Your Back: Don't Take Your Best Friend for Granted

Part Three

In the final installment of our series, “Your Back, Don’t Take Your Best Friend for Granted”, we will discuss the aging spine. As we have discussed in previous issues, your back begins to show the first signs of age during your thirties. From there, the spine begins to stiffen. The ligaments and joints become less flexible and easier to injure, while the bones begin to lose density and become more prone to fracture. By now most of us realize we are not immortal and do a better job taking care of ourselves. Many of us however, continue with the destructive habits of smoking, overeating and under exercising which place our friend the back at risk on many levels. Multiple myeloma, as well as cancer of the lung, breast, prostate, and kidney often spread to the spine, destroying bone, causing fractures and crushing the spinal cord. Arthritis can distort the spinal joints causing them to collapse or shift, causing nerves to be compressed. Osteoporosis can lead to fractures which deform the spine and compress the lungs, heart and abdomen. In the final analysis, the steps we take to minimize risk can make a big difference in the health we enjoy during our later years.

Welcome to the last third of our lives. Although age is showing on our friend, the back, most of us become blessed with some level of wisdom in our daily lives, and do a much better job taking care of ourselves. Spine maintenance comes down to three things: first, keep as close as possible to ideal body weight, second, exercise regularly to maintain heart/lung function, flexibility, muscle and bone mass, and lastly avoid smoking, and follow through with regular checkups to make sure that problems that arise are diagnosed early and treated promptly.

The Sedentary Spiral

As we age the percentage of fat in our bodies tends to rise and the percentage of muscle tends to drop. Since muscle is the tissue that burns most of our dietary calories, as we lose muscle mass, we become less able to burn the calories in the food we eat. Excess calories are turned into fat, and we gain weight. This slows our ability and willingness to exercise, which decreases the percentage of muscle which lowers our ability to burn calories, and so on. This downward sedentary spiral can rob years from our lives, place huge additional loads on our spine by adding weight and weakening supportive musculature, decrease bone density, decrease cardiac and pulmonary function, and dangerously increase low density lipoproteins (LDL) and cholesterol while lowering protective high density lipoproteins (HDL), increasing our risk of stroke and heart attack.

The key to staving off the sedentary spiral is exercise. Older individuals should have a thorough physical exam before beginning a new program. Such a program should be started with the long term in mind. In other words, think of it as a change in the way you are going to live from this point forward, not as a way to get fifteen pounds off by summer. It should include components of weight training to build muscle mass, aerobics to maintain heart and lung function, and stretching to achieve optimal joint balance and function. From the nursery to the nursing home, the benefits of exercise are available to all who wish to partake. Exercise has the following benefits:

1)      Burns excess calories

2)      Increases muscle mass to improve strength, endurance, and ability to burn calories

3)      Stresses bone to help maintain bone mass and prevent osteoporosis

4)      Increases heart muscle strength and pulmonary function

5)      Lowers blood pressure

6)      Stimulate and optimize gastrointestinal function

7)      Promotes circulation to muscles, joints, and spine

8)      Lowers cholesterol and low density lipoproteins (LDL)

9)      Releases endorphins reducing signs of depression, promoting sense of well being.

10)  Improves muscle balance and spinal alignment preventing excess spine loading

11)  Suppresses appetite which allows one to choose more healthy eating habits 

With all that is good about exercise, why are we getting so overweight as a people? Is it TV advertising? Is it junk food? Is it our busy lifestyles which rob us of our discretionary time? Are we just lazy? The problem is not a simple one, and the reasons are likely different for each of us. Ultimately, it is we as individuals who are responsible. Over the last few decades, we Americans have developed a culture more attuned to immediate gratification. Working today for benefits tomorrow has become more difficult for many of us. With our busy, lifestyles where we must balance many responsibilities within a limited period of time, very few things can be done on a regular schedule, 5 days per week. Many of us believe therefore, that since we cannot exercise an hour at a time, regularly, there is no point in starting at all. We all hesitate starting something when we feel we are likely to fail. This with a little dose of denial, and we are content to simply come home from a hard day’s work and sit in front of the TV, while our toes simply disappear from view. 

Exercise is not an all or nothing phenomenon. Even a little exercise now and then can do wonders for your health. Our bodies crave it. Studies have shown that even taking the stairs instead of the elevator can make a difference. If everyone in the Mid South reading this Wellness addition were to start an exercise program hundreds of lives would be saved each year! The bottom line? Grab a friend or significant other and “just do it”!

Effects of Osteoarthritis

Unfortunately, even with the optimal lifestyle, our spines do age. The arthritic wear and tear on our spines can create several common medical problems.  They include degenerative disc disease, spinal stenosis, degenerative spondylolisthesis and degenerative scoliosis.

Degenerative Disc Disease is a condition in which the aging intervertebral disc becomes a “pain generator”. As a disc wears out it loses its ability to move, support weight, and cushion the vertebrae above and below. Stresses in the disc caused by movement cause microscopic injury, inflammation and pain usually by stimulating small nerves within the outer ring or annulus of the disc. Any increase in activity induces further microscopic injury to the annulus and adjacent bone, inciting further inflammation and pain. Treatment consists of anti inflammatory medications such as Ibuprofen, Aspirin and others, which help inhibit the inflammation caused by microscopic tissue injury, and exercises which improve core strength in the muscles around the spine allowing them to stabilize the trunk and support some of the weight. In an aging spine it can be very challenging to verify the exact structure which is causing pain. Many times there are many structures at each disc level that are arthritic and many levels involved. Provocative discography has been the standard in verifying which levels and which structures are generating pain, yet even discography has been very controversial. Discography consists of injecting saline or radiographic dye into the discs to determine if the pressure thus created reproduces the patient’s typical pain pattern. A study properly done can help differentiate this very complicated mix of multilevel structures that are causing pain from those that are not. 

In patients with intractable pain from an identifiable disc, that have failed all other treatments, minimal access spinal fusion or disc replacement is usually offered. Minimal access fusion consists of gaining access to the disc through a small tube, removing the annulus and placing a spacer into the disc space which restores disc height. Bone is filled in around the spacer to promote the vertebra growing solidly together. This solid union, removes the stresses placed upon the annulus, prevents microscopic injury, turns off the inflammatory response that follows and decreases pain. Artificial disc replacements act to replace the biologic disc with a man made joint made of plastic and titanium. This new joint supports the weight without causing tissue injury and therefore again shuts off inflammation and pain. In early studies, disc replacement in those patients that met the criteria, was at least as successful limiting pain as fusion.

Spinal Stenosis occurs when the spinal canal that transmits the nerves between spinal cord and limb becomes narrowed. This narrowing is usually caused by arthritic deformation of the joints around the canal, ligament enlargement or in folding, and occasionally by abnormal sliding of the vertebrae which can pinch the nerves (spinal instability). The normal canal must be narrowed at least 50% for the nerves within to become squeezed or their accompanying blood supply to be limited. This usually causes pain, tingling, numbness and weakness in the legs, which comes on with activity and is relieved after a few minutes of rest, a symptom known as neurogenic claudication. The canal is slightly enlarged by bending forward, which is why patients with the advanced form of this condition will lean forward when they walk, or bend over a walker or shopping cart to get relief. Treatment includes core strengthening, epidural steroids injections and surgery. Strengthening only helps the patient maintain optimum trunk position which can occasionally help. Steroid injections minimize inflammation of nerves within the area of narrowing, perhaps allowing their minor swelling to subside and give them a bit more room. Epidurals are effective 65%-70% of the time short term; however this quickly decreases to about 35% improvement at 6 months. Surgery consists of removing arthritic tissues to open the canal back to its original size. It is usually about 85% effective in improving symptoms, requires an approximately two day hospital stay and will have patients back to pre surgical activity levels within four to six weeks.

Degenerative spondylolisthesis often accompanies spinal stenosis. Here the joints between two vertebrae become loose, and the upper vertebrae (and all the vertebrae above it) slip forward on the vertebrae below. The vertebrae become unhinged, which places greater stresses upon the discs and facets at that level. Advanced arthritis and disc collapse are often seen at levels of spondylolisthesis, and because the spinal canal develops a kink in it at that location, stenosis is never too far away. Treatment is conservative at first consisting of the same physical therapy, core trunk strengthening and stabilization exercises. Epidural steroids targeting compressed and inflamed nerves can also help. When surgery for nerve compression is necessary it is usually desirable to perform fusion as well. The reason for this is that the surgical procedure to decompress the spinal canal results in a destabilizing of the slip which in nearly half the patients will progress. As the slip gets worse the nerve compression usually recurs and the pain comes back. Thus decompression without fusion in this condition fails nearly 50% of the time, an unacceptably high failure rate for any surgery.  

Degenerative scoliosis is a common consequence of advanced spinal arthritis. As arthritis becomes severe often the disc spaces will not collapse the same amount on the left and right. If several adjacent discs collapse on one side and not on the other a curve will develop. Where advanced curves in adolescents are corrected and fused relatively easily, the aging spine is considerably more stiff, and the bone less strong. Moreover, aging individuals are more prone to surgical complications. Bracing is often considered in order to help control pain during activities. Again exercise and core strengthening are central themes. Any surgery of scoliosis consists of a long incision, multiple levels of bone grafting and metal instrumentation, in order to promote a solid fusion of the vertebral levels from the top of the incision to the bottom. In older individuals this can subsequently lead to secondary degeneration above the fusion, and aggravation of the weight bearing joints below it. These would include the sacroiliac joints, hip joints and knee joints. For these reasons and others, surgical treatment of degenerative scoliosis is done only as a last resort. 

Cancer

Cancer is one of the big killers of the aging population. After heart disease it is the biggest. Metastatic cancer from the breast, lung, kidney, prostate, and colon all frequent our friend the back. Multiple myeloma, a cancer of blood cells also commonly affects the spine. Any progressive increase in back pain, pain that is worse at night, pain associated with numbness, weakness or tingling in the legs, weight loss or loss of appetite, changes in bowel or bladder function all are danger signs that should take us immediately to our family physician for urgent evaluation and treatment.

Although we cannot prevent cancer we can minimize its effects in two important ways. First, we can steer clear of environmental agents we know cause cancer, such as tobacco, and excess sunlight. We can also eat healthy foods high in anti-oxidants, and use sun screen when outdoors which can help prevent many forms of cancer. Second, we can detect cancer early, greatly increasing the chance for cure. Regular physicals and prostate exams with PSA blood testing, colonoscopy in men over 50 year of age, as well as regular breast exams, mammography, and Papst smears in women are just a few steps we can all take to minimize our risks.

Osteoporosis

We all start life with largely cartilaginous skeletons. We gather bone mass through our childhood and early adult years peaking around 25 to 30. From that point on our skeletons gradually lose bone mineral. The sex hormones appear to provide some protective effect against bone loss, although poor diet, obesity and a sedentary lifestyle can hasten its coming. Losses of greater than 50% or more of bone mineral increase the chances for an osteoporosis related fracture. Women have a particularly difficult time immediately following menopause when estrogen levels fall. Loss of bone mineral can approach 3% per year for the first decade following menopause, leaving women at risk of developing osteoporosis. Taking basic preventative steps can reduce this rate to about 1% per year (about the same rate as men).

Osteoporosis is a condition in which the amount of bone mineral within or skeleton drops to dangerously low levels. Those bones that support our weight such as the spine and hip are the most at risk. Bones that are profoundly involved in osteoporosis can be caused to fracture with an activity as simple as a cough or sneeze. Over 700,000 fractures of the spine related to osteoporosis occur each year. It has been shown that vertebral compression fractures caused by osteoporosis can decrease lung capacity; throw off walking balance increasing the risk of additional falls and fractures, lead to secondary problems with muscle and bone loss, loss of independence, depression and a 25% increase in mortality within five years. 

Although osteoporosis favors women, nearly one fourth of its victims are men. Individuals who are blonde haired and blue eyed, have a positive family history, women who have had early menopause, or hysterectomy without hormone replacement, individuals who have been chronically ill or have taken oral steroids are the most at risk.  

Taking a few preventative steps can help our friend the back from weakening to the point of fracture. Multiple fractures can lead to progressive “dowager’s hump” deformity and forced dependency. These preventative steps include adequate weight bearing exercise and calcium intake (1200mg/day), with enough Vitamin D to allow absorption of dietary calcium (about 800IU/day). Estrogen supplementation can also limit bone loss during the first decade after menopause, unless there is a family history of breast cancer which can make estrogen replacement a poor choice. Individuals at risk for developing osteoporosis can undergo an inexpensive test (DEXA scan) to measure bone density. If bone mineral levels fall to one standard deviation below the mean (osteopenia) additional medications such as Fosamax or Actonel are indicated. These medications can reverse the trend for bone loss, but can be hard on the stomach. A new intravenous medication (Forteo) holds great promise for those that are unable to tolerate these oral medications.

Patients with acute or sub acute compression fractures (less than 4-6 months old) can now be treated by a procedure called Kyphoplasty. This procedure consists of placing a small balloon within the broken vertebra, one on either side, and expanding the crushed vertebra back into shape. The balloon is then withdrawn and the hallow space inside the bone is filled with bone cement to act as an internal cast. Patients undergoing this procedure are not cured of their osteoporosis, however the pain associated with the compression fracture is minimized in over 90% or patients, with a complication rate associated with the procedure of only about 3 in 1000.

Tips for the Aging Spine

1)      Fight the sedentary spiral with one part weight training, one part aerobics, one part stretching, at least three days per week

2)      If you are at risk get a DEXA scan in your late 40s, take calcium/Vitamin D supplements or six helpings of dairy products daily

3)      Watch your diet and keep your blood pressure, and cholesterol in a good place

4)      Get regular check ups, including breast exams, mammography and Papst smear if you are female, and prostate exam, PSA, chest X-ray, and colonoscopy if you are male.

5)      Report any sudden changes in health such as back pain, changes in bowel or bladder habits, weight loss or blood in urine or stool to your physician immediately.

6)      Have fun! Laugh! Stress is usually induced by worrying today about things that haven’t happened yet…and probably won’t! Don’t forget to stop and smell the flowers, as it seems we as a people so easily forget; each of us has but a precious few years on this wonderful Earth, and we need to strive to make the most of each and every one of them.

So there you have it. From cradle to the grave, our back has been there for us, and for most of us, it has gone the distance. Taking care of ourselves is not always easy, and it frankly won’t always pay off. But as mere mortals all we can do is play the odds. We can abuse our health and our backs hoping the odds won’t catch up with us, or we can take care of our health and our friend the back, putting the odds on our side. This decision is a recurring one, one that lasts a lifetime. No physician, medication, or surgical procedure can lift this burden from us. Just following the recommendations in this humble series, could add decades to the lives of many of those reading it. In the final judgment it is our responsibility to care for ourselves, so that we may live the lives we were given to their fullest.

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                                                    Last modified: 04/04/06