Back pain in elderly

Areesak Chotivichit M.D.

Associate professor
Orthopeadic surgery
Siriraj Hospital

Thaispineclinic.com
Back pain is common
60 yo female severe back and leg pain
80 yo female with chronic back pain radiate to thigh and buttock
75 yo female back pain 65 yo female severe back pain
 Type of pain

Axial pain
Radicular pain
Referred pain
*combination*
Anatomy of pain
 Axial pain
Mid line
Paraspinal
Sources
– Disc
– Facet joints
– Muscles and
ligaments
(1o,2o)
 Radicular pain
Along the dermatome
Shooting, electrical like
Numbness, weakess
– Proximal muscle
weakness may due to
pain!
Sources
– nerve
Mechanical
compression
Chemical irritation >
inflamation
 Dermatomal distribution
– T7 > epigastrium
– T10 > umbilicus
– L1 > groin
– L2,3 medial thigh
– L4 > anterior knee, medial leg
– L5 > lateral leg , dorsal foot
– S1 > calf,sole
 Referred pain

Scerlodertomal pattern
Low back to buttock
Facet joint to lateral hip
and thigh
SI joint to buttock,
lateral hip and thigh
* not below the knee*
 Etiology
Degenerative
Osteoporosis
– Minor trauma
Tumor
– Benign
– Malignant
Inflamation
– Septic, aseptic
Combination
 Others
Disecting aortic
aneurysm
Duodenal ulcer
Gall stone
KUB conditions
Neuritis
– Herpes zoster
 Degenerative
Degenerative = wear
and tear
Ageing
Stress
– Mechanical > work,
sports,hobby
– Chemical > smoking
Genetic
Diseases
 Degenerative

Symptom = wear and

tear rate – (repairing
+ compensative
capability)
Pain with activity
On and off
Course = months to
years
Degenerative = spondylosis

ิ
normal spondylosis
Multiple level spondylosis
 Osteoporosis

Post menopausal
Senile
Structural bone loose
its calcium
Micro and macro
fracture
 Osteoporotic fracture
Axial, referred pain
Radicular symptom is
unusual
Acute severe pain
after a fall
Gradually deformed
spine
Associated symptoms
Deformity
 Associated symptoms

Decreased lung
capacity
reduction in
abdominal space
– Loss appetite
– Poor nutrition
 Associated symptoms

Sleep loss
Decreased mobility
– accelerated bone
loss
– muscle
deconditioning
Depression
Loss of
independence
 Tumor
Benign
– Not common in elderly
– Associate with metabolic
disease
Malignant
– Common
– Dilemma with osteoporotic
fracture
* true night pain*
 Malignancy
Primary Metastasis
– Multiple myeloma – Lung
– Thyroid
– Breast
– Kidney
– Prostate
– GI
* Hx of *
 Approach
History
Physical exam
Investigation
Treatments
– Conservative
– Surgery
Facility & capability
 Red flag
True night pain
Getting a lot worse
History of a cancer
Osteoporosis / malignant fx.
30% false positive studies
Other comorbidity
 Treatments

conservative surgery
 Conservative treatments
Immediate
– Pain medications
– Modalities, bracing
– Limited activities
Definitive
– Rehabilitation
– Modified life style
 Conservative treatments

Tai-chi , yoga for elderly patients

Chiropractic manipulation

Cautious in elderly patients

80 yo female with chronic back pain radiate to thigh and buttock
for years treated with med, modalities, facet blocks
 Facet block
Xylocaine
Steroid
– Triamcinolone
– Depomedral
Multiple levels
Not more 3 months
interval
Complications
– Infection
Facet block – Dural leak
 Surgical treatment

Decompression
Stabilization
Realignment
Minimally invasive
surgery is a trend
 Indications
Failed conservative
Progressively neurological deficit
For tissue diagnosis
**********************
Goals are accepted
Doable procedures
 Spondylosis with stenosis

60 yo female c/o severe back and leg pain for 1 year, not able to walk
more than 10 steps with numbness and weakness of both legs
MRI showed severe degenerative and stenosis L3-S1
 L4-5

L5-S1
L3-4
Underwent a decompression and fusion L2-S1
 Spondylosis with stenosis

70 yo male with severe leg pain and claudication

,mild back pain
Myelogram showed severe multiple level stenosis,
underwent laminectomy of L4-5 no fusion
 Disc herniation in elderly

65 yo c/o severe back and anterior thigh pain for 3 days

MRI of T1 and T2 sagital
 T1
T2

Large ruptured disc L2-3 causing pending cauda equina

Underwent a microdiscectomy
 Osteoporosis
Non narcotic pain meds
Bracing
Anti-resorbtive agents
Calcium replacement
Vitamin D, K2, fluoride
Hormonal Tx.
Encourage upright acts.
 Vertebroplasty for osteoporosis

6 weeks Post op
im

75 yo female fell on her buttock underwent a vertebroplasty at 6 weeks

 Indications
Failed conservative
– painful osteoporotic fracture
– 3-4 weeks of meds,bracing,PT
Palliative pain Rx. for spinal tumor
– Malignant
– benign
 Contraindications
Coagulopathy
Extensive destruction of the vertebra
Neurological deficit due to compressive
lesion in spinal canal
Vertebra plana
Inadequate image quality
No surgical back up team
Cement and syringe injection
 The set up

Two plane c- arm x-ray with memory, contrast injector,

radiation shield
 Instruments

Percutaneous puncture Bone biopsy needle

Checking the position of the
needle
Osteoporosis with degenerative

7o yo female had osteoporosis fracture of L3 , s/p fusion

L4-5 10 years ago for stenosis and listhesis
Underwent a vertebroplasty at L3
 Complications

73 yo female underwent a vertebroplasty developed paresis both legs

Open surgery for osteoporosis

Neurological deficit patients

– Require decompression
– Seldom occur
Correct imbalanced deformity
– Adult scoliosis
– Degenerative spine
75 yo female fell on her buttock 2 months ago, she had
severe pain, neurological deficit and not able to ambulate
independently. She underwent “ Anterior grafting with
fibular bone and fixation with Anterior instrumentation
 Metastasis tumor

65 yo female c/o severe back pain mid and low back

rediate to both buttocks and posterior thighs no history of
cancer. Work up showed CA thyroid
 CA thyroid

MRI showed multiple metastasis lesion L1.L3 with

osteoporosis collapsed of T 12. She was treated with
thyriodectomy and radiation
 Multiple myeloma

78 yo male with severe back pain for 3

months with 2 weeks of weakness
Underwent a
decompression
and stabilization