General Principles in Older Adults
Back pain is 1 of the top 3 reasons for physician visits by older adults. Of the 1037 surviving subjects from the original Framingham Heart Study cohort (ages 68–100 years), 22% had back pain on most days. Although back pain in older adults is prevalent, costly, and leads to considerable morbidity, much of the literature has focused on younger populations with this condition.
Back pain is often categorized as acute (lasts less than 4 weeks), subacute (lasts between 4 and 12 weeks), or chronic (lasts longer than 3 months). Although much of the literature evaluates chronic symptoms, a recent article using longitudinal data reported that most back pain in older adults has a recurrent or episodic course. Understanding the various patterns of back pain in older persons is important as prevention and treatment planning may differ. Table 66–1 identifies the terminology used to describe back pain.
Table 66–1.Back pain terminology. ||Download (.pdf) Table 66–1. Back pain terminology.
|Cauda equina syndrome ||Compression of multiple nerve roots resulting in bilateral motor weakness (usually of legs), bowel or bladder incontinence, saddle anesthesia; a surgical emergency. |
|Kyphosis ||Outward curve of the thoracic spine. |
|Lordosis ||Inward curve of the lumbar spine. |
|Piriformis syndrome ||Entrapment resulting in pain, numbness, paresthesia, weakness in the distribution of sciatic nerve. Often after direct trauma to sacroiliac or gluteal region, occasionally caused by repetitive hip or lower-extremity movements or repeat pressure on the piriformis muscle. |
|Radiculopathy ||Impairment of a nerve root usually causing pain, numbness, tingling, or muscle weakness that usually corresponds with the nerve root. |
|Sciatica ||Pain, numbness, tingling in distribution of sciatic nerve. Symptoms radiate down posterior or lateral leg, usually to foot or ankle. Usually caused by mechanical pressure or inflammation of lumbosacral nerve root(s). |
|Scoliosis ||Abnormal, sideways curvature of the spine. |
|Spinal stenosis ||Narrowing of the central spinal canal by bone or soft tissue elements. Pain, numbness often radiate from low back to buttock and/or thigh and often associated with neurogenic claudication. |
|Spondylolisthesis ||Anterior displacement of vertebra on the one beneath. Graded by radiologist base on percentage of slippage on x-rays. |
|Spondylosis ||Arthritis of the spine. Radiographically: disc space narrowing and arthritic changes at facet joints. |
|Spondylolysis ||Fracture in the pars interarticularis where vertebral body and posterior elements, protecting the nerves are joined. |
In older individuals, there are several specific causes for back pain (eg, lumbar spinal stenosis, osteoporotic vertebral compression fractures, and sacral fractures) that are less common in younger individuals. Systemic conditions, such as malignancy and infections, although rarely the cause of back pain, are more common in older compared to younger age groups. One of the most challenging aspects of assessing and managing back pain is identifying the source(s) of pain in the older adult who often has multiple musculoskeletal comorbidities (eg, trochanteric bursitis, hip osteoarthritis, multilevel lumbar degenerative changes, and lumbar stenosis). ...