Deconstructing Chronic Low Back Pain in the Older Adult – Shifting the Paradigm from the Spine to the Person – Introduction
SOURCE: Pain Medicine 2015 (May); 16 (5): 881-885 ~ FULL TEXT
Debra K. Weiner
Geriatric Research, Education & Clinical Center,
VA Pittsburgh Healthcare System,
University of Pittsburgh,
Pittsburgh, PA, USA.
Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled , and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket. [1-3]
Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected.
This issue of Pain Medicine contains the first in a series of articles on how to systematically and comprehensively rethink our approach to evaluating and designing management for older adults with chronic low back pain (CLBP). The series is entitled “Deconstructing Chronic Low Back Pain in the Older Adult: Step-by-Step Evidence and Expert-Based Recommendations for Evaluation and Treatment” and the article in this issue focuses on hip osteoarthritis (OA), an important potential contributor to CLBP in older adults.
KEYWORDS: Back Pain; Chronic Low Back Pain; Chronic Pain; Elderly; Geriatric; Homeostenosis; Low Back Pain; Lumbar; Magnetic Resonance Imaging; Older Adults; Pain Management; Treatment Outcome
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To understand how we might attempt to improve the care of older adults with CLBP, let us start by examining current approaches. Management of patients with CLBP often begins with a search for the cause of pain using spinal imaging.
The vast majority of people with CLBP do not require imaging because they do not have “red flag” pathology, that is, serious disorders such as cancer or infection that require urgent treatment. 
Spinal imaging in the older adult who does not have red flags on history or physical examination will almost certainly reveal “abnormalities.” Imaging evidence of lumbar degenerative disc and facet disease is nearly ubiquitous in older adults, even those who are pain-free. 
An estimated 20% of older adults without neurogenic claudication have moderate to severe lumbar spinal stenosis on magnetic resonance imaging. 
Thus older adults may be especially susceptible to receiving invasive treatment guided principally by imaging-identified degenerative spinal pathology and it is not surprising that such treatment is often inefficacious.
While CLBP can be a management challenge for patients of all ages, we focus on older adults because of their vulnerability to undergoing degenerative spine disease-focused procedures that may not be necessary, as well as adverse drug effects and invasive treatment-associated morbidity. [7, 8]