History and Physical Examination of the Aging Spine

Published on 11/04/2015 by admin

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5 History and Physical Examination of the Aging Spine

Courtney W. Brown, Lonnie E. Loutzenhiser

KEY POINTS

• Problems affecting the aging spine are a multifactorial degenerative process affecting both the soft tissues and bony structures.
• These degenerative processes affect global balance, both sagittal and coronal, and produce neurological findings.
• Any physical findings must correlate with radiographic studies.
• Past history of surgery will influence the patient’s findings.
• Some apparent spinal problems may represent other pathology.

Introduction

With the increasing longevity in our society, the aging spine has become a ubiquitous problem. Natural physiological aging affects both soft tissue and bony structures, leading to the degenerative process in the spine. Each individual patient’s spinal problem has to be correlated and related to that individual’s physiological history, which includes genetics; familial, environmental, and/or occupational problems; as well as the multiple comorbidities with which all of us must live. Perhaps it would be best to outline these various areas of influence to better understand how our histories affect our aging spines.

Past Medical History

Congenital/Familial/Genetic

Abnormal skeletal spine development may occur on a congenital, familial, or genetic basis. This may include various combinations of failure of formation or segmentation of the vertebrae leading to such problems as hemivertebrae, congenital fusions (Klippel-Feil), and congenital scoliosis. These abnormalities may lead to an abnormal stress and wear and tear to relatively normal adjacent levels of the spine, thus having a detrimental effect on these levels through ligamentous and disc degeneration. This may lead to a progressively painful or unstable spine.

Adolescent idiopathic scoliosis, which appears to be genetic in origin, has a totally different influence on the spine as we mature, and can range from a stable balanced spine to a progressive curve with neurological compression and/or global spinal imbalance. Usually, this develops as a slow, progressive vertebral body subluxation secondary to the disc degeneration in the scoliotic levels. This may not occur until later years and at that time, become symptomatic. Aside from spinal pain, as a lumbar curve increases, patients may complain of the rib cage sliding against the pelvis as they become shorter.

Occupational/Environmental/Psychological

A patient’s occupation has a significant impact on the speed and severity of degenerative problems that occur in the adult spine. Certainly, a day laborer who performs loaded twisting of the spine, thus creating annular shearing, is much more likely to have traumatic breakdown of the discs and ligamentous structures than someone with a sedentary occupation. Additionally, smoking decreases the blood supply and nutrition to the vertebral endplates and the intervertebral discs, therefore negatively affecting their healing capabilities. Psychological stress can negatively affect a spine problem and potentiate the pain response to the degeneration. Thus, the patient’s pain threshold and psychological instability may produce increased symptoms through the combination of chronic pain, secondary gain, and subsequent depression. If the symptoms persist, symptom magnification may be a dominant factor. Thus, the physical disease of the spine may be overtaken by the patient’s psyche. The possibility of alcohol abuse and malnutrition also needs to be considered.

Comorbidities

Comorbidities, such as diabetes mellitus, cardiovascular disease, or renal disease, can produce neuropathic pain or neurological deficits. These may be extremely difficult to treat, either nonoperatively or operatively. Uncontrolled diabetes mellitus is well known to produce peripheral neuropathy leading to denervation, as well as pain. Cardiovascular disease, such as an aortic aneurysm or peripheral vascular disease, may cause vascular claudication mimicking spinal pathology. Additionally, patients may have a neurological disorder, such as Charcot-Marie-Tooth disease, that may affect the extremities as well as bowel and bladder function. Pulmonary pathology, such as a Pancoast tumor, may mimic the findings in patients with neck symptoms.

History

Origin of Pain

Pain can be described in multiple ways. The first should be the location and quality, as well as the severity of the pain. The pain must be described in terms of sharpness, dullness, burning, numbness, or throbbing. Is the pain intermittent or constant? Is it alternating in severity? The exacerbating or relieving factors should be noted. Is the pain improving or is it progressively getting worse? The pain may become better or worse with positioning. If worse, the etiology may be tumor or infection. Is the pain associated with any neurological symptoms? Any history of previous spinal procedures, as well as the result of those procedures, is crucially important to note and understand, as there may be some component of permanent damage as a result. The rating of pain from 1 to 10 may be misleading as patients who are repetitively questioned to quantify may become overly conditioned and magnify their response.

Neurological History

History of weakness, falls, gait abnormalities, difficulty with fine motor movement, bowel or bladder dysfunction, and/or sexual dysfunction are all potential signs of myelopathy. This should be obtained in the initial history, which should also include questions about grip strength, dropping items such as coffee cups, or burning the fingers. Upper extremity weakness or pain needs to be noted, along with any associated radicular symptoms into the arms or legs.

Past Surgical History

Any prior surgical history is important, as it may influence the spine. However, most important is the history of any prior spine procedures, their cause, what the procedure was, and what the results of the intervention were. Residual problems following the surgery become extremely important to document, and having copies of the medical record, including the operative notes, can be extremely important.

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