Chapter 31 Back pain in the elderly

Case 31.1

History

Larry is a 71-year-old male, in seemingly good physical condition, but with longstanding low back pain with diffuse radiation to both lower extremities without specific nerve root distribution. The pain is bilateral, but somewhat worse on the right side of the lower back. It is of a chronic nature and accompanied by stiffness. It is less severe in the morning and increases during the day.

For several years Larry has had stiffness after sitting and getting up in the morning. Three years ago he had an acute case of sciatica, located to the left side. The sciatica gradually got better with medication. Eighteen months later and ‘back to normal’, he suddenly began to experience pain in both lower extremities, especially distally, after running. This was accompanied by numbness and paresthaesia.

These symptoms gradually worsened, and within a few months he could not walk back and forth to his mail box (about 200 meters), without sitting down or stopping to rest. His symptoms seemed to improve more rapidly when he assumed a squatting position or lay down, rather than standing still or sitting.

The back pain, on the other hand, was aggravated by flexion/extension in all planes, as well as long periods of standing and sitting. None of his symptoms seemed to be temperature sensitive.

Larry has also complained about neck and shoulder pains.

He had not been involved in any severe accidents or had any serious illnesses which required hospitalisation. He had been diagnosed with type 2 diabetes mellitus a few years earlier and suffers from haemochromatosis, which is controlled by giving blood every 3 months.

Questions

1. Using only this information, list the possible causes of Larry’s lower extremity pain. Justify your answer.

2. Why was Larry asked about the relationship of pain to external forces such as position, motion, heat, cold and draft?

3. What do you need to examine in this patient?

Physical examination

General	Larry is well built and appears healthy, and looks younger than his stated age. He had some difficulties getting up from the sitting position and has a somewhat staccato gait
Vitals	• Pulse rate/min	74
	• Respiratory rate/min	14
	• Blood pressure mm Hg	120/84
	• Height (cm)	185
	• Weight (kg)	85
	• BMI	25
	• Temperature (degrees C)	36.6
Back	• There was a decrease and/or flattening of the lumbar lordosis, but otherwise the spinal curvatures were within normal range • General decreased mobility in the spine was observed with: flexion and/or extension; lateral flexion bilaterally; rotation, especially towards the right side • Muscle tone was slightly elevated in the low back • On motion palpation there was limited joint movement in the lumbosacral region. Posterior–anterior (P–A) provocation in the area, especially over the sacroiliac joints and L3–L4 produced local pain and increased radiation to the lower extremities
Limbs	• Hip movement was within normal ranges • Muscle tone was slightly elevated in the lower extremities, muscle strength symmetrical and within the normal range • Posterior tibial pulse was weak, but symmetrical • Achilles reflexes decreased, but symmetrical • Patellar reflex normal • Lasegue’s test: 30 degrees right and 45 degrees left • Slight changes in sensory skin perception in the lower extremities, but with no dermatomal characteristics • No other neurological findings

Questions

4. What information can you obtain from these findings? Can you narrow your differential diagnosis?

5. Explain the significance of the following signs, in context of your differential diagnosis:

a increasing pain in lower extremities on movement and/or walking

b changes in sensory perception in the lower extremities

c increased pain and radiation on P-A provocation in the lumbosacral area.

6. Larry is referred to a medical practitioner. What investigations are required? Why?

Investigations

Magnetic resonance imaging (MRI) of lumbosacral area

Level L1/L2 and L2/L3 demonstrates normal relations. At L3/L4 there are slight degenerative changes in the intervertebral disc, but marked arthrosis in the articular processes and hypertrophic joint facets with thickening of the ligaments.

There is a marked broad based bulging of the intervertebral disc. Together this produces a marked spinal stenosis in this level.

It should be pointed out that there is a bulging from the medial facet joint on the left side that might represent a degeneration cyst although this is not indicated by the signals.

In level L4/L5 there are marked degenerative changes in the intervertebral disc as well as height reduction and a broad based bulging of the disc. There is minimal arthrosis in the articular processes. Centrally, there is satisfying opening/room, but there is narrowing in both the recesses and root canals bilaterally.

In the L5/S1 level there are marked degenerative changes in the intervertebral disc with marked height loss and broad based bulging of disc tissue, most marked in the root canals. In combination with degenerative deposits, this causes foraminal stenosis bilaterally.

Conclusion: marked spinal stenosis L3/L4, reduced space in recesses and nerve root canals L4/L5, and narrow nerve root canals bilaterally L5/S1.

Ultrasound

Ultrasound examination of the circulatory system in the pelvis and lower extremities showed age related changes such as minor calcifications epically in the aortic bifurcation, but defined as being within normal ranges.

Question

7. What is the most likely diagnosis, based on these results? Justify your answer.

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