The Aging Spine

Our society is heading into an era of dramatic social transformation as the "aging" individuals encompass an ever larger proportion of the overall population. Significant demographic changes are expected due to increases in life expectancy and decreases in the birth rates in most western countries. Not only will there be important economic consequences to these changes, but also political and health care consequences. In the arena of medicine, the aging population will provide challenges in the delivery of health care, the cost of medical care, and the expanding notion of quality of life for the elderly. Continued progress in areas of cardiology, cancer research, neurology and the entire field of medicine can expected to not only increase life expectancy but also intensify the issues of quality of life. Once we can expect to live 100 years old, we wish to assure that we can also perform the usual activities of daily living (or even participate in sports) up to that age. The secondary medical aspects of aging (not life and death) such as the painful degenerative conditions then become very important.

Degenerative conditions of the spine are present in all elderly people. Many people remain completely symptom free from these conditions. However, those individuals that do suffer are frequently severely compromised in their activities of daily living and may require significant medical and nursing support. As the population undergoes the demographic changes of a growing elderly population it is important to aggressively pursue research and teaching in areas of the "aging spine" to design effective diagnostic and treatment approaches for the degenerative disorders. Our team is involved in a variety of studies relating to the aging spine and we have participated in the Scoliosis Research Society committee of the aging spine.

Degenerative conditions of the Spine

The common clinical degenerative disorders of the spine include: spinal stenosis, osteoporotic compression fractures, degenerative spondylolisthesis, adult scoliosis, degenerative disc disease. Although many other conditions exist, most of these disorders are in fact not entirely separate entities but rather disease states along a continuum. Furthermore, many of these conditions overlap in their presence and presentation in any one individual.

Degeneration of the spine begins in the third decade of life. Gradual intervertebral disc changes can be noted at that time. Eventually, a progressive pattern of disc height loss with facet (the small joints in the back) degeneration and ligamentous/capsular hypertrophy (thickening) is seen. Further along the degenerative pathway complete disc space loss can be noted, facet ankylosis (fusion) or subluxation (dislocation) can be seen, and vertebral body changes in conjunction with significant changes in spinal contour (such as adult scoliosis) become evident. Although differences in clinical presentation as well as predominant degenerative structure vary between individuals, a common pathway of degeneration may be present in all individuals.

With progressive degeneration a stage of bony and soft tissue failure can develop. In bony structures this involves fracture (compression fractures and osteoporosis), whereas in soft tissue structures an inability to maintain normal bony alignment becomes clearly apparent (adult scoliosis, spondylolisthesis). In some individuals this last stage never develops or rather an alternate path of stabilization occurs in which bony structures become ankylosed or tightly attached to another by soft tissue reaction.

The degenerative process of the spine is an inevitable one. In most people this degeneration does not severely compromise quality of life. It remains poorly understood why this process is painful and incapacitating in some individuals and only minimally noticeable in others. The real issue from a healthcare perspective is pain associated with the "aging spine" and finding effective solutions to maintaining quality of life.

Treatment of the painful "aging" Spine

A variety of treatments are available for the clinical syndromes related to degeneration of the spine. Medical treatment must be customized for each patient and focuses upon the predominant degenerative problem causing symptoms in that individual. Treatments range from pain medications to manipulations, injection therapies, physical therapy and finally surgery. The effectiveness of non-operative treatments has come under question in several studies. Benefits have been noted with "physical therapy" in many degenerative syndromes although standardization of treatment and high quality investigation into optimal effectiveness of exercise, and strengthening programs has been limited. The effectiveness of manipulation has only been clearly demonstrated in low back pain of short duration but not in chronic low back pain. Injection therapies appear to offer no therapeutic benefit with trigger point injections yet have been shown to give some temporary relief with epidural steroid injections. Again the effectiveness of the therapy appears to be very dependent upon the technique employed and the primary degenerative problem in the patient.

Surgery in those patients with severe symptoms and a clear focal problem can be very effective in the setting of degenerative problems. When non-operative treatment fails, even in the elderly, safe operative intervention is possible.

Conclusions

Spinal degeneration is an inevitable part of aging. This process is occasionally painful and significantly compromises quality of life. Although aging and degeneration can not be avoided, there is increasing evidence that maintaining an active lifestyle including exercise on a regular basis is very helpful in avoiding clinical symptoms. The treatment of patients suffering from degenerative problems is carefully tailored on an individual basis. We have found that a close collaboration between the primary physician, the spine specialist, and physical therapists is essential for effective treatment.

Read more about Non-operative Treatments.