(Chronic) Low Back Pain

in Elderly
Jimmy Barus
Dept. of Neurology
Faculty of Medicine, Atma Jaya Catholic University of
Indonesia

Global prevalence of LBP

Hoy D et al, 2012, A Systematic Review of the Global Prevalence of

Low Back Pain, Arthritis & Rheumatism;64(6) :20282037

yo RA, Weinstein, JN, 2001. Low back pain, NEJM;344(5):363-370

Lumbar Spine Disorders in Elderly

Patients
Disk
degeneration
Intervertebral
joint
degeneration
(Degenerative
spondylolisthesis
)

Low back pain

Osteoporotic spine fracture

Kyphotic and
scoliotic spine
deformity

Neurological
symptoms of
lower limb

Stages of low back pain in elderly

Dysfunction

Lesions causes developent of

mechanical inflammation

Instability

Progression of the
degenerative process
develops instability and pain

Restabilizati
on

Restriction of motion due to

spur formation, joints
deformation etc

Pattern of spine and related structure

disorders

Most common Pain Generators in Chronic LBP in

Elderly

Pain generator Detection

Facet joint
Motion palpation
dysfunction
Tissue texture changes
Tenderness
Internal disc
Specific imaging technique
disruption
Vibration
Response to loading
Myofascial
Palpation muscle spasm
trigger points
Radiculopathy
Nerve root tension
Neurologic deficit
clinically/electrophysiologica
lly

Murphy, D.R., 2000, Non Surgical Approach to Chronic LBP, Medicine & Health Rhode Island;83(4)
Sizer, P.S., et al. 2001. Pain generators of the lumbar spine, Pain Practice;1(3).

Pattern of back disorders

ain worse with flexion

Claudicant pain eased by
Disc prolapse (plus neurological sign)flexion
Spinal Stenosis
Annular tear

ain worse with extension and rotationProgressive bilateral

Facet joint disorder
neurological
Spondylolysis
deficit and spinchter
Localised buttock pain
disturbance
Central disc prolapse
Sacroiliac disorder
Cauda equina syndrome
Sord compression
Spinal vascular accident

peed C, 2004. ABC of rheumatology : Low back pain, BMJ;328: 1119-1121

Mekanisme Proteksi Nyeri

Spinothalamic
tract

spasme otot

Descending influences
Joint receptor (nociceptor)

II-IV
III-IV
I

B Joint dysfunction
or pain

Ia

Nociceptor
-Motoaxon

A Muscle pain

-Motoaxon
Muscle spindle

Chronic/degenerative
Low Back Pain

7/19/16

10

Important points in diagnosing

LBP in elderly
MRI and
procedure

other imaging/diagnostic
tend to show false-positive
findings
Physician should not necessarily
conclude that clinical symptom is
attributable to abnormal findings on
the images
Careful history taking and physical
findings are important
Functional diagnosis sometimes
provides evidence

Assessment of elderly with chronic

pain
Assess pain intensity
Complete history and physical
examination (including
comorbidities
Review intensity, location,
excacerbating/alleviating factors,
and impact on mood and sleep
Screen for cognitive impairment
Screen for depression

Multidisciplinn
ary approach
is always the
best

Review of ADL
Assessment of gait and balance,
hearing, and visual impairment
Kaye AD et al, 2010. Pain management in the elderly population: A review, The Ochsner

Treatment of lumbar spine disorders in

elderly patients
Conservative Therapies (first
choice)

Medication (NSAID, muscle relaxants, adjuvant

analgesics etc)
Local/Block theraphy
Physical & Psychological therapy (physiotherapy,
therapeutic exercise, CBT)

Surgical therapies (second choice)

Decompression
Spine fusion

Yamamoto H, 2003. Low back pain due to degenerative disease in elderly patients, JMAJ;46(10):433-438

Treatment of Pain in elderly: Adapted WHO

Ladder for elderly
Recovery

IPM

Strong opioids
+/- adjuvants
Acetaminophen +
weak opioids +/adjuvants
Acetaminophen/COX 2
specific NSAID +/adjuvants

Surgery

Celecoxib in Flare up of Chronic Low

Back Pain
Percentage of successful responders at week 6
P = 0.013P = 0.001 P = 0.123 P = 0.008
66.0
65.4
64.1
63.2
50.2
60.0 56.8
55.1
49.9
50.0 -

Successful responders (%)

70.0 -

Celecoxib
200 mg bid
Tramadol HCI
50 mg qid

40.0 30.0 20.0 10.0 0.0 Evaluable

population
(study 1)

ITT
population
(study 1)

Evaluable
ITT
population population
(study 2)
(study 2)
ODonnel JB, Ekman E et al. J Int Med Res 2009;37(6):1-14.

SUCCESS-1: Fewer Complicated Upper GI

Events* With Celecoxib vs Nonselective
NSAIDs
Nonselective NSAIDs (diclofenac 50 mg BID
or naproxen 500 mg BID)

Cumulative Incidence (%) of

Complicated Upper GI Events*

0.25

Nonselective NSAIDs

Celecoxib (100 or 200 mg BID)

0.20

0.15

P=.002

0.10

Celecoxib

0.05

0
0

20

40

80

100

120

3716
7466

3604
7204

616
1357

Exposure, days

Number at Risk
Nonselective NSAIDs
Celecoxib

60

4393
8797

4388
8792

4191
8412

3957
7954

* Includes perforation, obstruction, and bleeding due to gastric or duodenal ulcer, or upper GI hemorrhage with
significant bleeding/volume loss.
Adapted from Singh G et al. Am J Med. 2006;119(3):255-266. 2006 with permission from Elsevier.

Cardiovascular Events
McGettigan and Henry Meta-Analysis of
Observational Studies

McGettigan P, Henry D PLoS Med 2011;8:e1001098

18

Pregabalin, celecoxib, and their combination for treatment of

chronic low back pain
Romano CL et al, 2009, J. Orthopaed Traumatol;10:185 - 191
Mean VAS pain reduction after treatment
Celecoxib + Pregabalin (LANSS>12, N=16)
Celecoxib + Pregabalin (LANSS<12, N=20)
Celecoxib + Pregabalin (All patients, N=36)
Pregabalin + placebo (LANSS>12, N=16)
Pregabalin + placebo (LANSS<12, N=20)
Pregabalin + placebo (All patients, N=36)
Celecoxib + placebo (LANSS>12, N=16)
Celecoxib + placebo (LANSS<12, N=20)
Celecoxib + placebo (All patients, N=36)
-5

10

15

20 25 30 35
% VAS reduction

A LANSS score 12 suggests neuropathic pain; a LANSS score <12 suggests nociceptive pain
VAS, visual analogue scale

40

45

50

55

Copyright 2007 American Heart Association

Antman, EM et al. Use of nonsteroidal antiinflammatory drugs: an update for

clinicians: a scientific statement from the American Heart Association. Circulation

19

 Interventional therapies:
Facet joint intervention mixed evidence
Could be effective in selected patients
Image guided transforaminal approach
yielded better outcome than blind procedure

Surgical
Intractable pain, spinal stenosis, progression
of symptoms (especially those with
neurological deficits)

Case illustration
Seorang laki-laki usia 69 tahun, pensiunan guru,
datang dengan keluhan nyeri punggung bawah
menjalar ke tungkai bawah kanan kambuhan
sejak 2 tahun dan semakin memberat sejak 3
bulan terakhir.
Nyeri punggung bawah dirasakan konstan, dan
memberat dengan aktivitas, duduk maupun
berdiri dalam jangka waktu lama,
membungkuk, dan saat mengangkat beban
berat. Nyeri berkurang jika pasien berbaring
sambil menekuk lutut kanan

 Penjalaran nyeri sampai ke tungkai bawah kanan

sisi lateral dan punggung kaki, dirasakan berupa

sensasi panas/terbakar konstan, memberat saat
malam hari. Kadang terasa seperti tertusuk jarum.
Riwayat penyakit dahulu: Riwayat Stroke ringan 2

tahun yang lalu + hipertensi.

Obat-obatan saat ini: Asam asetil salisilat 1x80 mg;

candesartan 1x8 mg

 Pemeriksaan fisik yang relevan:

Intensitas nyeri 7/10

Berkurangnya ROM vertebra lumbalis ke segala arah
Nyeri saat fleksi dan rotasi ke kanan
Nyeri tekan pada area paraspinal kanan
Tanda Lasegue (+) pada tungkai kanan, 450
Penurunan sensasi suhu dan rangsang tajam (pinprick) pada tungkai bawah kanan mulai bawah lutut
terutama pada sisi lateral sampai ke punggung kaki
Mampu berdiri jinjit maupun berjalan dengan bertumpu
pada tumit

 Pemeriksaan fisik yang relevan

Tidak ditemukan adanya atrofi otot

Berkurangnya kekuatan dorsofleksi ibu jari kanan
Refleks patela dan akiles dalam batas normal
Sulit tidur karena sering merasa nyeri pada malam hari
Aktivitas fisik terbatas karena pergerakan tertentu memicu
nyeri

Hasil MRI (1 bulan yang

lalu)
Protrusi diskus
lumbalis 4/5
dengan kompresi
pada radiks L5
kanan
Bulging diskus
L5/S1 sentral
Perubahan
degeneratif sendi
faset L3-4; L4-5,
dan L5-S1 bilateral

Pertanyaan 1
Kondisi apa sajakah yang berperan
sebagai Pain Contributor/Pain
Generator pada kasus ini ?
A. Perubahan degeneratif pada sendi faset
L3-4; L4-5, dan L5-S1 bilateral
B. Spasme otot paravertebra lumbal kanan
C. Kompresi dan iskemia radiks L5
D. Degenerasi/Protrusio diskus

Pertanyaan 2
Manakah pilihan terapi farmakologis
berikut yang paling sesuai diberikan
pada pasien ini?
A. Meloksikam + Pregabalin + Tizanidin
B. Asetaminofen + Diklofenak + Pregabalin
C. Amitriptilin + Tramadol + Tizanidin
D. Celekoksib + Tramadol + Eperisone HCL
E. Asetaminofen + Fenitoin + Eperisone HCl
F. Celekoksib + Eperisone HCl + Metilkobalamin

Take home points

(Chronic) low back pain/(c) LBP in elderly usually has
multiple pathological underlying process
The problem of CLBP in elderly is not only pain, but also
quality of life (physical and psychological problems) that
needs to be addressed simultaneously in order to provide
better care
Multidisciplinnary approach in CLBP usually works better
Always consider safety and efficacy of all
approach/treatment program, educate properly and do
not forget to WORK TOGETHER AS A TEAM

Terima kasih

Multidisciplinnary approach in chronic

pain
is always the best