Cartilage can pinch nerves too. “Think of squeezing the jelly out of a donut. When the bones of the spine push down on the discs, the cartilage of the disc comes out, similar to the jelly within a donut. This cartilage can press on the nerve and pinch it,” says Alok Sharan, M.D., chief of the orthopedic spine service at Montefiore Medical Center in the Bronx, N.Y.
Bone spurs are bony projections among any joints. “In the back, they result from the vertebrae’s attempts to repair itself, but more often they cause nerve pinching,” Brandwin says. Sciatica—pain from your back down the leg—is one result of pinched nerves.
Less commonly discussed problems
Your abdominal muscles support your back and tend to weaken with age, especially without strengthening exercises needed for back support. “Someone carrying a big belly can be straining their back,” Brandwin says.
“Your coccyx, or tailbone, is one of the most serious and challenging sources of back pain in older adults,” says Patrick Foye, M.D., director of the coccyx pain service, (www.tailbone.info) at New Jersey Medical School in Newark. “The tailbone is actually a series of bones at the base of your spine. As people age, these bones can fuse, fracture, dislocate, or develop arthritis. Sitting becomes intensely painful. But for years doctors could only offer two options: ‘grin and bear it’ or undergo a very radical surgery removing the tailbone.”
Treatment options
Older adults need to be careful about medications for back pain. “There is more likelihood of drug interactions, or drugs for fighting pain may last longer in the system,” Clark says.
“I can’t tell you how many older people take pain killers to relieve back pain, then fall and break a hip from the drug’s sedative effects,” Brandwin adds.
Weeks of bed rest is no longer recommended, especially for older adults. “They become easily fatigued and have more back spasms. They can also become more socially isolated, leading to depression,” Clark says. Instead, movement—including aquatic exercises and physical therapy—is highly recommended for back pain.
Foye is teaching a new treatment—an injection— for tailbone pain. “If the cause is inflammation near the tailbone, sometimes we inject steroids. But more often I inject a local anesthetic,” he says.
“At the tailbone, a local anesthetic injection can decrease the irritability of a major nerve network (the ganglion impar), often bringing years of relief,” Foye says. “We might bring your tailbone pain down from a 10 to a 4 initially, and often even better after a couple of injections. (Results vary with each individual.) We have had people say that now, after the proper injections, they can sit for a 45-minute drive to go visit their grandkids,” he adds.
What about surgery?
“For people with pinched nerves, we remove what’s compressing the nerve, either the bone spur or the excess cartilage. Sometimes when the spine starts to slip and the vertebrae are on top of each other, we fuse the two bones together, a process called spinal fusion,” Sharan says.
But back surgeries tend to be tricky. “Fusions can cause additional stresses on the next disc level. If the next level isn’t normal, you may find it only aggravates the problem,” Hisey says.
“We find people get about the same 50/50 chance of back pain relief from therapy and/or medications that they get from surgery,” Brandwin says. “Surgery is not the first and foremost treatment for chronic back pain; it’s the last resort. You should only discuss surgery when something nerve-related is involved, like a bone spur pressing on the nerve.”
Proper diagnosis is critical
Notice that Brandwin doesn’t say have surgery; he says discuss it. “An x-ray might show a bone spur on the right, but your pain is on the left, so the spur isn’t the cause of the pain,” he says.
“All bone spurs don’t have to be removed. Surgery can just make them worse, especially if it doesn’t truly address the source of the pain,” Hisey adds.
Not all back pain has to do with the back. “Your problem could be from aneurysms, ulcers, kidney disease, and cancers, among other things. You have to get a total picture,” Brandwin says.
Proper diagnosis is ultimately the greatest challenge in fighting back pain. “Right now, the gold standard is an MRI. It will generally give you a structural look at what’s really causing pain, by showing images not just of bone, but disc spaces and nerve roots as well,” Brandwin says.
“Back pain usually has more than one cause. You can fix something in the spine but if you still have weak muscles, you may still have back pain,” Brandwin says. That is why a good team approach, starting with your primary care doctor, is critical.