Peggers Super Summaries: The Aging Spine

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Octavia Wells
5 years ago
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1 Aging Spine: AGING PROCESS Osteopenia 10% of 50 year old males and 25% of 50 year females Disc dehydration Facet degeneration Soft tissue hypertrophy 2 0 deformity Leg pain worse than back pain from nerve root compression SPINAL STENOSIS 20% have concurrent PVD Causes o Bone OA of facets or vertebra Spondylolisthesis neoplasia o Soft tissues Ligamentum flavum hypertrophy Facet cysts Infections Iatrogenic from surgery o Discs Dehydration and decrease height Prolapse less likely in elderly as discs are stiffer o DISH diffuse idiopathic skeletal hyperostosis Spinal calcifications Neurogenic claudication vs vascular Neurogenic claudication Vascular claudication Numbness + - Bladder 12% - Pain in legs Leg give way Progressive with exercise Standing pain present relieved Walking uphill pain Decreases pain Increases pain Sexual + -/+ Myelopathy o Can occur concurrently with spinal stenosis

2 o Ask about numbness in upper limbs! o UMN signs Natural Hx o 70% stay the same o 15% get better o 15% get worse Examination o Decrease lordosis o Weakness LMN signs o Absent ankle reflex in 50% (although this is absent in 20% of pop anyway) Imaging o MRI o If spondylolisthesis try flexion and extension views to see how unstable Mx o Conservative Analgesia Activity modification Walking aids Epidural 10-15% temporary relief o Surgical Stenosis decompression 70% success INVOLVES o Undercutting Flavectomy o Laminotomy removing inferior aspect of superior lamina < 1/3 removed in order not to destabilise the facet joint o Forminotomy Fusion Instrumented ie with metal Non instrumented ie without metal Disc decompression 90% success Surgery complications o Dural tears o Infection o Epidural haematoma extreme lower back pain post op but can also develop slowly over 7-10 days o PE o Blood loss NON SPECIFIC LBP Overview o 4% of all GP consultations

3 o 90% improve at 6-8/52 o HOWEVER, ¾ still having some residual pain at 3 & 12/12 Diagnosis o Mechanical back pain (not radicular) o Arthritis o SIJ o Stenosis o Degenerative disc Non specific spinal back pain NSBP o Symptoms Back pain dominating symptom No radicular signs No red flags No deformity / inflammation (bloods) / no # / no infection / no tumour / no cauda equina o Causes Disc Spine Facets Muscle ligaments Red flags scan these o Past hx of cancer o ESR > 50 o Unwell / fever o Unexplained weight loss o Age < 16 o Known osteoporosis Pink flags when lots present also represents a red flag o Thoracic pain o Age <16 years >50 years o HIV At 6/52 what to review o Review diagnosis o Advice and education o Conservative no evidence that core stability is any better than the rest Drug Mx Exercise Manual therapy Acupuncture

4 Cognitive Process Profile (CPP) Stratifying patients by risk of chronicity o Keele et al Low risk advice Mediusm risk PT High risk psychology Spinal Stenosis: DESCRIPTION Verbiest described pain on walking / standing in back and legs in 1954 CAUSES Developmental o Short pedicles ie achondroplasia Acquired o Disc degeneration o Facet degeneration o Ligamentum flavum thickening o Osteophytes o Combination PATHOLOGY loss of sagittal balance canal decreases in diameter if extended critical diameter <14mm CLINICALLY back or leg pain on walking or standing relieved by sitting or squatting for typically >10 mins shopping trolley helps significant day to day variation lower limb fatigue / heaviness / give way 12% have bladder disturbance INVESTIGATIONS MRI CT or myelography if MRI contra-indicated DD PVD Hip OA Mx Conservative o Explanation o Analgesics o Walking aids

5 o Rucksacks for sagittal balance o Epidurals or nerve root injections Surgical o Decompressing Cauda equine Lateral recess Exit foramina o Stabilising If > grade 2 spondylolisthesis OUTCOMES 70% have good outcome 5% will regret o Nerve root damage o Cauda equine o Infections o Recurrence o 80 year olds have worse outcome Fairbank et al Spine 2002 o Mena exercise tolerance 420m o Stenosis 65m post op 200m o Thus none approach normality

LUMBAR SPINAL STENOSIS

LUMBAR SPINAL STENOSIS Always occurs in the mobile segment. Factors play role in Stenosis Pre existing congenital or developmental narrowing of the lumbar spinal canal Translation of one anatomic segment