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Diagnosing Low Back Pain in the Elderly

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Leg pain aggravated by walking and standing but relieved by sitting suggests spinal stenosis ... Leg pain always check distal pulses (to distinguish vascular ... – PowerPoint PPT presentation

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Title: Diagnosing Low Back Pain in the Elderly


1
Diagnosing Low Back Pain in the Elderly
  • G. Barry Robbins D.O., FACN
  • Associate Professor of Neurobehavioral Sciences
  • KCOM
  • A College of ATSU

2
Risk Factors of LBP
  • Repetitive lifting
  • Vibration
  • Smoking and Alcohol abuse
  • Multiple pregnancies
  • Inactivity
  • Osteoporosis
  • Familial Trend
  • Anxiety associated with depression

3
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

4
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

5
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.

6
4 Important Areas to Assess in the Elderly
  • Characteristics of the pain
  • Presence of malignancy
  • History of non-spinal medical problems
  • Psychosocial status

7
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

8
LBP (cont)
  • Chronic LBP
  • Aging-related degenerative disk and joint disease
  • Malignancy
  • Paget disease
  • Fibromyalgia
  • Diffuse idiopathic skeletal hyperostosis

9
LBP (cont)
  • Predominant leg pain associated with LBP
  • Trochanteric bursitis
  • Osteoarthritis of the hip
  • Lumbar canal stenosis
  • Intervertebral disk herniation

10
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

11
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

12
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

13
Cancer (Deyo 1988)
14
Cancer (cont)
15
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

16
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

17
Nuclear MedicineMetastatic Bone Disease
18
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

19
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

20
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

21
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

22
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)

23
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24
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

25
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

26
Compression fracture
27
Radiograph (left) Vertebral compression fracture
(arrow) in an elderly patient. Bone scan (right
shows increased uptake in the acutely compressed
vertebra.
28
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

29
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

30
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

31
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.

32
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.

33
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

34
Sensitivity/Specificity
35
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36
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38
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39
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)

40
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41
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42
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

43
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

44
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

45
DISH SYNDROME
46
DISH SYNDROME
47
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

48
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

49
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

50
CATOsteoarthritis of the SpineSclerotic and
Hypertrophied Facets
51
Lumbar Myelogram
  • Herniated Nucleus Pulposus with Central Canal
    Stenosis

52
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)

53
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

54
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)

55
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

56
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
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