During history-taking and physical examination it is important to differentiate between cervical spine radiculopathy and cervical myelopathy. It is extremely important to specify the type of pain and its anatomical distribution (Rana, 2011). Complaints of deep aching pain and a burning sensation specifically bilaterally or in both upper and lower extremities are suggestive of spinal cord involvement. Many patients lose hand dexterity.

Most patients present with decreased neck range of motion (ROM) and paraspinous muscle spasm. There may be tenderness directly over the spinous process. Radicular pain is typically exacerbated by moving the neck or shoulders and it is common for pain to radiate either within a specific nerve distribution down the arm, into the scapular region or proximately into the occiput. A clinical prediction rule (CPR) can aid the clinician in diagnosing cervical radiculopathy (Wainner et al., 2003). Predictor variables are: (1) cervical spine rotation toward the involved side<60°; (2) positive upper limb tension test; (3) positive cervical spine distraction test (symptom relief); and (4) a positive Spurling test. The presence of three or more predictor variables indicates a moderate shift in probability that a patient will test positive for cervical spine radiculopathy using needle electromyography. In cases of cervical myelopathy, both upper and lower neurological examination should be performed. Imaging modalities are extremely useful in differentiating various types of cervical disease. Probably the most useful test is computerized tomography (CT) with intrathecal contrast which provides excellent differential between bone and soft tissue lesions and can accurately demonstrate canal size and foraminal narrowing. Magnetic resonance imaging (MRI) is useful as a noninvasive way of evaluating the spinal cord, soft tissues and neural structures (Rana, 2011). Plain radiographs can demonstrate bony changes and obvious foraminal narrowing, but tend to be more generalized (see Chapter 14).

In generating a differential diagnosis when working with an older individual, other diseases should be considered (Rana, 2011). Cancerous conditions that can refer pain to the neck region include metastatic lesions, leukemia, cervical spine bone or spinal cord tumors, lung cancer, Pancoast tumor, esophageal cancer and thyroid cancer. Neoplasms, the most common being metastatic tumors from carcinoma of the breast, prostate, kidney or thyroid, should be sought. Pain resulting from metastatic disease tends to be more intense at night and is often unremitting. Viscerogenic conditions such as angina, myocardial infarction or aortic aneurysm should be ruled out. Additionally, the pulmonary conditions such as a pneumothorax, pneumonia and tracheobronchial irritation should be ruled out as well (Goodman & Snyder, 2013).

Sepsis of the skeleton occurs infrequently in the cervical spine but is commonly seen in the lumbosacral spine and can occur following urogenital procedures. In those over the age of 65, sepsis of skin, soft tissue and bone accounts for 4.4% of all patients hospitalized for sepsis (Martin et al., 2006). Other inflammatory diseases can also lead to myelopathy; they include rheumatoid arthritis, ankylosing spondylitis, Reiter’s syndrome and diffuse idiopathic skeletal hypertrophy (DISH). However, most patients with such diseases present with other joint symptoms before the cervical spine becomes involved (Rana, 2011).

Cervical disc disease must be differentiated from primary shoulder disorders (Rana, 2011). Rotator cuff tendonitis, subacromial bursitis and acromioclavicular joint problems can present with shoulder pain that radiates into the paraspinous muscle area. It is possible for a patient to have both primary shoulder disease and degenerative disc disease of the cervical spine. Selective injections, particularly into the subacromial space or the glenohumeral joint, can be helpful in differential diagnosis. Polymyalgia rheumatica should also be considered when an older patient presents specifically with significant proximal pain and stiffness in the morning. This can develop into an acute emergency if the patient develops temporal arteritis and visual difficulties. A patient who presents with these symptoms should be referred to a physician immediately for evaluation and treatment.

Other neurological findings that may be confused with cervical radiculopathies include compressive neuropathies such as entrapment of the suprascapular nerve, with pain in the upper scapular region and atrophy of the rotator cuff musculature. Median and ulnar nerve compression and thoracic outlet syndrome also present with shoulder pain, along with paresthesia or weakness. Differentiation can be determined by nerve conduction studies or electromyelograms (see Chapters 32 and 33).

The bilateral vertebral arteries pass through the foramen transversarium and join to form the basilar artery and supply the circle of Willis. Age-related degenerative changes in the cervical spine may compromise this circulation, especially when the neck is extended, and are a possible cause of dizziness or balance complaints (Kesson & Atkins, 2005).

The majority of cervical symptoms in the geriatric patient can be treated by means of physical therapy and careful monitoring. Surgery is indicated primarily in a patient with myelopathy, progressive compression of the spinal cord or significant nerve root encroachment that causes pain and progressive weakness in a specific nerve distribution. In a study involving patients over 55 years of age, 3 weeks of mechanical traction and exercise showed improvement of neck pain (Raney et al., 2009). Escortell et al. (2008) studied 90 patients with subacute or chronic neck pain, with 47 patients randomly allocated for manual therapy and 43 for transcutaneous electrical stimulation. Both manual therapy and transcutaneous electrical stimulation were found to reduce neck pain, although there were no differences between the groups. Manual techniques, such as mobilization and stretching, are often helpful but the vertebrobasilar system must be cleared. Clinically, cervical spondylosis, and especially vertebral artery compromise, may limit cervical spine ROM exercises, mobilization, manipulation and the use of the Hallpike maneuver. Cervical manipulation should be used with extreme caution because of the documented risk of encroachment on the vertebral arteries and the possibility of stroke (Carlesso et al., 2010).

If the symptoms of cervical myelopathy or radiculopathy do not respond to conservative measures an anterior cervical discectomy and fusion (ACDF) procedure is commonly performed. Good to excellent results have been obtained in 88–94% of patients undergoing the ACDF procedure. Total disc replacement (arthroplasty) surgery has been recently developed and performed, with studies showing comparable or even better results (Smith et al., 2012). In a systematic meta-analysis, Fouyas et al. (2002) reported evidence that cervical spine surgery for spondylotic radiculopathy or myelopathy did not provide greater benefits than were derived from conservative therapy at 1 or 2 years.

The most common disorder of the thoracic spine in geriatric patients results from osteoporosis. Nearly 44 million Americans have osteoporosis and 50% of women and 20% of men over the age of 50 will incur a fracture due to osteoporosis (NOF, 2010). As bone mass decreases in elderly individuals, the vertebral bodies are at particular risk for compression fractures. A patient with multiple compression fractures in the thoracic spine can develop a severe kyphotic deformity (‘dowager’s hump’). Minimal trauma or none at all may create fragility fractures in the geriatric population with low bone mineral density (see Chapters 18 and 60). In a new fracture there is significant tenderness, with palpation of the spinous process and paraspinous muscle spasm. The neurological examination generally remains intact.

Compression fractures must be differentiated as old from new, and from malignancies. Plain radiographs are not the ‘gold standard’ (see Chapter 14, Figure 14.13). It is not uncommon for a patient with multiple myeloma or metastatic disease to present with a compression fracture (Rana, 2011). A bone scan, which may demonstrate lesions in other skeletal areas, is useful in differentiating a malignancy from a compression fracture resulting from osteoporosis.

Other thoracic spinal abnormalities include infections and degenerative disc disease. DISH is commonly found in the thoracic spine, presenting as stiffness and local pain. Other visceral problems can present as acute thoracic back pain in older patients, particularly ruptured aortic aneurysms, angina, myocardial infarctions, mediastinal tumors, breast cancer, lung infections, acute pneumonia, pneumothorax, peptic ulcer disease, kidney disease, pancreatic disease and acute cholecystitis (Goodman & Snyder, 2013). A careful physical examination and laboratory and diagnostic studies can differentiate viscerogenic from spinal disorders.

Treatment of compression fractures involves analgesics and brief bedrest followed by gradual mobilization and weight-bearing with assistive devices, if required. Caution must be exercised because the biomechanics (long lever arm) of lifting a walker can actually provoke increased thoracic pain. A wheeled walker reduces biomechanical strain. Prolonged bedrest leads to further osteopenia caused by disuse and to other complications, including pneumonia and urinary incontinence. If analgesics are incapable of resolving these symptoms or if polypharmacy is a concern, a transcutaneous electrical nerve stimulation (TENS) unit may be helpful in relieving pain. External immobilization such as Jewett or other hyperextension braces are often of little use for these patients because they can be extremely uncomfortable and often cause chest compression and resultant difficulties in lung expansion and breathing. If necessary, a simple extended corset can be used for support. The Spinomed lightweight moldable brace has been shown to improve trunk strength, improve forced expiratory volume and decrease kyphosis, pain and postural sway (Pfeifer et al., 2004). Within a period of 1–2 weeks, once the symptoms have resolved, extension exercises may be useful in preventing further kyphotic deformity.

If pain persists for longer than 2–3 months, surgical intervention with kyphoplasty or vertebroplasty may be beneficial (see Chapter 18); however, efficacy is not clearly established (Kallmes et al., 2009). Chen et al. (2011) reported that a post-vertebroplasty back exercise program resulted in more favorable daily function at 2 years compared to non-exercise grouped patients. New studies investigating combined interventions of surgery with exercise, posture and body mechanics are needed. Vitamin D deficiency, a risk factor for osteoporotic fractures, and hyperkyphosis contribute to weakness and mobility dysfunction and are amenable to intervention (Katzman et al., 2010; Boucher, 2012).

Clinically, the aging spine presents with a loss of height and mobility. Degenerative changes in discs and spondylosis of the zygopophyseal joints are common, with changes starting as early as the second decade of life and progressing with age (Siemionow et al., 2011). It is estimated that, by the age of 45, approximately 75% of males and 60% of females have some lumbar disc degeneration at grades 1–4. The amount increases to over 90% and 80%, respectively, by the age of 65, with increased frequency of grade 3–4 degeneration (Badley, 1987). The changes include loss of the water content, which diminishes from nearly 90% at birth to 65–71% at 75 years. Reductions also occur in the proteoglycans and number and structure of collagens (Kesson & Atkins, 2005), thereby diminishing the pliability of the intervertebral disc leading to disc collapse and protrusion. As discs collapse, instability in the adjacent vertebrae develops, often causing mechanical low back problems. In addition, significant arthritic change can lead to stenosis of the central spinal canal or the intervertebral foramina of the nerve roots.

Patients with spinal stenosis tend to have a classic presentation. Typically, there is pain in the lower back or pain radiating down both legs, usually after walking for a brief time. Symptoms are relieved with sitting or flexion of the spine but recur when walking is resumed. These symptoms of neurogenic claudication are similar to the experience of lower limb claudication resulting from vascular compromise. However, with vascular claudication, symptoms of lower extremity (LE) pain are induced by physical activity, when blood flow demand of the muscles is inadequate, and relieved by rest when muscular blood flow demand decreases. Unlike neurogenic claudication, vascular claudication is not influenced by spine postures. Clinicians often use a bicycle test to differentiate between neurogenic and vascular claudication. With neurogenic claudication LE symptoms are typically present when cycling with the spine in extension and relieved with the spine in flexion. With vascular claudication LE symptoms are not influenced by posture and are relieved with rest from cycling activity. Fritz et al. (1997a) used a two-stage treadmill to differentiate between vascular and neurogenic claudication. Treadmill walking on a 15° incline (flexed spine posture) allowed for increased tolerance compared to level treadmill walking (extended spine posture). Recovery time was more prolonged with neurogenic claudication. Physical examination of a patient with spinal stenosis often demonstrates symptoms after hyperextension of the spine which leads to narrowing of the spinal canal in the lumbosacral region resulting in cord compression. The symptoms may also be aggravated by stenosis of the vertebral foramina, which often leads to radicular symptoms in addition to the claudication.

Treatment of spinal stenosis in severe cases is almost always surgical; however, age-related comorbidities may limit this option. Often, multiple vertebrae require decompression and fusion is accompanied by spinal instrumentation to provide rigidity and stability of the spine until the vertebrae have fused. The results of decompressive spinal surgery for stenosis tend to indicate better outcomes than conservative treatment (Pearson et al., 2012), but long-term effects of surgery are variable; thus conservative care like manual therapy and strengthening exercises may offer alternatives (May & Comer, 2013).

Less invasive surgical procedures are being performed to maintain the dimensions of the spinal canal and intervertebral foramen. An interspinous process distraction spacer is surgically placed to prevent spinal canal narrowing, intervertebral foramen narrowing and compression of the spinal neural elements. These devices allow motion but limit segmental spine extension. Nandakumar et al. (2010) reported the Xstop device was effective in decompression of the stenosed segment after 2 years. These less invasive techniques are particularly adventitious in the elderly population with numerous comorbidities.

In mild cases, nonsteroidal anti-inflammatories and, occasionally, epidural steroid blocks may be helpful in relieving the patient’s symptoms. In addition to history and physical examination, the diagnosis of spinal stenosis can easily be made with the use of computerized tomography, with or without intrathecal contrast. Lumbosacral supports and corsets are often uncomfortable and provide little if any relief of symptoms. Abdominal exercises and stretching provide the most relief to a patient suffering from mechanical low back pain. Occasionally, massage, hot packs and ultrasound are also useful in resolving symptoms. Reduced weight-bearing walking in an aquatic program or harness suspension on land have been shown to reduce symptoms and improve exercise tolerance (Fritz et al., 1997b). It is important to remember many patients with spinal stenosis have osteoporosis as well as concomitant degenerative changes, thus, a therapeutic exercise program should be individualized. This program should include postural retraining and overall strengthening and conditioning, with stenosis favoring flexion and osteoporosis extension (see Chapter 60).

A review of systems for a viscerogenic origin of low back pain is imperative. Disorders of the cardiovascular, gastrointestinal, renal, urologic and gynecologic systems often cause low back pain (Goodman & Snyder, 2013). Therefore, the medical history is very important because back pain can result from pathologies in specific structures such as the aorta (especially aneurysm), kidney, bowel, uterus or prostate (Kesson & Atkins, 2005; Goodman & Snyder, 2013). When a patient experiences acute low back pain without trauma, silent compression fracture, infection or neoplasm must be considered. Radiographic studies and laboratory tests should differentiate the abnormalities.

Unexplained weight loss and pain without cause may raise a suspicion of cancer. Multiple myeloma, a neoplastic disorder involving immature plasma cells in bone marrow often produces back or rib pain. Non-Hodgkin’s lymphoma may also involve bone (Beers et al., 2011). Metastatic bone disease from primary breast or prostate cancers is frequently found in the lumbar spine and may present in a variety of ways. Metastasis from colon cancer is less common but can occur (Lurie et al., 2000). Neoplastic bone pain is usually a boring pain that often wakes the patient at night; rest does not relieve the pain. These symptoms are significant in a patient with a history of cancer (Kesson & Atkins, 2005). Weakness and fatigue may also be reported.

Osteomyelitis, discitis and other spinal infections must be ruled out, especially because radiographic evidence of degenerative changes is common in the aging spine (see Chapter 14). Lurie and associates (2000) presented the case of an 80-year-old man with arthritic changes in the spine and hips, including severe spinal stenosis. Treatment with rest and medications, including codeine, was ineffective. The patient had a decompressive laminectomy without relief of symptoms. After further workup and sound clinical reasoning, the patient was started on intravenous antibiotics for a spine infection, which rendered a gradual improvement. It should be noted that spinal infections mimic back pain and radicular complaints but they do not always present with typical features of infection. Fortunately, spinal infections are not common, accounting for about 0.01% of cases in primary care (Lurie et al., 2000).

Approximately 90% of individuals affected by Paget’s disease are asymptomatic. Diagnosis is usually made by reports of bone pain or deformity, radiography or detection of elevated serum alkaline phosphatase levels upon routine biochemical testing. The most common complaints reported are pain, skeletal deformity and changes in skin temperature. Other clinical manifestations include diminished mobility and unsteady gait; in more severe cases of Paget’s disease, pathological fractures may manifest. The major clinical features are outlined in Table 24.1.

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