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 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 . 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, , 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. 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 . 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 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 , such as in se claudlcatlon vere spinal stenosis. Other causes include tumor mass, large disk Figure 1 - This diagram shows the mechanism ofdegenerative , 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 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 . Local ] n should signal a need for immedi with degenerative changes in the 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 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 . 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 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. Reproducing the symptoms by positioning the spine in exten sion is a good way to differentiate neurogenic from vascular clau- dication. Pain resulting from disk disease has an opposite pattern; there is exacerbation in flexed po sitions, such as sitting and bend ing forward. Sensory testing of the lumbar dermatomes includes evaluating pinprick, light touch, and vibra Figure 3 - Colorized, myelography shows inci-eased stenosis in extension (A) ver tion or proprioception. Testing for susflexion (B). a stocking-glove nondermatomal

THE .JOURNAL OF MUSCULOSKELETAL MEDICINE • MAY 2005 distribution sensory loss requires and examining for distal alopecia, and lateral views, can provide in further evaluation to determine nail dystrophy, and other dys- formation about the degree of de whether a peripheral neuropathy, trophic changes can rule out ath generative changes present and such as in diabetes, is also pres erosclerosis and vascular claudi- about old and new fractures. ent. In some cases, diabetic and cation. Ifbothpedal pulses are ab Oblique views are appropriate to other peripheral neuropathy can sent, noninvasive lower extremity screen for , which cause some burning pain and vascular studies are indicated. may be symptomatic. Adding flex dyesthesias. Electromyographic Usually, sites of tenderness with ion and extension views provides studies will confirm peripheral palpation along the spine corre information about the segment neuropathy. spond to the site ofpathology and stability of the spine; translation- Motor weakness can be present should be correlated with other al motion between 2 adjacent ver in a radicular or multiradicular physical findings and radiography. tebrae is abnormal and can be as pattern. Deep tendon reflexes can Findings on physical examina sociated with symptoms. be normal or hyporeflexive. Ifthey tion that support the diagnosis of MRI studies can provide more are hyperactive, or if Babinsld compression fracture can include specific information about central signs (great toe extension while or gibbus deformity (a and foraminal stenosis. Infor the other toes splay on stroking of mation can be obtained about the plantar surface ofthe foot) are diskhydration/desiccation orpro- present, further evaluation of the trusion/hemiation, ligamentum brain and the cervical and thorac It is important to flavum hypertrophy, lateral recess ic spinal cord may be indicated. stenosis, neoplasm, and healed Results ofthe classic neural ten screenfor other and unhealed fractures (Figure 4). sion sign, or straight leg raising causes ofpain Because MRI measures tissue flu test, may be normal with neural id, it has limited ability to differ entrapment at L4 or above.Testing during the physical entiate bone lesions from soft tis for upper lumbar tension signs examination. sue lesions or calcification of tis with a prone knee bend is sensitive sues, such as osteophytes. Bone for entrapment from L2 to L4. scans also can elicit unhealed Many older patients have difficul compression fractures. ty in lying prone; testing can be fixed, forward angulation of the CT can provide more accurate done in a side-lying position. vertebrae) and focal tenderness information about bone structures A rectal examination should be with palpation orpercussion. Typ than MRI but with less detail of done to rule out distal neoplasm ically, the neurologic examination soft tissues. Myelography with CT andprostatitis. Sphincterstrength results are normal. follow-up allows for a dynamic as and control and perianal sensa Comorbidities are common. In sessment of intrathecal contrast tion should be assessed. quiry about the patient's social flow during the myelogram com It is important to screen for oth situation, mental status, and mood ponent. The presence of contrast in er causes of pain during the phys is appropriate. A comprehensive the canal adds information about ical examination. Evaluating hip review of systems and the general soft tissue hypertrophy/stenosis; range ofmotion rules out primary physical examination is also nec it is used frequently in the cervical hip pathology as a source of pain. essary to exclude pertinent co- spine to clarify details of patho Pain in the anterior groin with hip morbidities that may influence logic structures. MRI allows for flexion combined "with internal ro treatment of spinal conditions or evaluation on a noninvasive basis. tation and adduction suggests hip require treatment themselves. In cases that require clarification pathology. Do not perform this mo of pathology, or if the patient can tion if a patient has had total or Imaging not tolerate MRI (eg, pacemaker, partial hip replacement. Plain x-ray films of the lumbar claustrophobia), myelography and Palpation of peripheral pulses spine, including anteroposterior CT are indicated. (continued) THE JOURNAL OF MUSCULOSKELETAL MEDICINE • MAY 2005 Managing spinal conditions in older persons

well as global conditioning. Studies following the natural history of symptomatic spinal stenosis show the average wait for surgery to be close to 4 years. Al though improvement can occur with conservative care, results from surgery are more favorable.^ Johnsson and coworkers^ ob served untreated Swedish Registry patients with lumbar spinal steno sis for 4 years; they reported that Figure 4-MR7(2A7aZ 64;! and sagittal (B) views 15% ofpatients worsened, 15% im show a high T2 signal in the vertebral body that is typical ofunhealedfractures. proved, and 70% were unchanged. In mild to moderate cases, the de Degenerative changes are shown walking short distances and with cision to be treated surgically is a in imaging studies in many pa sitting, and has hip flexor tight lifestyle issue to be made at the tients. Therefore, it is imperative ness, a short course of physical patient's discretion, to correlate imaging findings with therapy can reverse the s'^nnptoms. There are few well-controlled a thorough history- and physical It should be aimed at devising a trials oftreatment ofpatients who examination to define treatment simple home exercise program of have spinal stenosis. In the only options. body mechanics training, stretch prospective randomized study of ing, and strengthening. The pro conservative treatment for pa TREATMENT OF COMMON gram needs to be simple to per tients who have spinal stenosis, PROBLEMS form without the use of special Zucherman and colleagues® found Spinal stenosis ized equipment. It should allow for a success rate of only 4% over 2 Treatment of patients V\7ith spinal change to provide positive rein years. Other authors confirmed stenosis is determined by the forcement to encourage ongoing this finding in less controlled severity of presenting symptoms participation. studies,®'"' although some improve and the patient's general health. We often recommend stationary ment occurs in a third of patients. The presence of cauda equina syn bicycling as an exercise that pa A 50% success rate was seen with drome requires urgent imaging tients can perform to maintain use of the X STOP Interspinous and, usually, surgery; however, a cardiovascular and muscular con , a minimally invasive pro multilevel decompression surgery ditioning. Flexibility exercises cedure that usually is performed may not be appropriate for some should target the pelvic girdle, in with local anesthesia (Figure 5).Al older patients who have multiple cluding the hamstring, psoas, and though this outcome seems low, in comorhidities. gluteal muscles. Pelvic tilt with recent prospective controlled .se Initial neurogenic intermittent concurrent, abdominal and gluteal ries using the same outcomes cri claudication symptoms are trou strengthening is key in lumbar teria for with orwith blesome but usually result in lim stabilization training. out fusion, B. Strumquist (person itation of function that may be Many patients -with spinal steno al communication, June 2003) and tolerable. As long as neurologic sis also have degenerative changes J. ICatz (personal communication, symptoms are relieved with sit in otherjoints. For them, exercis November 2003) also showed a 50% ting, nei-ve damage prohaljly is not ing in a swimming pool, enrolling success rate. Otlier numerous stud present and surgical inten'ention in a fonnal class for patients vdth ies that showed higher surgical is elective. arthritis, or simply walking arm- success rates were uncontrolled or If a patient has intermittent pit-deep in the water can be bene- were dependent on unvalidated or symptoms, is pain-free while ficialfor symptom management as surgeon-based outcomes tools. (continued) • THE.IOURWAL OF MUSCULOSimLETAL MEDICINE • MAY 2005 JUO. IM 5uencyof< l.S^i jaimeni. Among -jais of Ef>JBREl^ itgnandes) ant Managing Spinal conditions serious adverse o o r jorintic art/iritis, in oldcr persons body system , hypertension,, is, pancreatitis, phadenopathy. •ssion, multiplB lary embolism, ohropathy, kid- eived ENBREi,- following seri.' .•tinalbleetfirtg,' events were: A ineta-analysis reported a adult patients 0.33%mortalityrate and 15%com- Figure S ~ The XSTOP Interspinous Implant Ivem™ vS' Pl^^ation rate for decompressive for patients with spinal :ee also PRE- surgeiies.® Although laminectomv / Jllltillilliiirf |iy^ r, cutaneous • i , ^ stenosis involves a meifitus.and: required an average hospitaliza- minimally invasive procedure. Anatomic (paSVem^ of 4to 6 days, most patients placement ofthe X STOP aSSweJe' ^ procedure device is shown. The population^; were discharged on the dayit was deviceis awaiting FDA imoreS-l Complications were in- approval in this country. Je^r JaSi frec^ent and of minor severity. The perpatient-i device is approved in Europe and 7ce,the fol-, y . ts; abscess: ^^^psn and awaitmg FDA approval in this country. SbSl medications in patients img twice, wlth Spinalstenosis should follow SySS-^ World Health Organization 1 -W - Wto: analgesic pyramid.^ The back pain clinical trials have defined the ter the injection because the un component of spinal stenosis is time to initiate treatment, the fre considered nociceptive. Over-the- derlying pathophysiology is un edduring quency of injections, or the num changed. When these guidelines 3£: analgesic agents, such as ber ofprocedures to perform. Pro iDdysys-: acetaminophen and NSAIDs, can are followed by patients who have '9nt93in.igbtgain. "* 1- j ceeding with epidural cortico relatively mild disease, symptom oreure (see!(see -"6 used on an as-needed basis. steroid injections for an acute xia.diar- ; ^If these agents prove insuffi- remission may last for many aplasti'c exacerbation of pain is common, MINGS), , cient, mild opiate/acetaminophen months or years. When there is a consis- especially if a radicular compo cauda equina syndrome present, tral ner- , combinations can be used. Pa- nent, lower extremity pain, is pres nssuch I tients need to be informed that severe pain, or poor response to lamma- ent. The injection can provide a of prior I narcotic analgesics should beused nonsurgical treatment, surgery more rapid attenuation of pain can be considered. ^ to facilitate rest and sleep and not and allow for active participation : to allow excess activity; in the long in an exercise program. run, analgesics tend to worsen Osteoporotic fracture The appears to Lumbar or thoracic osteoporotic their condition by aggravating the remain effective in the epidural structural problem while dimin fracture treatment focuses on space for 6 weeks. For many pa symptom management. Analgesics ishingpainperception. tients, the anti-inflammatory ef Low-dose tricyclics, such as allow for early mobilization to fects of the injections are not ob avoid the deconditioning conse nortriptyline, may he useful for served for up to 2 weeks. Patients neuropathic pam.'° Monitoring quences of prolonged bed rest. should he reminded not to overdo If the patient requires mild or older patients for adverse effects, their activity if they feel better af- especially cognitive changes, se moderate opiates, aggressive use dation, and constipation, is impor- tant. Aggressive use of stool soft eners, water consumption and, Practice Points possibly, laxatives is needed for Spinal conditlans in olderpersons, the "redflaas " management of constipation. _Epidural corticosteroid injec mducfing cauda equina syndromei require urgerttmediGal attehtion ' tion, or epidural block, is another nonsurgical treatment tool that may be effective in patients with spinal stenosis.Nowell-controlled

the JOITRNAL of MUSCULOSKELETAL medicine • MAY Managing spinal conditions in older persons

Figure6- The CASH (A), JewettIB), and Taylor 10) braces are lightweight styles availablefor patients withosteoporoticfrac-' tures. Bracing provides both support and a reminder to modifi' movement. i

of stool softeners and laxatives are associated with disabling sis and usually require genaraT is necessary'. Teaching good body pain for several weeks or more, or anesthesia. ; mechanics—specifically, move with severe dysfunction in activ Two techniques are currently: ment into and out ofbed with min ities of daily living that require available: vertebroplasty and ley-; imal spine rotation and avoidance hospitalization, an injection of phoplasty, The former involves in-: of lifting and bending—aids in methyl methacrylate into un- jection into the fracture with an' pain control. If patients find ice or healed fractures immobilizes the attempt to restore fragments to a! heat helpful for symptomatic re fragments and usually provides more anatomic position; the latter.r lief, they can use it for 20-minute pain relief. Before resorting to involves reducing the collapsed; intervals. cement injection, adequate time fracture fragments with a balloonj. The use of bracing provides should be allowed for healing. and then applying cement. The! both support and the reminder to The injection techniques can be clinical results of the 2 procedures !, modify movement. For compres associated with death and paraly are similar. • sion fractures in the lower lumbar spine, a canvas corset may provide sufficient support. For upper lum bar or lower thoracic fractures, a References thoracic-lumbar-style orthosis is 1. Kirkaldy-Wi[lis WH, WedgeJH, Yong-Hing K, Reilly spinal stenosis; conservative or surgical manage required. Lightweight styles in J. Pathology and pathogenesisof lumbarspondylo- ment?: a prospective 10-year study. Spine. 2000; clude the Cruciate or CASH, Jew sis and sienosis. Spine. 1978:3:319-328. 25:1424-1435. ett, and Taylor braces (Figure 6). 2. Matkovic V KHsovic D, liich JZ. Epidemiology of 7. Hall S, Bartleson JD, Onofno BM, et al. Lumbar fractures duringgrowth and aging.Phi'sMedRehab spinal stenosis: clinical features, diagnostic proce In some cases, osteoporosis may Clin. 1995;6'415-439. dures, and results of surgical treatment in 68 pa contrilmte to chronic back or pel 3. ItatzJW,Stuck!G. LipsonSJ,et al. Prediaorsof sur tients. Anninxem Med. 1985:103:271-275. gicaloutcome in degenerative lumbar spinalsteno 8. TurnerJA, HerronL, Deyo RA Meta-analj'Sis of the vic pain with microfractures.The sis.Sp/ne. 1999:24:2229-2233. results of lumbar spine fusion.Aaa Onhop Scend medical treatment of patients with— 4. Jolirisson K£, Rosen 1,Uden A. TIte natural course Suppl. 1993:251:120-122, of lumbar spinal stenosis. Clin Orthop Relax Res. 9. WorldHealthOrganization.Cancerpain relief with osteoporosis varies according to 1992:279:82-86. a guide to opicHd availability'. Geneva: World Healtli severity and etiology. Patients may 5. Zuclierman JF, Hsu ItV, Harijen CA, et al. A Organization; 1996. prospective randomized multi-center study for the 10. MaxMB.Aniidepressanis as analgesics. In: Fields respond to medical treatment of treatment of lumbar spinal stenosis v.ith the X STOP HL, Liebesl'.indJC, eds. PharmacologicalApp'oaches their osteoporosis. Most fractures interspinous imptant: 1-year results. Eur Spine J. to the Treatmentof ChronicPain:NewConcept and 2004:13:22-31. Criticallssues. Seattle: lASP Press: 1994:229-246. heal within 8 weeks. 5. Amundsen T, Weber H, Nordal HJ, et al. Lumbar In fractures that do not heal and

THE JOTIRNAtI OEMTOrTrr.nrtiCET.ETAT- lurEnTnTUir . tutav nnntt THE JOUB.