Wear and tear (aka degenerative, arthritic) processes are regarded as a normal ageing process in the spine. In fact these changes can start to begin to be seen from the age of about 20 onwards. Although a lot of patients who have wear and tear problems in their spine do not have symptoms, the proportion of patients will develop pain affected both their spine, and their legs and or arms.
It is also possible for the wear and tear changes in their spine to affect the shape of the spine leading to curvatures of the spine. Another very wide spread problem that is associated with an older age group population as far as the spine is concerned is standard osteoporosis. This is a condition whereby the bones of the spine can begin to collapse often without history of trauma due to the thinning of the bone related to the condition.
Back pain is therefore a reasonably common symptom that patients experience with age. This can either be related to pain in the lower back or less commonly in the cervical spine i.e. the neck. Not uncommonly patients will also experience pain radiating down one or both legs. This is usually due to pinching of the nerves in the spine, secondary to the wear and tear processes that are taking place. Typically this affects patients by reducing the distance they are able to walk before they develop pain in their legs which will often cause them to stop walking and sit down. Patients will also often find discomfort with prolonged standing or prolonged sitting. Patients may also identify numbness or tingling or pins and needles affecting one or both legs. Very occasionally patients will develop problems with their bowel or bladder function.
In patients in whom symptoms are not settling and who indeed have been present for longer than 6 to 8 weeks investigations are a sensible way forward. These would include often plain x rays or sometimes MRI scans which give a very accurate picture of what is going on in the spine. The MRI scan in particular can identify whether there is significant pinching or narrowing around the nerves. If patients are suspected of having osteoporosis or if there is a family history of osteoporosis then it is often sensible to arrange Dexa scans to confirm this diagnosis.
It is undoubtedly the case that most patients who have back pain in combination with leg pain can and should be managed without the need for surgical intervention. Simple treatments therefore consist of pain control with simple painkillers and often a gentle programme of exercise. Physiotherapy can also have an important role in these patients. There is undoubtedly a role also for other treatments such as chiropody, osteopathy and acupuncture. Therapeutic injections, for example epidural injections and nerve root injections can also be considered. These are injections usually done under sedation and are performed if there is evidence of nerves that are being irritated in the spine. The role of surgery for back related problems are predominantly in patients who have leg pain which is worse than their back pain. Clearly it is not possible to give patients new spines as it would be a hip or a knee. Occasionally spinal fusion operations could be considered as part of an operation to free up nerves. Very occasionally the development of back pain can be the signal of something more sinister happening with patients and therefore it is occasionally the case that other processes and diseases are identified as part of the investigation of patients with back pain. Patients who suffer from osteoporotic fractures of the spine can be considered for certain cement augmentation techniques if their symptoms are not settling.
Back and leg pain are therefore common as part of an ageing process and while most of the symptoms patients suffer from can be managed without the need for intervention, there is undoubtedly a role for surgery in certain cases.
Guy Selmon MB BS, FRCS(Tr & Orth) is a Orthopaedic Consultant at The Horder Centre