Back pain in people over 65

The prevalence of back pain declines slightly after the age of 65. It is commoner in women. Severity, chronicity and disability may worsen with age although the results of studies are inconsistent.

Although the majority have non-specific back pain, most of which is due to degenerative disease, the incidence of specific back pain rises in comparison to younger people.

Degenerative disease of the spine

With advancing age, these changes are universal. However, even though the majority of the population have X ray evidence of degenerative disease of the spine by age 65, there is poor correlation with symptoms.

Spondylolisthesis is the forward movement of one vertebral body over the vertebral body beneath it. In older people the most common cause is degenerative change in the spine. It is usually an incidental X ray finding and does not usually cause a clinical problem. Symptoms, if present are usually non-specific and nerve root entrapment is uncommon. Occasionally it can cause narrowing of the spinal canal resulting in spinal stenosis.

Degenerative disease of the spine predisposes to spinal stenosis and prolapsed inter-vertebral disc (see relevant sections).

Metabolic bone disease

Osteoporosis is the metabolic bone disease of greatest clinical and economic significance in the elderly (see relevant section).

Paget’s disease (osteitis deformans) occurs in 3 percent of elderly people. It is caused by increased bone turnover. The resulting bone is larger than normal but is mechanically weak. It is usually asymptomatic. The most commonly affected bones are the skull, pelvis, femur and tibia and the lumbar spine. Any symptoms that occur depend upon the bones affected.

Symptoms arise from:

• Deformities and fractures in the weakened bone.
• Nerve compression by the expanding bone (for example the auditory nerve, resulting in deafness).
• Cardiac failure due to an increased blood supply to the affected bone.

Back pain due to Paget’s disease may be treated with analgaesics, but may warrant treatment with specific medication such as calcitonin and bisphosphonates (for example, etidronate).

Ankylosing Spondylitis

In the elderly, advanced spinal disease may result in fused or “bamboo” spine, spinal fracture, or spondylodiscitis, all of which result in significant reduction of spinal mobility.

Treatment includes physiotherapy, exercise, education and non-steroidal anti-inflammatory medication (NSAIDs) as this reduces discomfort and the risk of permanent deformity.

Neoplasm (Tumour/cancer)

The incidence of back pain caused by neoplasm increases with age. In one study, 7 percent of people with back pain over the age of 50 were found to have a neoplastic cause, either primary or secondary, compared with no cases of neoplasm in people under the age of 50.

Infection

Although uncommon, these are more common as a cause of back pain in the elderly.

People with infections of the spine are usually generally unwell. Treatment is usually with the relevant antibacterial agent, usually antibiotics.

Treatment of non-specific back pain.

Treatment of non-specific back pain is similar to that in younger people with some minor exceptions.