive disc degeneration results in loss of disc height with
attendant loading of the posterior elements of the spine, including the
facet joints. This leads to facet joint arthropathy with osteophyte
formation. Concomitantly, the ligamentum flavum tends to hypertrophy and
the degenerative disc material protrudes posteriorly. The result of all
of these processes is encroachment on the central canal and the neural
foramina due to facet osteophytes, ligamentum flavum hypertrophy, and
disc bulging. The most common levels involved are L4-5, L5-S1, and, less
commonly, L3-4. Associated degenerative spondylolisthesis is relatively
common, especially in women, and tends to exacerbate the nerve root
compression.
Clinical manifestations ? The characteristic clinical syndrome
associated with spinal stenosis is neurogenic claudication [16,19]. This
consists of two elements:
Pain radiating beyond the back to the buttocks, thighs, or lower
legs, often causing the patient to stop walking. Numbness and tingling
may occur in one or both lower extremities.
Worsening of pain with extension of the lumbar spine, and
improvement with forward flexion of the hips, knees, or lumbar spine as
occurs with sitting or stooping forward. Patients may learn to relieve
pain by leaning over a table, or resting with the trunk prone over the
stairway.
One study evaluated the sensitivity and specificity of a variety of
historical and physical findings for spinal stenosis (show table 3) [20]:
Pain radiating below the buttock is relatively sensitive for spinal
stenosis, but pain radiating below the knee occurs in only one-half of
patients.
Improvement in pain with sitting is fairly sensitive, occurring in
about three-quarters of patients. The complete absence of pain while
sitting is somewhat less sensitive, but more specific for spinal stenosis.
Increased pain with lumbar extension is a useful finding, which is
most specific if the patients are asked to extend for a full 30 seconds,
and a positive response is defined as pain radiating beyond the buttock
into the thighs.
A positive Romberg sign (in which patients have difficulty
maintaining balance with their eyes closed) and a wide-based gate are
highly specific for spinal stenosis, but not very sensitive.
Severe involvement is suggested when the patient cannot walk farther
than one block before the onset of claudication, but is able to walk
farther when using a grocery cart (due to forward spinal tilt).
Diagnosis ? A herniated disc syndrome has some features of spinal
stenosis (eg, radiating pain and neurologic deficits), but differs in
the relationship between posture and symptoms. As noted above, spinal
stenosis is improved with lumbar flexion and sitting, both of which
often worsen the pain with a herniated disc (show table 2). Radiologic
procedures are often helpful in establishing the correct diagnosis; they
are generally used only in patients with severe symptoms or those who
fail the initial therapeutic regimen described below.
Computed tomography, with or without contrast media, has been
helpful in differentiating many diseases of the spine, including
herniated disc, facet degeneration, and spinal stenosis. As an example,
one study found CT to be only slightly less accurate for the diagnosis
of herniated disc and spinal stenosis than contrast myelography (72
versus 83 percent for surgically confirmed herniated disc, and 89 versus
93 percent for spinal stenosis) [21].
MRI is also useful in patients with suspected spinal stenosis
despite a lack of bony detail. It does not use ionizing radiation and
has no apparent adverse biologic effects, although it may be difficult
to tolerate for claustrophobic patients.
Elective contrast myelography followed by CT is reserved for
patients with atypical pain, or for localization of the site of
pathology preceding operative intervention. Although CT combined with
myelography represents the gold standard, high resolution CT and MRI are
less invasive.
Patients in the 50 to 65 year age range sometimes present with "mixed
mechanics," suggesting the presence of both stenosis and a superimposed
disc. These patients tend to be uncomfortable with prolonged extension
and flexion. Imaging studies can confirm the presence of both a disc
protrusion as well as stenosis arising from facet joint and ligamentum
flavum hypertrophy.
Differentiation of symptomatic lumbar spinal stenosis from facet
arthropathy has practical clinical utility. Patients with spinal
stenosis may respond, at least temporarily, to epidural steroid
infections with or without caudal epidural block [20,22] and are
candidates for decompressive laminectomy if conservative treatment fails
[14,16,23-27].
Initial management ? Many patients improve and live independently with
spinal stenosis. Thus, unless severe stenosis is suspected, simple at
home advice using the following treatment program should be undertaken.
Imaging studies should be considered only after the following regimen
has been given a trial for several months.
Alcohol, smoking, and long-acting hypnotics should be curtailed.
Alcohol and hypnotic use may lead to falls that can precipitate
progressive symptoms, while smoking can accelerate osteoporosis and
related fractures.
Ideal body weight should be maintained to minimize stress on the
lower back.
Patients with spondylolisthesis should maintain good abdominal tone
and live with the abdominal muscles contracted as much as possible. This
effort to prevent further slippage may reduce painful episodes.
The patient should be provided with a back care pamphlet and a list
of the guidelines for lower back protection. (See "Joint protection
program for the low back").
We encourage walking to the point of pain, followed by a moment's
rest. The patient can take a chair out on the driveway, time the
duration of walking until discomfort begins, then rest a minute or two,
and walk again. The patient can observe change over time.
If walking is severely curtailed on the first encounter, aquatherapy
should be tried using a flotation device such as the AquaJogger. It is
approved for insurance payment as a stabilization aid for hydrotherapy
programs. The CPT code is AquaJogger 99070. If not locally available, it
can be obtained at Sports Science International, PO Box 1453, Eugene,
Oregon 97440, (800) 922-9544.
Exercise that strengthens lower limbs often prevents falls and
further problems. The chinning bar gravity stretch exercise has been
particularly effective for many elderly patients. (See "Rehabilitation
program for the low back", for a description of exercises for the lower
back in specific disorders). Patients who try this should begin
gradually and be warned that shoulder strain and pain should be avoided.
Medical therapies include antiinflammatory drugs, rest, analgesics,
and physical therapy such as heat, ultrasound, and exercises to
strengthen abdominal muscles and reduce lumbar lordosis. Nonnarcotic
analgesics should be available; the patient should be encouraged to use
them for several days and then omit them a day or two in order to
prevent tolerance. Nonsteroidal antiinflammatory drugs are often
helpful, but elderly patients are best begun on an acetaminophen or
nonacetylated salicylate such as salsalate or magnesium salicylate.
Lumbar epidural injections ? Lumbar epidural steroid injections may be
of benefit in patients with lumbar spinal stenosis [23,24]. One report,
for example, evaluated 40 patients with low back pain and sciatica
characteristic of spinal stenosis or a herniated lumbar disc; the
patients were treated with one, two, or three injections of 80 mg of
Depo-Medrol [23]. Approximately 60 percent of patients reported varying
degrees of relief from leg and back pain immediately after injection.
However, only 24 percent were asymptomatic at follow-up examination; in
these patients, there was no correlation between relief of pain and the
number of injections. (See "Epidural steroid injections").
Another prospective study evaluated the efficacy of a combined approach
-- corticosteroids (80 mg Depo-Medrol) plus a caudal epidural block (0.5
percent lidocaine) ? in relieving pain in elderly symptomatic patients
suffering from degenerative lumbar canal stenosis [24]. The pain level,
rated on a five point scale, fell from 3.43 to 1.5; the duration of pain
relief ranged from 4 to 10 months.
Caudal epidural injections of triamcinolone plus procaine hydrochloride
are reserved for patients with intractable sciatic pain who have failed
a comprehensive regimen of psychosocial interventions, physical therapy,
and medications. Complications are rare, but cost is significant.
Soft tissue injection ? Soft tissue injection of steroids may be tried
in patients with spinal stenosis. We have seen many patients who failed
lumbar epidural blocks, but have ongoing benefit from soft tissue
injections. A total of 60 to 80 mg of methylprednisolone or other
crystalline steroid mixed with 1 to 2 mL of lidocaine hydrochloride is
used. With the needle as a probe (2-inch 20 gauge or 3.5-inch spinal
needle), injections deep into the erector spinae, at the region of the
apophyseal joints of L3-L4, L4-L5, and L5-S1, into the sacroiliac
joints, and into the deep gluteal muscles on each side (if tender) may
provide several months of relief.
Surgical decompression ? Patients who continue to be symptomatic despite
conservative therapy may be offered surgery if they are otherwise in
good health. A meta-analysis of 74 studies found that 64 percent of
patients treated surgically for lumbar spinal stenosis had
good-to-excellent outcomes [27]. Similar findings were noted in a
retrospective study of 88 patients who underwent a laminectomy at our
institution; at three to five years, 52 percent were free of severe
pain, 17 percent had undergone a second operation, and 30 percent had
severe pain [25]. By seven to ten years, 30 percent still had severe
pain, and reoperations were performed in 24 percent [28].
In a more recent study of patients with severe lumbar spinal stenosis,
surgical treatment was associated with greater improvement in patient
reported outcomes than nonsurgical treatment at four years, even after
adjustment for differences in baseline characteristics among the
treatment groups [29]. After four years, 70 percent of the surgically
treated and 52 percent of the nonsurgically treated patients reported
that their predominant symptom, either leg or back pain, was better. The
relative benefit of surgery declined over time but remained superior to
nonsurgical treatment.
Prognostic factors indicating a lower likelihood of success include
prolonged disease duration, severe symptoms, sphincter disturbances,
psychosomatic disorders, insurance and medical-legal issues, and a poor
self-assessment of the patient's overall general health. In one study,
for example, voiding dysfunction and urodynamic abnormality were only
partially reversed with decompressive laminectomy [30]. Prior
laminectomy involving a single interspace has also been associated with
poor long-term outcome in patients undergoing laminectomy for
degenerative lumbar stenosis [31]. In contrast, more severe compression
of the cauda is associated with better outcomes [32,33].
Symptomatic degenerative spinal disease which does not result in nerve
root involvement is less responsive to lumbar epidural steroid injection
and, in the opinion of most authorities should not be managed surgically.
