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Gwendoline McLaughlin
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1 WINTER 2004 Chairman s Column By Edward C. Benzel, M.D. Chairman, Cleveland Clinic Spine Institute This edition of The Spinal Column is devoted to an increasingly prevalent and important issue in all of our practices the management of the aging spine. We write about two important topics: back pain in the elderly, with a brief description of our new Mature Spine Clinic; and the management of an often missed or undiagnosed clinical entity, cervical spondylotic myelopathy. The presence of the latter is often attributed to simply getting old. However, from both medical and surgical perspectives, getting old is an unacceptable diagnosis when we have reasonable therapeutic modalities that can improve the patient s quality of life. In the year 2000, 20 percent of all Americans were older than age 65 (33 million people). Twelve percent of them were older than the age of 85. The census bureau predicts that in the year 2030, there will be 65 million Americans age 65 and over, with people commonly living into their 80s, 90s, and 100s. Unfortunately, the human spine is designed to function well only until approximately age 35, when wear and tear and degenerative processes often begin manifesting themselves. Today, the management of the symptomatic aging spine is fraught with difficulty (challenging from a clinical efficacy perspective) and complicated by uncertainty (management strategies are often unproven and hence unpredictable). The expanding elderly population will only compound these issues. The Cleveland Clinic Spine Institute is aggressively pursuing unique medical (non-operative) The census bureau predicts that in the year 2030, there will be 65 million Americans age 65 and over. management strategies for older patients with spinal disorders. Studies regarding the use of new and innovative medications are in progress. The Spine Institute also is addressing the problem with a wide variety of surgical strategies. These include minimally invasive approaches to decompression and fusion, stabilization procedures for the degenerated spine, deformity correction procedures for the deformed and painful spine and decompression procedures for cervical and lumbar stenosis. Triage is an extraordinarily important issue in this changing landscape. The Cleveland Clinic s patient care motto is the right patient, to the right doctor, the first time. This is a critical concept, particularly for the elderly who often cannot afford nor endure trips to multiple physicians in search of the one physician who may provide the help they seek. The Spine Institute s new triage methods streamline this path for patients. Society s burden (economic, physical and emotional) of health care delivery to our aging population, including spine pathology management, is increasing at an alarming rate. Well developed programmatic, strategic niches, such as those employed at The Cleveland Clinic and in our Spine Institute, are critical, not only to the health and well-being of our patients, but also to the viability of the health care delivery system itself. Our programs in both medical and surgical arenas directly address the issues of the aging spine. We feel confident that these efforts will help us care for our patients ever more effectively now and in the future. For additional information about the Spine Institute, please feel free to contact me at 216/ , or our administrator, Kathy Huffman, at 216/ To refer patients, call 216/ or 800/ , ext

2 Back Pain in the Elderly By Daniel Mazanec, M.D. Vice Chairman, Cleveland Clinic Spine Institute The evaluation and management of back pain in older patients is more complex and challenging than in younger patients. Low back pain in the elderly has a much wider range of possible diagnoses, including a much higher incidence of malignant or visceral causes. The overriding objectives in assessing the older person with back pain are to differentiate common musculoskeletal pain from serious visceral or nonspinal pain; identify patients with primary radicular pain; identify comorbidities; and recognize complicating psychosocial issues. Classifying the pain into acute (fewer than four weeks in duration), sub-acute or chronic (beyond four weeks in duration), and pain with associated leg pain is useful in planning the workup. Acute causes: Lumbar strain/sprain Osteoporotic fracture, vertebral or pelvic Abdominal aortic aneurysm Subacute/chronic: Degenerative disk and joint disease (mechanical degenerative) Malignancy Fibromyalgia Polymyalgia rheumatica Parkinson s disease Paget s disease Diffuse idiopathic skeletal hyperostosis (DISH) Predominant leg pain associated with back pain: Trochanteric bursitis Osteoarthritis of the hip Lumbar canal stenosis General References Evaluation Evaluation begins with a careful history and physical examination, even more critical in older patients because of the broader differential diagnoses and higher frequency of comorbid conditions. Four areas should be assessed when taking the history of the older patient: Characteristics of the pain Red flags for cancer Nonspinal medical problems Psychosocial factors Pain characteristics Location: Pain radiating below the knee strongly suggests lower lumbar radiculopathy, while pain localized to the upper anterior thigh or groin suggests upper lumbar radiculopathy or hip disease. Pain over the lateral hip may implicate trochanteric bursitis. Onset: Knowing whether the pain is acute or insidious in onset helps narrow the differential diagnosis. Degenerative mechanical pain typically has a gradual onset, while pain secondary to an osteoporotic compression fracture is usually sudden and severe. Positional change: Malignant or visceral pain is usually constant, irrespective of position, while mechanical pain often subsides when the patient is supine and worsens with movement. Most patients with leg symptoms due to spinal stenosis are more comfortable sitting than standing. Red flags for cancer Malignant diseases are the cause of back pain in as many as 7 percent of patients over age 50. Consider these red flags: Ettinger WH, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The fitness arthritis and seniors trial (FAST). JAMA 1997;277: AGS Panel on Chronic Pain in Older Persons. The Management of Chronic Pain in Older Persons. JAGS 1998;46: Prior history of cancer Pain that is usually constant Pain at night that disturbs sleep Unexplained weight loss of more than 10 pounds in three months Back pain that progresses despite appropriate treatment Nonspinal medical conditions Certain medical conditions may confound the diagnosis and affect treatment choices. Diabetes-related peripheral vascular disease, diabetic neuropathy or polyradiculopathy may superficially mimic the neurogenic claudication of spinal stenosis. Ischemic heart disease and congestive heart failure, like diabetes, places patients at increased risk of NSAID-related nephrotoxicity and gastrointestinal toxicity. Psychosocial factors Nonorganic issues, including psychologic ones, often complicate the management of low back pain in patients of all ages. For a frail, elderly patient, the onset of back pain may seriously compromise an already marginally functional status, thereby threatening independence. The needs of an ill or disabled spouse may prevent the older adult with back pain from seeking or complying with treatment. Even mild cognitive impairment (e.g., dementia) significantly limits therapeutic choices. Mental and physical function must be carefully assessed in the elderly patient and may necessitate extended social services. Physical examination The examination of the elderly patient includes observations and maneuvers performed in all age groups, with certain areas receiving special attention. The physical examination should include careful observation of posture, looking for increased thoracic kyphosis, characteristic of vertebral compression. In- 2

$Causes of back pain in the elderly Spinal stenosis Vertebral compression fracture Buckling of ligamentum flavum creased muscle tone and stiffness may suggest Parkinson s disease.$

3 Causes of back pain in the elderly Spinal stenosis Vertebral compression fracture Buckling of ligamentum flavum creased muscle tone and stiffness may suggest Parkinson s disease. Assessing distal pulses is important in distinguishing vascular from neurogenic claudication. Imaging Imaging studies must be interpreted cautiously in the older patient because irrelevant, false-positive findings increase with age. Spine radiographs only need to be performed in persons older than 50 years when symptoms are unimproved by four weeks. Unless malignancy or infectious causes are suspected, CT or MRI is not indicated in most older patients with back pain. Both demonstrate abnormalities in at least 50 percent of asymptomatic persons older than 40 years, and the likelihood of such abnormalities increases with age. Abdominal aortic aneurysm Malignancy (sagittal section) Degenerative disk disease Bony osteophytes on facets and foramen Forestier disease (diffuse idiopathic skeletal hyperostosis) Elderly spine with flattened lumbar curvature and forward cervical section Treatment Options The most common cause of chronic back pain in the elderly remains nonspecific multilevel degenerative disk and joint disease with associated myofascial strain or sprain. Treatment is directed at relief of symptoms and improvement in function. Pharmacological and nonpharmacological approaches may be combined for best results with least risk of toxicity. Treating associated depression and poor sleep can help improve pain and mood. Surgery is rarely appropriate. For acute back pain, physical activity shortens the duration of symptoms. But for older patients with chronic back pain, the role of exercise is not well studied and there are safety concerns due to patients comorbid conditions and general frailty. Passive modalities, such as heat, ultrasound, massage or ice, may provide temporary relief. Participation in group exercise activities has not been studied, though it has been shown to benefit older persons with osteoarthritis of the knee. Occupational and physical therapists play an important role in educating patients about their back pain. Chiropractic manipulation, particularly highvelocity manipulation, may risk spinal fracture in the older patient. Lumbar support can improve symptoms in patients with mechanical, degenerative back pain. An appropriately sized cane may assist coexisting hip or knee osteoarthritis and can relieve some back symptoms. Transcutaneous electrical nerve stimulation (TENS) has been shown no more effective than placebo. The neutraceuticals glucosamine and chondritin have in some trials been shown as effective as NSAIDs. However, long-term toxicity has not been studied, and concerns remain about contamination and impurities. Acetominophen should be the firstline analgesic for most older patients with mechanical degenerative back pain. The risk of toxicity is the greatest factor in deciding whether to prescribe NSAIDs, and they are strongly contraindicated in older patients with a history of congestive heart failure or ulcers. Cyclooxygenase- 2 (COX-2) inhibiting NSAIDs are less toxic to the GI system. Long-term opioid maintenance therapy is gaining acceptance for carefully selected and monitored patients with chronic nonmalignant back pain. Finally, tricyclic antidepressants can help improve the quality of sleep and reduce pain in some patients. New Mature Spine Clinic Serves Seniors with Back Pain Recognizing the challenges of diagnosing and managing back pain in the elderly, the Cleveland Clinic Spine Institute has launched the Mature Spine Clinic. The goal of the clinic is to provide comprehensive long-term medical and nursing management of older patients with chronic degenerative spine disease. A multidisciplinary team provides care, which includes orthotics for bracing, physical and occupational therapy to improve mobility and maximize independent functioning, dietary supplementation, and opioid and non-opioid analgesia as appropriate. Special attention to evaluation and management of osteoporosis is also provided. As the program grows, the clinic will facilitate shared visits (group appointments) to enhance care and education for this special population. Led by a spine specialist, nurse practitioner and orthotics specialist, the Mature Spine Clinic provides care for patients 60 and older. The clinic is held on Wednesday mornings and Thursday afternoons. To refer patients, call 216/444-BACK (2225). 3

Cervical Spondylotic Myelopathy Requires Prompt Surgery By Thomas Mroz, M.D.

Cleveland Clinic Spine Institute With widely varying signs and symptoms and no single pathognomonic finding, cervical spondylotic myelopathy presents a diagnostic challenge.

Cervical spondylotic myelopathy, the result of narrowing of the cervical spinal canal by degenerative and congenital changes, is the most common type of spinal cord dysfunction in patients older than

4 Cervical Spondylotic Myelopathy Requires Prompt Surgery By Thomas Mroz, M.D., and Richard Schlenk, M.D. Cleveland Clinic Spine Institute With widely varying signs and symptoms and no single pathognomonic finding, cervical spondylotic myelopathy presents a diagnostic challenge. Yet making the correct diagnosis is critical because appropriate surgical intervention is associated with improved outcomes. Cervical spondylotic myelopathy, the result of narrowing of the cervical spinal canal by degenerative and congenital changes, is the most common type of spinal cord dysfunction in patients older than 55 years and the most common cause of acquired spastic paresis in the middle and later years of life. 1,2 Pathologic mechanisms Both static and dynamic mechanisms are involved in the pathogenesis of cervical spondylotic myelopathy. Static factors include congenital spinal canal stenosis (<13 mm anterior-posterior diameter); disc herniation; osteophyte formation in the vertebral bodies; degenerative osteophytosis of the uncovertebral and facet joints; and hypertrophy of the ligamentum flavum and posterior longitudinal ligaments. Dynamic factors are abnormal forces placed on the spinal column and spinal Spine configuration dictates surgical approach Lordosis (dorsal approach indicated) Kyphosis (ventral approach indicated) cord during flexion and extension of the cervical spine under normal physiologic loads. Trauma caused to the spinal cord by repetitive compression against an osteophytic bar during normal flexion and extension of the cervical spine is an example. C5 through C7, the region of the spine with the highest frequency of cervical spondylotic changes, also is the area in which the vascular supply is the most tenuous. 3 Cervical spondylotic myelopathy can also be caused by spinal cord ischemia. Pathologic findings that indicate a vascular mechanism include spinal cord necrosis and cavitation in gray matter. Insidious onset The onset of cervical spondylotic myelopathy is generally insidious, with long periods of fixed disability and episodic worsening. In one series, 3 symptom duration ranged from one week to 26 years. Almost half of patients presented with symptoms of more than one year in duration. Cervical spondylotic myelopathy causes a variety of signs and symptoms, and has no single pathognomonic finding. The first sign is commonly gait Straight (dorsal or ventral approach indicated) spasticity, followed by upper extremity numbness and loss of fine motor control in the hands. Other symptoms: Pain in the neck, subscapular area or shoulder. Numbness or paresthesia in the upper extremities, usually nonspecific. Sensory changes in the lower extremities. Motor weakness in the extremities. Gait difficulties ( spastic gait, hesitant and jerky). Myelopathic or upper motor neuron findings such as spasticity, hyperreflexia, clonus, Babinski and Hoffman signs, and bowel and bladder dysfunction. Lower motor neuron findings such as upper extremity hyporeflexia and atrophy. Diagnosis The differential diagnosis of cervical spondylotic myelopathy is quite broad. It is important to rule out multiple sclerosis and amyotrophic lateral sclerosis. Cervical spondylotic myelopathy does not affect the cranial nerves or the normal jaw jerk reflex, whereas the other disorders may. In addition, amyotrophic lateral sclerosis is a pure motor disease, therefore, sensation is unaffected. 2 Cervical spondylotic myelopathy may have motor findings similar to those of amyotrophic lateral sclerosis, in addition to sensory findings such as numbness or paresthesia in the upper extremities. Other disorders in the differential diagnosis include spinal cord tumors, syringomyelia, subacute combined degeneration, cerebral hemisphere disease, and peripheral neuropathy. Normal pressure hydrocephalus, which may have gait and bladder involvement, should also be considered. 4

5 The Next Big Thing? Radiographic studies The diagnostic workup of cervical spondylotic myelopathy often includes cervical radiographs, which may demonstrate osteophyte formation, kyphosis or subluxation. The most valuable tool, however, is MRI. Along with the ability to rule out a tumor or syrinx (a slit-like cavity in the spinal cord), MRI permits specific evaluation of the spinal cord, intervertebral discs, vertebral osteophytes and ligaments. 3 Surgery Cervical spondylotic myelopathy patients treated medically (i.e., with collar immobilization and traction) show continual progressive neurologic deterioration. One series of 1,355 patients treated conservatively revealed no improvement in 64 percent and neurological deterioration in 26 percent. In addition, patients with cervical spondylotic myelopathy are at an increased risk of spinal cord injury from relatively mild trauma. With decreased anterior-posterior diameter of the cervical spinal canal, the spinal cord has limited room to move. 3 Many traumatic cervical injuries are due to hyperextension, which results in maximal narrowing of the spinal canal. Early surgery can improve prognosis. Montgomery and Brower 2 found that the prognosis after surgery was better for patients with less than one year of symptoms, young age, fewer levels of involvement and unilateral motor deficit. Dorsal or ventral approach? Both dorsal and ventral surgical approaches are appropriate for cervical References 1. Small JM, Dillin WH, Watkins RG. Clinical syndromes in cervical myelopathy. In: Herkowitz H, Garfin SR, Balderson RA, et al, editors. The Spine. 4th ed. Philadelphia: W.B. Saunders Co., 1999: Montgomery DM, Brower RS. Cervical spondylotic myelopathy: clinical syndrome and natural history. Orthop Clin North Am 1992; 23: spondylotic myelopathy. Since no clinical study has demonstrated a significant difference in the outcomes of the two approaches, the choice is based on surgeon preference. The dorsal approach involves cervical laminectomy, while the ventral approach involves either discectomy at one or more levels with interbody fusion or one or more corpectomies with interbody fusion. Corpectomy typically involves cervical plating to provide stability until fusion occurs. Factors guiding the surgeon s decision: The relative location of the stenosis (dorsal vs. ventral). For patients with cervical spine stenosis that primarily results from dorsal compression, cervical laminectomy (dorsal approach) is better. For patients with ventral disc herniations and osteophytes, however, cervical laminectomy alone does not allow sufficient access to the ventral spinal cord. These patients may benefit more from a ventral decompression and fusion procedure. The alignment of the cervical spine 3. Gross JD, Benzel EC. Dorsal surgical approach for cervical spondylotic myelopathy. In: Camins MB, editor. Techniques in Neurosurgery. Philadelphia: Lippincott Williams & Wilkins, 1999: Benzel E. Cervical spondylotic myelopathy: posterior surgical approaches. In: Cooper PR, editor. Degenerative Disease of the Cervical Spine. Illinois: American Association of Neurological Surgeons, 1993: (kyphosis vs. lordosis). For patients with effective cervical kyphosis, dorsal decompression is associated with a high probability of failure. 4 In these patients, cervical laminectomy can worsen the ventral spinal cord compression by tethering the dural sac and its contents over ventral osteophytes, which leads to neurologic deterioration. 3 A dorsal approach in this situation may also lead to progressive kyphotic deformity and instability requiring repeat surgery and stabilization. For patients with effective lordosis, a dorsal approach is often optimal for spinal cord decompression, especially with dorsal compression. It should be noted that when compression is ventral (e.g., herniated nucleus pulposus), the decompression is optimally performed from a ventral approach, even if the cervical spine is configured in lordosis. Between kyphosis and lordosis is a gray zone in which the surgical approach is chosen on the basis of the biases and clinical judgment of the surgeon. 4 CCSI LOCATIONS For referrals, call 216/444-BACK The Cleveland Clinic s Main Campus Lutheran Hospital Euclid Hospital Independence Family Health Center Solon Family Health Center Strongsville Family Health Center Westlake Family Health Center 5

6 CCSI Clinical Trials The Spinal Column is published by the Cleveland Clinic Spine Institute to provide up-to-date information about the department s research and services. The information contained in this publication is for research purposes only and should not be relied upon as medical advice. It has not been designed to replace a physician s independent medical judgment about the appropriateness or risks of a procedure for a given patient. Co-Editor: Edward C. Benzel, M.D. Chairman, Cleveland Clinic Spine Institute Co-Editor: Daniel J. Mazanec, M.D., F.A.C.P. Vice Chairman, Cleveland Clinic Spine Institute Head, Section of Spine Medicine Marketing Manager: Yen Izanec Marketing Coordinator: Charmaine Jones Art Director: Doug Crouch Atrial using a unique medical approach to lumbosacral radiculopathy is seeking patient volunteers who meet the following criteria: Men or women age 18 to 55 years Leg pain diagnosed as sciatica lumbosacral radiculopathy of onset 2 12 weeks prior to study Pain severity at least 4 on a 0-10 analog scale Positive straight leg raise test Contact Dr. Mazanec at 216/ to refer a patient. Spinal Laminectomy vs. Instrumented Pedicle screw fusion (SLIP) study is a prospective, randomized multicenter trial that aims to determine if lumbar fusion improves surgical outcomes for patients with a specific type of back problem involving nerve compression (spinal stenosis) and one spinal bone slipping forward on another (spondylolisthesis). CCSI, which is one of six IRBapproved centers for the SLIP trial, is seeking patient volunteers who meet the following criteria: Men or women age 50 to 75 Diagnosis of spinal stenosis and grade I spondylolisthesis Patients with a history of lumbar surgery at the level of stenosis are excluded. More information about the trial is available at Contact Dr. Benzel at 216/ to refer a patient Euclid Avenue Cleveland, OH FIRST CLASS MAIL U.S. POSTAGE PAID CLEVELAND, OH Permit No For referrals to the Cleveland Clinic Spine Institute, call 216/444-BACK (2225)

Cervical spondylotic myelopathy: Make the difficult diagnosis, then refer for surgery

Cervical spondylotic myelopathy: Make the difficult diagnosis, then refer for surgery REVIEW CME CREDIT WILLIAM E. MCCORMICK, MD Department of Neurosurgery, The Cleveland Clinic MICHAEL P. STEINMETZ, MD Department of Neurosurgery, The Cleveland Clinic EDWARD C. BENZEL, MD Department of