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Managing Spinal Conditions in Older Persons

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Managing Spinal Conditions in Older Persons JAMES ZUCHERMAN, MD JUDY SILVERMAN, MD Considering the patienfs overall medical status is crucial Managing spinal conditions in older persons ABSTRACT: Older patients who present with spinal complaints do not need to accept pain and diminished functional capacity as conse quences ofaging. Spinal stenosis results from the natural progression ofdegenerative changes in the spine. Thoracolumbar compression fractures usually are caused by trauma but also are common in pa tients who have osteoporosis. Mobility testing can help identif]^ un derlying pathology and deinse an exercise program. It is important to screenfor other causes ofpain, such as hip pathology. Radiography, MRI, and CTare useful imaging studies. The presence ofcauda equina syndrome requires urgent imaging and, usually, surgery. In This is the seventh in a special se some cases, a short course ofphysical therapy can reverse symptoms. ries ofarticles on the evaluation Lumbar or thoracic osteoporoticfracture treatmentfocuses on and management ofback pain. symptom management. (J Musculoskel Med. 2005;22:214-222) The percentage of the US popula the most common severe condi healthful living habits. Judicious ' tion older than 65 years has been tions in older persons. Consider use of exercise, proper body me increasing during the past centu ing a patient's overall medical sta chanics, medications, and surgery , ry and is peaking as baby boomers tus is crucial in management of can result in improvement in func- ; reach older age, Many older per these problems, because comor- tion and quality of Hfe. In this ar- | sons have aches, pains, and dimin bidities can affect treatment op tide, we describe the diagnosis ished functional capacity but do tions and outcomes. Osteoarthritis and management of the spinal ; not complain to a doctor even in peripheral joints, mental de conditions that occurfrequently in '[ if they are severe; they assume cline, cardiovascular disease, and older persons. : that these concerns are a normal physical deconditioning make it part of the aging process. At the much more difficult for older per PATIENT ASSESSMENT other end of the spectrum—and sons to deal with spinal disease. In History and presentation ^ increasingly more common—are addition, the disease and its re The "red flags" of spinal disorders , older persons who will not accept sultant physical disability take a are not seen frequently, but when any deterioration in their func toll on the patient's entire life; the present, they require urgent eval- - tional capacity and recreational "burden" of the disease plagues nation or at least attention. The ; capabilities. these patients with psychological, symptoms include loss ofbowel or • Spinal conditions—degenerative social, and physical deterioration. bladder control, saddle anesthe spinal stenosis and osteoporotic Older patients who present with sia, pain at night or with lying compression fractures—represent spinal complaints do not need to down, progressive limb wealoiess, ; accept the aches and pains as a gait disturbance, unexplained consequence of aging, Many of the weight loss, fever, and a history of Dr Zuchennan is an orthopedic spine sur spinal problems associated with malignancy. geon and medical director and Dr Silver- aging can be mollified greatly by Because women may have a his- . man is a physiatrist and algologist at St Mary'sSpine Center, St Maiy'sHospital and finding and maintaining the right tory of stress incontinence result Medical Center, in San Fi'ancisco. balance of physical activity and ing from pelvic floor relaxation, it ; THE JOURNAL OF MUSCULOSIOILETAL MEDICINE • MAY 2005 is important to inquire about a Age-related change in the pattern of bladder changes control—spontaneous dribbling, a Disk sense of incomplete bladder emp degeneration tying, or not being aware of when Spinal the bladder is empty after void Facet ing—^rather than incontinence hypertrophy degeneration with sneezing, coughing, orlaugh ing. Gauda equina syndrome is Thickening of characterized by pain or sensory spinal loss in the buttocks and perineum ligaments Lumbar with disturbed bowel or bladder spinal control. It is the result of com stenosis Intermittent pression on the lower nerve roots neurogenic in the spinal canal, such as in se claudlcatlon vere spinal stenosis. Other causes include tumor mass, large disk Figure 1 - This diagram shows the mechanism ofdegenerative lumbar spinal stenosis, a common condition in olderpersons. ?e- hemiation, abscess, and displaced m bone fragments after fractures. In natural progression of degenera the spine in a flexed position (as in preexisting spinal stenosis, a tive changes in the spine. In this a grocery store) is easier than small insult can tip the patient degenerative cascade, each spinal walking in a more erect position. over into significant neurologic level is defined as consisting of a Typically, this symptom pattern IS i compression.When it is identified 3-joint complex, the disk and 2 results from spinal stenosis or e-^ Ji early, immediate surgical decom facet joints (Figure 1}.'The effects neurogenic claudication and the cy J pression can prevent permanent of aging—^tears in the annular phenomenon of diminished spinal neurologic insult and allow for fibers and desiccation of the disk canal size in positions of exten recovery of bowel and bladder with subsequent loss of disk sion (standing, walking, and lean ISr 1l control. height and buckling of the liga- ing backward) (Figure 3). Patients al J The presence of any red flags mentum flavum—are associated may not feel any back pain. Local ] n should signal a need for immedi with degenerative changes in the nerve root or rootlet compression ate imaging, usually MRI, because facet joints, including synovitis, may cause leg pain by obstructing it is sensitive to tumors, infec cartilage destruction, capsular the blood supply. Because flexion tions, and soft tissue structural laxity, and hypertrophy of the lig- of the lumbar spine enlarges the derangements; also, MRI provides amentumflavum (Figure 2). Osteo- spinal canal both centrally and 'S adequate information about bony phytes can form on both the facet laterally, patients are relieved with n . structures. For patients who pre-„ joints and the vertebral bodies.^ sitting and bending over. I. , sent with pain and normal neuro The combination ofchanges caus Some patients deny pain and re e I logic examination results, there is es both central and lateral ste port only walking difficulty—in .1 r i rarely any urgency for obtaining nosis as the various structures particular, a loss ofbalance or sen imaging studies. Symptoms of around the neural elements both sation (or not knowing where the neoplasm for which MRI may be enlarge and collapse. ground is). In patient evaluation, appropriate include a history of Symptoms are determined by peripheral neuropathy and cer i i unexplained weight loss and pain dynamic changes in spinal canal vical or thoracic stenosis with f i at night or with recumbence, pos size. Some patients complain of spinal cord compression shouldbe sibly with a history of cancer, es pain or a sense of fatigue in the considered possible contributors pecially breast, prostate, or lung legs with walking that resolves to their symptoms. cancer. with sitting. They report that Another common problem in t I Spinal stenosis results from the walking while pushing a cart with older patients—thoracolumbar THE JOURNAL OF MUSCULOSKELETAL MEDICDJE • MAY 2005 215 Managing spinal conditions in olderpersons chair. The physician should in quire about the presence of red flags, because protrusion or ret- ropulsion of bone can cause cauda equina syndrome. Acute patho logic fractures also occur as a result ofmetastatic disease. When they are present, further workup is needed to define the primary Physical examination Figure 2 -Age-related changes produce a constellation ofneural impingement This begins with the patient's sim symptoms: the ligamentumflavum h]rpertrophies and buckles into the spinal ply standing and walking. Is there canal (A), intervertebral disks lose hydration and bulge into the spinal canal (B), a flattening of the lumbar lordo- and wear and tear causes thefacetjoints to hypertrophy (C). sis? Does the patient stand with compression fractures—usually is protective effects of estrogen after flexion at the hips to try to open heralded by a traumatic insult. menopause—^become symptomat the intervertebral foramen? Is the However, these fractures also are ic with an increased incidence of patient's gait wide-based to im common in patients who have os long bone and compression frac prove balance and stability? Is teoporosis and no trauma.^ Usual tures approximately a decade ear there foot drop or slap? Does the ly, localized back pain and tender lier than men.^ patient have sufficient strength to ness correspond to the site of the Vertebral compression fractures walk on his or her toes or heels? fracture. In atypical cases, neu can occur acutely with or without (Be sure to provide enough support rologic deficit may result when trauma, or they may have an in to ensure that patients do not fall.} the posterior cortex of the verte sidious onset of symptoms. In Range of motion testing in bral body is also involved. Most of citing events include coughing, stenosis may show less restriction these fractures are stable; a care lifting, and bending forward dur with flexion and greater loss of ful neurologic examination should ing simple home-care tasks. Com range with extension. Mobility be performed to screen for neural plaints include sharp, focal back testing and determination of entrapment at the fracture site. pain that increases with move which positions induce pain and Osteoporosis affects women and ment, such as moving into and out which relieve it can help devise an men increasingly as they age. On of bed, or with weight bearing or exercise program and identify the average, women—who have small pressure, as with sitting, standing, nature of the underlying pathol er frames and loss of the bone- or leaning against the back of a ogy.
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