Conditions of the Aging Spine

Osteoporosis & Compression Fractures

Osteoporosis is a decrease in bone mass, more commonly seen in women during the post-menopausal period. The bone mass decrease includes both the mineral component (e.g., calcium and phosphorus) and the organic component (e.g., protein) of bone. About 15 million to 20 million people have osteoporosis, and among them, more than 500,000 suffer spinal fractures as a result each year. These fractures can occur with minimal trauma such as a fall to the ground, or no trauma at all.

Symptoms & Imaging Evaluation

Back pain is the most common symptom of osteoporosis. Back pain and other symptoms of osteoporosis – like infections, other metabolic bone diseases, and benign or malignant bone tumors – can mimic the symptoms of other conditions. That is why imaging evaluation is crucial in confirming a diagnosis of osteoporosis, such as:

• X-rays show wedge or compression fractures of the vertebrae
• MRI or CT scans can further evaluate fractures
• Bone density tests confirm the presence of osteoporosis in most instances
• Bone biopsy confirms osteoporosis in some cases

Treatment Options

Fortunately, most spinal fractures due to osteoporosis are successfully treated with just medication to control the pain, but the underlying osteoporosis should also be addressed. The treatment of osteoporosis itself is rapidly evolving.

Nonoperative Treatment

Some of the therapies used to manage osteoporosis are:

• Bisphosphonates to help maintain and possibly increase bone mass
• Back braces to help control pain and may thwart scoliosis and/or kyphosis from worsening. Although braces usually do not correct the wedging of the bone, they do support the spine and may decrease secondary muscle spasm.
• Calcitonin to slow the breakdown of the minerals in bone.
• Combinations of calcium, vitamin D, and estrogen, though controversial, are still used.

Operative Treatment

May be necessary to control pain, in rare instances, to stabilize the structure of the spine, or decompress the nerve roots or spinal cord. New techniques to treat the problem of compressed vertebrae include:

• Vertebroplasty involves an injection of bone cement into vertebrae to improve the strength of the bone.
• Kyphoplasty, similar to vertebroplasty, except that a balloon is inflated in the vertebra to create a space before the filling with bone cement. Both procedures require at least sedation and local anesthesia but sometimes require general anesthesia. With both procedures, very tiny incisions are made under x-ray control. As with any other surgical procedure, there are certain risks.

Osteoarthritis & Related Conditions

Degenerative Discs & Facet Joints

Degeneration of the discs and the small joints of the spine (facet joints) is generally a normal part of the aging process.

Symptoms & Diagnosis

Degeneration is detectable by x-ray, but may not cause any symptoms. However, in some individuals, it can cause significant back and/or leg pain. In patients with advanced degeneration, x-rays show marked narrowing of the discs as well as arthritic changes in the facet joints. The arthritic changes in the facet joints may cause narrowing of the space where spinal nerves are located, called stenosis. Stenosis can result in leg pain, or what many lay people refer to as "sciatica".

Treatment Options

Nonoperative treatment

Usually effective in managing the symptoms of degenerative discs or facet joints, and includes:

• Exercise to improve muscle support of the back
• Anti-inflammatory medications
• Braces
• Bed rest for a short time of one or two days for an acute episode of lower back pain for pain control (with gradual return of activities as soon as possible)

Operative treatment

May be required to alleviate pain associated with severe and progressive degenerative changes. Potential surgeries are:

• Spinal Fusion (the connection of two vertebra) with (hooks, rods, and/or screws) or without, and the use of bone grafts or bone graft substitutes to allow the two vertebra to weld together. The complete healing of a fusion can take 3-6 months and heals in a similar way as a broken bone.
• Posterior Lumbar Laminectomy/Decompression removes part of the vertebral layer and facet joints to reduce pressure on the nerves in the spine and the associated pain.

Spinal Stenosis

As arthritis or disk degeneration and facet arthritis worsens, the spinal canal (the space which contains the spinal cord and nerve roots) can narrow—causing stenosis. During the narrowing, a large ligament (ligamentum flavum) that crosses the space between 2 vertebrae can shorten and become relatively thicker. The thicker ligament, the arthritis in the facet joint, and the narrowed disk space puts added pressure on the nerves in the spinal canal.

Symptoms

The constriction of the spinal canal, or stenosis, produces symptoms known as neurogenic claudication. The patient can have leg pain while walking and standing (and is usually relieved by sitting or lying down). The constriction around one or two nerves can cause leg pain known as radiculopathy. Worsening of pain varies with position, but may be relieved by lying down.

Imaging Evaluation & Diagnostics

Pain from spinal stenosis must be differentiated from similar pain caused by circulatory problems, arthritis of the hips, or diabetic nerve problems through one or more of the following diagnostic tools:

• Computerized tomography (CT) for initial diagnosis
• Magnetic resonance imaging (MRI) scans when further diagnostic investigation is needed
• EMG and nerve conduction tests can differentiate this condition from diabetic nerve involvement

Treatment Options

Nonoperative Treatment

• Anti-inflammatory medicines
• Exercise
• Physical therapy
• Local anesthesia or steroids injections in muscles and ligaments
• Epidural in the spinal canal (near specific nerve roots)

Operative Treatment

Surgical decompression of the involved vertebrae allows patients to walk farther and stand longer without pain.

• Decompression surgery removes the roof of the spinal canal (laminectomy) and enlarging the spaces where the nerve roots exit the canal (foraminotomy). The result is decompressed nerve roots and pain relief.
• Vertebral fusion may be necessary (often in conjunction with decompression surgery) if instability is present. The spinal fusion joins together and heal spinal segments fusing bone, either from the pelvis (iliac crest) or from the bone bank (donated bone). In the majority of cases, a metal implant consisting of screws and rods is used to help maintain stability at these segments while the fusion heals.

The hospital stay is generally shorter if spinal fusion is not performed and a bit longer if it is. In either case, particularly if a patient’s condition had debilitated rapidly preoperatively, a short stay in a rehab facility to regain strength and mobility may be needed. The actual details of post-discharge care, resumption of normal physical and athletic activities, driving, and the possible use of a brace will be provided by the patient's surgeon.

Herniated or Ruptured Lumbar Disc

Herniated discs most commonly arise in patients ages 20 to 50 years, but can occur at all ages. In older patients, they may again be associated with arthritis and nerve root compression.

Symptoms

Typically, most people will have an occasional episode of low back pain not necessarily associated with a traumatic event and will subsequently develop nerve-related leg pain, commonly known as sciatica. If these symptoms don’t resolve in several weeks, a physician should be consulted to see if the pain is a result of a disc rupture or herniation. Discs rupture and herniate because of degeneration and tears in various parts of the disc. In addition to low back pain and sciatica, patients with a severely ruptured or herniated disc may experience loss of bladder or bowel function and progressive leg weakness.

Imaging Evaluation & Diagnostics

If a patient has symptoms of a herniated or ruptured disk, a magnetic resonance imaging (MRI) scan or a computerized tomography (CT) scan should be performed to identify the abnormality.

Treatment Options

Non-Operative Treatment

Self-limited symptoms usually respond well to the following:

• Restriction of activity
• Non-steroidal anti-inflammatory medications
• Short periods of bed rest
• Oral steroid medications, still viable and used to treat the sciatica, are often associated with significant complications and should be used for brief periods, typically 5-7 days.
• Epidural in the spinal canal (near specific nerve roots)
• Exercise and physical therapy if pain is particularly severe. If the symptoms decrease, gradual return of full activities may take about 2 - 6 weeks.

Operative Treatment

If 6 weeks to 3 months with non operative measures does not produce symptom improvement, or if leg pain or weakness persists or worsens, surgical treatment may be suggested. The most common procedure for this condition is a discectomy in which a small incision is made in the back and the herniated portion of the disc is removed. Relief of symptoms is often quite dramatic. Healthy patients can have this surgery in an outpatient setting, but occasionally the side effects of anesthesia and pain medication used postoperatively require admission to the hospital for a 1 to 2 days. After the surgery, some recovery is necessary, but gradual return to full activities is the rule. The time it takes to return to work and sports activities varies and should be discussed with the patient's surgeon.

Cervical Degenerative Disc Disease

Neck pain and stiffness frequently occur in the aging spine. This is due to arthritic changes in the joints and degenerated discs, often revealed through regular x-rays.

Symptoms & Diagnostics

When neck pain is associated with pain and/or numbness or weakness in the shoulder, arm, or hand, further workup may be needed, as these symptoms indicate pressure on the spinal cord or one or more nerve roots. Severe spinal cord pressure in the neck may cause symptoms of arm and leg weakness, imbalance, and problems with the hand use, such as buttoning shirts, and handwriting. Evaluation includes the following diagnostic measures:

• Thorough neurologic examination
• Imaging using an MRI and/or CT scan.

Treatment Options

Nonoperative Treatment

Initial treatment can consist of any of the following:

• Immobilization with a collar
• Non-steroidal anti-inflammatory medications
• Physical therapy

Operative Treatment

If the symptoms are significant and persistent after nonoperative measures and/or a significant neurological deficit is apparent, surgical treatment is often necessary.

• Anterior cervical discectomy and fusion is most commonly performed for cervical degenerative disc disease and can also include removal of the degenerative bony spurs that occur around the border of the discs. The fusion is performed with either bone from the pelvis (iliac crest) or from the bone bank (donated bone), and the vertebrae are usually fixed together using a metal plate and screws.
• Posterior decompression and stabilization might be performed as an alternative to anterior cervical discectomy, if multiple levels are involved. This procedure uses plates and screws, and may also require a fusion.