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Most of us experience back pain at some time in our lives. Back problems are a very common reason for older adults to visit their healthcare provider. However, the back problems of older adults are often very different from those seen in younger people. For example, a slipped disk is a common cause of back pain in younger adults but is unlikely to occur after age 60. In older adults, back pain often becomes chronic, typically cycling between improving for a while and then coming back. Neck pain is also common among older adults. It is most commonly caused by tension in the neck muscles or problems with the spine in the neck area.
Several conditions can cause back pain in older adults, including cancer, infection, and degenerative conditions of the spine. Degenerative conditions are usually from wear and tear over time. Typical problems include the following:
Narrowing along the lower spinal canal The spinal cord sits within a bony canal formed by the backbones, or vertebrae. Narrowing within the lower part of this canal is called “lumbar spinal stenosis.” This narrowing can be caused by bony growths that interfere with or obstruct the canal. These growths develop in response to chronic wear, a protruding disk, or thickening of ligaments along the spine. The result is pain in the back or the legs. The pain increases when standing or walking, and decreases when sitting, bending forward, walking uphill, or lying in a flexed or “bent” position. Walking with an assistive device, such as a cane or walker, or with a shopping cart, also tends to lessen the pain. Instability of the lower spine Over time, degenerative disk disease of the lower back may result in a lumbar spine that is unstable. This is especially the case when a problem at one disk is out of proportion to the other disk spaces. This instability can push some of the vertebrae forward, which pinches spinal nerves and results in severe pain in the back or down the back of the legs. The pain usually comes on suddenly, often after a quick movement or substantial bending of the lower back. This pain usually lasts only minutes to hours but returns often and with changes in position. Sciatica is pain and inflammation of the sciatic nerve. It usually causes a sharp, cutting pain that is felt from the buttock down the back of the leg to the foot. Alternatively, the pain can be felt in only one or a few isolated spots within these areas. There are two common patterns of sciatic pain in older adults. In some people, the pain comes on only with standing and walking, which may limit the person’s ability to walk long distances. This type of sciatica is most commonly caused by a narrowing along the lower spine. In other people, the pain may come on suddenly while the person is not moving and is then made worse by suddenly changing position (eg, getting out of a bed or chair). This sudden and persistent pain usually goes away on its own in several weeks. Fractures of the backbones, or vertebrae, in the mid to lower back are a common cause of back pain in older adults. These fractures are typically caused by osteoporosis, which thins the bone in the vertebrae and makes them more likely to break (see also Osteoporosis). Pain begins suddenly and is felt deep at the point of the fracture, but may also travel to the side, abdomen, and legs. The area over the involved vertebra is often very tender. The pain from a sudden vertebral fracture usually lasts from 2 weeks to 2 months. Pain usually gets worse when standing and walking, and gets better by lying down. People often have trouble walking for about 2 weeks, and their activity is limited for about a month. Lower back pain in older women may also be due to osteoporosis and fractures in the lower part of the pelvis. Pain often comes on suddenly and usually involves the lower back, although it can also be felt in the buttocks or hip area. The pain usually goes away on its own in 4–6 weeks. The prognosis for recovery is excellent, with no lasting nervous system problems. Back problems can also be caused by other conditions, including some types of cancer, infection in the backbones or spinal column, or even an aneurysm, which is a bulge in a weak area of the wall of a blood vessel. The chance of cancer as a cause of back pain increases in people over 50 years old, in people who have a history of cancer, and in people with pain that lasts longer than a month. Infection is also more common in people who are on hemodialysis, or who have an indwelling IV catheter, a history of recent or chronic urinary tract infections, or a history of intravenous drug abuse. When backaches are caused by these underlying conditions, the pain usually gets steadily worse over several days to weeks and typically is not related to being in certain positions. Urgent warning signals that require immediate evaluation by a physician are pain in the upper part of the back, fever, pain going down below the knee, difficulty walking, significant pain after a fall, and loss of bowel or bladder control. Because of the risk of spinal cord problems, an emergency evaluation is warranted for any person known to have cancer who also experiences back pain. Diseases of the hip can also cause pain in the back and leg, which resembles the pain of back disease. Back disease is more likely to cause pain when moving from lying down to sitting up, or when bending or stooping. Hip disease causes pain after sitting for a long time or when moving from sitting to standing up. Your healthcare provider will ask questions about the type of pain you are feeling and how long you have had the pain. This can help to find out the specific type of back problem or if another condition is involved. During the physical examination, you will probably be asked to bend your back forward, backward, and from side to side. The joints in your feet, legs, and hips will be checked for their range of motion. This is to see if the back pain is being caused by problems with the muscles, nerves, or joints in these areas. Your healthcare provider will also watch you get out of a chair and walk as one way to check for limps or other walking problems (see also Problems with Walking). You will probably also have X-rays taken of your back, and your healthcare provider may also recommend more sophisticated imaging tests, such as an MRI or CAT scan. These imaging techniques can identify spinal narrowing, possible instability, and other problems with the anatomy of the back. However, some problems with the anatomy of the spine that do not cause pain are common in older adults, and most older adults without back pain also have some of these anatomy problems. Therefore, although an anatomy problem may be found on an X-ray or an MRI, it may not be the source of the pain. This means that making a diagnosis and developing a treatment plan and prognosis are all difficult. Because low back pain usually produces muscle spasms, the basic treatment consists of rest and pain relievers. If the pain does not resolve in a few weeks, further medical evaluation should be done. Backache caused by infections, tumors, or aneurysms is treated by treating the specific underlying cause. As soon as the initial symptoms lessen, a gentle exercise program can help strengthen the back and stomach muscles, which will improve the stability of the spine. A water exercise program is ideal because rehabilitation is rapid and the change of hurting the back again is low. Walking in chest-high water and performing the flutter kick are two simple water exercises that are very helpful. Back braces (eg, metal or plastic corsets) can also be used to prevent the lower spine from moving. Surgery may be considered in cases of severely pinched nerves, but it does not always help. If persistent pain is caused by spinal instability, surgery that fuses vertebrae together can limit motion and decrease the instability and pain. Many older adults with lumbar spinal stenosis get long-term benefits from surgeries that relieve pressure on the spinal cord (eg, laminectomy) and stabilize the spine. A relatively new treatment for vertebral fractures due to osteoporosis is called vertebroplasty. In this procedure, bone cement is injected into the collapsed vertebra. The long-term benefit of this procedure is unknown. Other less traditional therapies, such as acupuncture or corticosteroid injection, have not been consistently helpful. Changes in the spine in the area of the neck (ie, the cervical spine) due to normal wear and tear are seen on neck X-rays in virtually everyone over the age of 65. Usually, there is no pain or disability. However, three conditions do commonly cause neck pain from pressure on the spine or nerves in the neck: People with these spinal problems often wake up in the morning with neck pain. The pain can also travel into the shoulders and arms. Fully turning the neck is difficult, making certain activities (such as backing an automobile out of a driveway) painful. Compression of the spinal cord Compression of the spinal cord in the neck by bony growths can result in weakness in the legs and an urgent and frequent need to urinate. Because the course of this condition is variable, specific recommendations for treatment are difficult to make. Many people improve very slowly despite significant changes on X-rays. Pressure on a nerve root in the neck is commonly referred to as a pinched nerve. This can be caused by several things, including bony growths that press against the nerves where they exit from the spinal column and nerve compression by a slipped disk. Symptoms of a pinched nerve can include the following:
Symptoms often go away on their own in 3–6 weeks. If arm weakness continues or gets worse, further medical evaluation should be done. When a disk in the neck (ie, a cervical disk) ruptures or “slips,” it puts pressure on the spine (see Figure). This results in pain in the neck, shoulder blades, and upper shoulders that is sometimes confused with a muscle spasm. People with this condition have pain and limited motion with some, but not all, neck movements. If the nerve roots are affected, there may also be pain and weakness in the muscles associated with these nerves. Neck pain can also be caused by underlying conditions, such as inflammatory conditions of the joints (eg, rheumatoid arthritis) or muscles. Inflammatory conditions are characterized by morning stiffness and general symptoms such as fatigue, fever, and weight loss. Other muscles or joints elsewhere in the body may also be painful. Affected people do not have the characteristic physical findings of people with the spinal disease discussed above. Neck pain is primarily evaluated by history and physical examination. The neck is manipulated through four types of movement: turning to the right, turning to the left, flexing (or bending) forward, and extending backward toward the back. Spinal problems (eg, slipped disk or pinched nerve) are suggested by a range of motion in the neck that is more on one side than on the other in some (but not all) of these movements, and by weak arm muscles associated with the nerves that come off the spinal cord in the neck area. X-rays, MRIs, and CAT scans are commonly used to evaluate neck pain, but they do not always show a clear diagnosis. Many older adults have visible abnormalities of the spine in the neck area that do not cause pain or disability. Problems with the spine or nerves in the neck have been treated using many different approaches, including the following:
As a rule of thumb, simple treatments such as collars to keep the neck from moving are tried before more aggressive treatments are considered. Most pain and muscle weakness gets better within 4 weeks. If muscle weakness lasts longer than 4 weeks, further evaluation should be done. Aggressive surgery for neck problems is risky and the results are often inconsistent. Therefore, the decision to operate depends greatly on how severe the symptoms are and whether or not they are getting worse. |
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Published: 11/4/2005