Back pain has many causes. In this article, I will discuss some of the more common pathologic conditions of the spine.
Probably the most common cause of back pain among older patients is osteoarthritis, a wear-and-tear degenerative process. With this condition, the disc spaces narrow, and irritating bone spurs develop. Osteoarthritis is part of the natural aging process and in most cases is considered unavoidable.
Osteoarthritis can cause intermittent bouts of pain in the lower back area. Activities that stress the spine, such as bending, twisting, and heavy lifting, frequently cause this pain to flare up. Also, changes in the weather are known to worsen symptoms.
Another common malady affecting the spines of older patients is spinal stenosis. With the aging process, the joints of the back, called facets, may enlarge and develop spurs. These spurs may impinge on the spinal canal. The discs may also bulge into the spinal canal. These processes may narrow the spinal canal to the point at which nerves are severely pinched.
Spinal stenosis typically causes pain and numbness that radiate into the thigh and calves. This pain is called "neurogenic claudication." The pain is typically worsened by walking and is relieved by sitting and bending forward. Patients commonly report that leaning over a grocery cart relieves their pain while they are shopping. This happens because flexing the spine enlarges the spinal canal and takes pressure off the nerves (Figure 1).
Another spinal disorder seen among older patients is spinal instability or deformity. One form of this condition is called degenerative spondylolisthesis. This condition occurs not too infrequently among senior citizens. This condition is characterized by a forward slippage of one vertebra on another, most commonly the L4 vertebra on the L5 vertebra. This slippage is caused by arthritis and degeneration of the disc. It may result in pinching of the nerves going to the legs. Spondylolisthesis may cause both low back pain and radiating leg pain (Figure 2).
Spinal deformity also occurs among older patients. One type of deformity is a curvature of the spine, called scoliosis. This curvature develops in the spine because of arthritis and degeneration of the discs. This deformity may cause pain and spinal imbalance. Both spondylolisthesis and scoliosis can be diagnosed with x-rays taken in the doctor's office (Figure 3).
The conditions mentioned thus far are generally chronic, non-life-threatening conditions. Infrequently, a more serious problem can occur in the spine, such as a tumor or infection. Symptoms of these conditions include unrelenting pain, even with bed rest; unexplained weight loss; unusual bleeding in the urine or bowel movements; and fevers and night sweats. If you have these symptoms, you should contact your doctor immediately.
The initial treatment of these conditions (except for infection or tumor) is usually nonoperative.
Exercise is helpful in treatment. Your physician may recommend specific exercises aimed at strengthening the muscles around the spine. These exercises are often done under the guidance of a physical therapist. Also, low-impact aerobic conditioning through activities such as walking, riding a bicycle, or water exercises may be beneficial.
Medications may be helpful. Arthritis medications (also called nonsteroidal anti-inflammatory drugs) can help with degenerative spinal conditions. Some of these medications may be obtained over the counter, including acetaminophen, ibuprofen, and naproxen. Your physician may also prescribe mild pain-relieving medications for acute flare-ups of an aching back.
Another important part of treatment is lifestyle modifications. In other words, "if it hurts, don't do it." Lifestyle modifications include avoiding repetitive bending and twisting activities, heavy lifting, and long periods of sitting or standing.
Your physician or a physical therapist can instruct you in proper body mechanics. Proper lifting techniques can limit the flare-ups of back pain. You should hold heavy objects close to your body and squat at the hips and knees rather than bending at the back when lifting. Proper posture will also help prevent bouts of back pain. When sitting or driving for long periods, you should take frequent short breaks to walk around and stretch. This activity improves the circulation to the spinal structures (Figure 4).
Occasionally, your doctor may prescribe a back brace or support to treat your back. A brace can help with back pain and can prevent further injury. Because wearing a brace too much can cause muscular weakness, we generally tell patients to limit their brace wearing to eight hours per day.
Sometimes, when these noninvasive treatments are unsuccessful in relieving pain, cortisone (steroid) injections into the spinal canal (lumbar epidural steroid injections) or into the joints of the spine (facet blocks) can be beneficial. These injections can relieve the pain of spinal stenosis or facet arthritis. The relief may be temporary, though. The effect of these injections may last several weeks or several months.
Most often, spinal disorders or diseases respond to nonoperative treatment. Sometimes, however, when pain persists despite these treatments, surgery may become necessary.
In cases of spinal stenosis, the nerves may be pinched because of enlarged arthritic facet joints, bone spurs, or bulging discs. An operation called a laminectomy can successfully remove the impingement on the nerves and relieve the pain. This operation entails unroofing the spine and removing bone spurs or disc material that is pinching the nerves. Typically, this surgery lasts for one to two hours, and patients may begin walking again on the day after surgery. On average, patients go home from the hospital in two or three days.
When spinal instability or a deformity is present, an operation called a fusion (or an arthrodesis) may be necessary to relieve pain and improve the patient's functioning. This operation entails removing bone graft from the pelvic bone and transferring it to the vertebra to be fused. Frequently, bone screws and rods may be applied to the spine to immobilize the vertebra or to correct a deformity. This operation may last for two to four hours. Again, patients are usually allowed to begin walking on the day after surgery. The hospitalization period for this surgery is on average three to five days.
In closing, when the "seasoned" spine develops pain or problems, many treatment methods, both nonoperative and operative, are effective in relieving pain and restoring normal function. Talk to your doctor about these treatments if you are having problems with your back.