Disc Herniation - Between Herniated Disc & Surgery (3. API - aging pain inflammation)
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The primary finding of this study was that older adults demonstrated improvements in disability and pain with nonsurgical treatment that were not significantly different from those seen in younger adults over 6 months of follow-up, either with or without adjustment for potential confounders.
No prior studies of nonsurgical treatment of MR-confirmed acute LDH have utilized repeated assessment with validated outcome measures at fixed intervals 30 - This has left a notable gap in our knowledge base regarding the course of improvement early in nonsurgically treated LDH. A secondary finding of this study was that while rates of improvement in disability were not significantly different in older adults as compared to younger adults, a greater amount of the total improvement in pain intensity occurred in the first month of follow-up in older adults.
However, this difference with respect to rate of improvement in pain intensity was quite small, and not likely to be clinically significant. Although some authors have asserted that the outcomes of LDH with nonsurgical treatment are poor in older adults 16 - 18 , to our knowledge, only one prospective study including nonsurgically treated patients has reported a negative influence of age on outcomes with LDH.
On the contrary, the current study demonstrates that in a nonsurgical specialty spine clinic, the diagnosis of LDH is quite common, corroborating prior reports from surgical clinics. The overly simplistic paradigm of LDH as a disorder primarily of younger adults, and LSS as a disorder primarily of older adults, may potentially lead to misdiagnosis if relied upon heavily. This study has limitations.
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First, the relatively small sample size of this study may have limited our statistical power to detect differences between the two age groups with respect to the study outcomes. For this reason, we were unable to examine whether different age cutpoints below age 60 were associated with clinical outcomes. Second, our findings may not be generalizable to older adults with severe bony stenosis in addition to stenosis secondary to LDH, since these adults may have been excluded due to our predefined study criteria.
However, many subjects in this sample had moderate bony stenosis at one or more levels. Third, this study does not allow us to assess whether differences in outcomes affecting older adults may have emerged after longer than 6 months of follow-up. We believe this to be highly unlikely, in light of multiple studies which document that the vast majority of improvement in LDH occurs over the first 6 months of recovery 3 , Fourth, the influence of some important psychological factors such as treatment expectancy, coping, self-efficacy, and fear avoidance beliefs were not examined in this study.
Future studies may wish to examine the effects of these factors in older adults with LDH. Last, formal testing for cognitive impairments using mental status examination was not performed on all subjects. The well-documented increase in the utilization of spinal decompression procedures for older adults over recent decades is likely driven by many different factors.
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The current study offers no evidence to support the notion that outcomes of LDH with nonsurgical treatment are different in older adults as compared to younger adults. Other explanations for increasing rates of spine surgery in older adults include an increasing prevalence of spinal disorders in the community, surgical advancements in patient selection and technique allowing safer procedures for older adults, or a lack of consensus on indications for surgery.
Further research is warranted to investigate the reasons behind increased surgical rates, and to determine whether this translates into better patient outcomes, at a reasonable cost to society. The authors declare that they have no potential financial and personal conflict of interests in the publication of this study. Europe PMC requires Javascript to function effectively.
Prospective longitudinal comparative cohort study. Outpatient specialty spine clinic. One hundred thirty-three consecutive patients with radicular pain and magnetic resonance-confirmed acute LDH 89 younger, 44 older. Nonsurgical treatment customized for the individual patient. Patient-reported disability on the Oswestry Disability Index ODI , leg pain intensity, and back pain intensity were recorded at baseline and 1, 3, and 6 months. Older adults demonstrated improvements in ODI range and pain intensity range with nonsurgical treatment that were not significantly different from those seen in younger adults at 6 month follow-up, with or without adjustment for potential confounders.
A greater amount of the total improvement in leg pain and back pain in older adults was noted in the first month of follow-up than in younger adults. The snippet could not be located in the article text. This may be because the snippet appears in a figure legend, contains special characters or spans different sections of the article.
J Am Geriatr Soc. Author manuscript; available in PMC Mar 1. Suri was involved with study concept and design, acquisition of data, analysis of data, interpretation of data, and drafting of the manuscript. Hunter was involved with study concept and design, analysis of data, interpretation of data, and manuscript preparation. Jouve, Hartigan, Limke, and Pena were involved with acquisition of data and manuscript preparation.
Li was involved with analysis of data, interpretation of data, and manuscript preparation. Luz was involved with acquisition of data and manuscript preparation. Rainville was involved with study concept and design, acquisition of data, interpretation of data, and manuscript preparation. All authors were involved with critical revision of the manuscript for important intellectual content and approved the final version.
The publisher's final edited version of this article is available at J Am Geriatr Soc. See other articles in PMC that cite the published article.
Lumbar Disk Disease (Herniated Disk)
Design Prospective longitudinal comparative cohort study. Setting Outpatient specialty spine clinic. Participants consecutive patients with radicular pain and MR-confirmed acute LDH 89 younger adults and 44 older adults. Intervention Nonsurgical treatment tailored to the individual patient. Measurements Patient-reported disability on the Oswestry Disability Index ODI , leg pain intensity, and back pain intensity were recorded at baseline, 1, 3, and 6 months. Results Older adults demonstrated improvements in ODI range and pain intensity range with nonsurgical treatment that were not significantly different from those seen in younger adults at 6 month follow-up, either with or without adjustment for potential confounders.
Physical Examination Characteristics Each participant received a comprehensive physical examination for the evaluation of lumbar radiculopathy by one of six board-certified physiatrists specializing in spine care. Magnetic Resonance Imaging Characteristics MRI imaging scans consisted at minimum of T1 and T2 weighted images of the lumbar spine in the sagittal and axial planes.
Outcomes Patient-reported disability and pain intensity were recorded at the baseline clinic visit.
Nonsurgical Treatment of Lumbar Disk Herniation: Are Outcomes Different in Older Adults?
Statistical Analysis To characterize the study population at baseline, we calculated means and standard deviations SD for continuous variables, medians and interquartile ranges IQR for ordinal variables, and frequencies and proportions for categorical variables. Open in a separate window. Footnotes Conflict of Interest: Prevalence of symptoms of cervical and lumbar stenosis among participants in the Osteoporotic Fractures in Men Study.
Associations of back and leg pain with health status and functional capacity of older adults: Findings from the retirement community back pain study. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. Jonsson B, Stromqvist B. Influence of age on symptoms and signs in lumbar disc herniation. Lumbar disc herniation in the elderly.
Histological changes in aging lumbar intervertebral discs. Their role in protrusions and prolapses. J Bone Joint Surg. The Aging Lumbar Spine: Principles and Practice of Spine Surgery. Clinical and pathologic characteristics of lumbar disk herniation in the elderly. Herniated lumbar disc in patients over the age of fifty. Focus issue on lumbar disc herniation: Spine Phila Pa ; Trends and variations in the use of spine surgery. Clin Orthop Relat Res.
Outpatient lumbar spine decompression in patients 65 years of age or older. Surgical treatment of lumbar disc herniation in elderly patients. J Bone Joint Surg Br. Surgical results of lumbar disc herniation in the elderly. Kulali A, von Wild K. Lumbar spinal surgery for sciatica due to intervertebral disc disease in the elderly. A controlled, prospective study with ten years of observation. Compositional influences for regression of the sequestered lumbar disc hernia in dogs. The effect of age on inflammatory responses and nerve root injuries after lumbar disc herniation: An experimental study in a canine model.
Age-related effects of cocultured rat nucleus pulposus cells and macrophages on nitric oxide production and cytokine imbalance. What can the history and physical examination tell us about low back pain? The accuracy of the physical examination for the diagnosis of midlumbar and low lumbar nerve root impingement. Spine Phila Pa Jun 10; Epub ahead of print. Comparison of four tests of quadriceps strength in L3 or L4 radiculopathies. Aids to the Examination of the Peripheral Nervous System. Nomenclature and classification of lumbar disc pathology.
The Oswestry Disability Index. The visual analogue pain intensity scale: The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. The fragments of disk material can then press on the nerve roots that are located just behind the disk space.
This can cause pain, weakness, numbness, or changes in sensation. Lumbar disk disease is due to a change in the structure of the normal disk. Most of the time, disk disease comes as a result of aging and the degeneration that occurs within the disk. Occasionally, severe trauma can cause a normal disk to herniate.
Trauma may also cause an already herniated disk to worsen. The symptoms of lumbar disk disease vary depending on where the disk has herniated, and what nerve root it is pushing on. The following are the most common symptoms of lumbar disk disease. However, each individual may experience different symptoms. Intermittent or continuous back pain. This may be made worse by movement, coughing, sneezing, or standing for long periods of time. Pain that starts near the back or buttock and travels down the leg to the calf or into the foot. The symptoms of lumbar disk disease may resemble other conditions or medical problems.
In addition to a complete medical history and physical examination, diagnostic procedures for lumbar disk disease may include the following:. A diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
Long-term follow-up study of surgically managed cases. Army veteran Richard Shetter sought a second opinion from the Johns Hopkins orthopaedic spine division. The primary outcome was the ODI change score at 6 months. Either your web browser doesn't support Javascript or it is currently turned off. You may learn how to do activities more safely. Second, our findings may not be generalizable to older adults with severe bony stenosis in addition to stenosis secondary to LDH, since these adults may have been excluded due to our predefined study criteria. The pressure bulges the annulus outward in the beginning.
Magnetic resonance imaging MRI. A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. A procedure that uses dye injected into the spinal canal to make the structure clearly visible on X-rays. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs.
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CT scans are more detailed than general X-rays. Typically, conservative therapy is the first line of treatment to manage lumbar disk disease. This may include a combination of the following:. Patient education on proper body mechanics to help decrease the chance of worsening pain or damage to the disk.