Low Back Pain In Older People

Intervertebral disc degeneration occurs with aging which causes a progressive deterioration of the adjacent bone, muscles, zygapophyseal (facet) joints and ligaments. It is difficult to differentiate normal aging from pathological processes. Genetics accounts for 50-70% of disc degeneration variability

 

Up to 75% of the total axial compressive load is carried by the anterior column

The intervertebral disc can withstand 2.8 to 13.0kN of compressive force

Intradiscal proteoglycan content progressively declines with advancing age

Vertebral endplate permeability decreases beginning in the second decade of life

Changes first affect the endplate, followed by the nucleus pulposus and the annulus fibrosis over several spinal levels

Calcified nucleus pulposus herniation through the endplate is called a Schmorl’s node

Degeneration of the normally avascular intervertebral disc allows blood vessels and nociceptive fibers to penetrate the disc introducing inflammatory mediators into the previously avascular space.

The degenerative cascade describes the loss of hydrostatic pressure within the nucleus pulposus resulting in increased compressive loads on the annulus fibrosis and zygapophyseal (facet) joints.

Intervertebral disc injuries never fully heal.

Osteophytes increase the load bearing surface area.

The aging ligamentum flavum looses elastin content causing anterior bulging that can contribute to central spinal stenosis.

Loss of dorsal extensor muscle and the abdominal flexors muscle equilibrium.

Treatment can include:

Nonsteroidal anti-inflammatory medications such as naprosyn or ibuprofen

Analgesics

Acupuncture has been described to be helpful

Lumbar stabilization focuses on stabilizing the painful pathologic region with muscular development and movement patterns

Flexion or extension bias in stretching and strengthening

Mechanical evaluation to determine a direction of preference

Heat, cold, ultrasound, and transcutaneous electrical nerve stimulation have been used for symptomatic relief of pain and muscle spasms.

Trigger point injections

Epidural steroid injections for symptoms related to radiculitis, radiculopathy or stenosis

Surgical decompression and/or fusion for unrelenting pain

 

References

Benoist M. Natural history of the aging spine. Eur Spine J. 2003 Oct;12 Suppl 2:S86-9.

Panagos A. Rehabilitation Medicine Quick Reference-Spine (ed. Buschbacher R.M.) New York: Demos Publishing; 2010. p. 2-3.

Kirkaldy-Willis WH, Wedge JH, Yong-Hing K, Reilly J. Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine. 1978 Dec;3(4):319-28.

Andre Panagos, MD

820 Second Avenue, Suite 6D

New York, NY 10017

Tel. 212-682-6970, Fax. 212-682-6979

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