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Musculoskeletal
Aging
Dorothy D. Sherwood, MD, FACP
4/19/2012
Overview
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Pathobiology
Clinical Presentation and Treatment of:
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Cervical Spine
Lumbar Spine
Hip
Knee
Pathobiology of DJD
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Degeneration of Cartilage
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Chondrocyte: Normal function to create and
break down matrix
Proinflammatory cytokines ( IL 1, 6,7,8 and TNF
alpha) cause chondrocytes to stop making
healthy matrix and increase the breakdown of
cartilage
Thickening of subchondral bone,osteophyte
formation, hypertrophy, ligamental injuries.
Risk Factors
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AGE! 50 to 80% of people over 60 have
symptomatic DJD
Obesity
Genetics
Injuries
Crystal arthopathies
Vitamin D deficiency
Cervical Spine Disease
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Anatomy:
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8 cervical nerves with ventral and dorsal roots
Spinal nerve spits into the dorsal ramus and the
ventral ramus
Dorsal ramus – posterior neck pain
Ventral ramus – Brachial plexus as well as
paraverterbral neck pain
Myotome- group of muscles innervated by a
spinal nerve
Dermatome- sensory innervation.
Cervical
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80 to 90 % of non-traumatic cervical pain is
due to DJD – but DD included
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Rheumatoid Arthritis
Spondyloarthritis
Polymyagia Rheumatica
Bone Mets/Cord Tumor
Infection
Multiple Sclerosis
Cervical DJD
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Stiff neck/cervical strain: c/o neck pain, restricted
ROM, para-spinal muscle tenderness – may or
may not have trigger points; no weakness, no
sensory symptoms, will have LROM of the neck
on exam. Neurological exam normal.
Management: NSAID if tolerated in elderly; low
dose hydrocodone if needed for further relief of
pain ( sleep interuption ) ; avoid muscle relaxers –
don’t work and are very anticholinergic.
Cervical DJD
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Cervical Spondylosis – DJD
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Cervical Spondylitic myelopathy: weakness,
impaired coordination, gait impairment, bowel or
bladder incontinece, babinsky
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Due to cord compression by arthritic changes.
Think of it as squeezing the cord
Cervical Radiculopathy: pain, weakness, sensory
changes and reflex changes due to pinching the
nerve at the cervical foramen
Cervical DJD
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Physical Exam:
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Cervical ROM
Muscle palpation
Strength, reflexes, sensory, gait, upper motor neuron signs
Maneuvers: Spurling, Elvey, Upward Traction
Imaging:
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X ray Cervical spine: shows curvature, shows position of
vertebra, shows arthritic changes that can be causing pain,
metastatic lesion, osteomylitis
MRI Cervical Spine: age >50, immunocompromised, h/o cancer,
neurological findings, fever – non-contrast if just looking for DJD
changes. Gadolinium in patietns with GFR < 30 causes
Nephrogenic Systemic Fibrosis
CT Cervical Spine: looking more for boney problems
Cervical DJD
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Treatment:
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Motor findings: refer to Neurosurgeon of choice
Sensory findings: respond well to time…
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Steroid taper
TCA
Gabapentin
Narcotics
If safe, NSAID is always indicated ( but not if you
are using a steroid taper )
NSAID and Elderly
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Renal Toxicity
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GI Toxicity
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Age is major risk factor after known CKD
CHF
Hypertension with chronic meds
Volume Depletion
Age
H. pylori
Steroid use
Anticoagulant use
Prior h/o bleeding ulcer
Choice: lowest dose, shortest duration, monitor every 3
months for GI and or Renal Toxicity
Use PPI in all patients over age 70
Lumbar Spine Disease
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Pathophysiology
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Loss of Interverterbral disc with degeneration
Loat on the Facets
Facet hypertrophy
Ligament hypertrophy
Lumbar DJD
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Terminology:
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Spondylosis: arthritis
Spondylolisthesis: slippage – Grade 1 to 4
Sondylolysis: fracture of the pars interarticularis
Spinal Stenosis; squeezing the cord
Radiculopathy: nerve root compression
Lumbar
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Clinical Presentation:
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Pain
Sensory Loss
Weakness
Neruogenic Claudication
Bowel, Bladder incontinece, Erectile Dysfunction
– Cauda Equina or Conus Medullaris Syndrome (
compression at T11)
Lumbar DJD
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DD:
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Vascular
Distal polyneuropathy
DJD hip and knee
SI Joint pain
Inflammatory conditions
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Arachnoiditis
Chronic Demylinating Polyneuropathy
Sarcoidosis
Carcinomatous meiningitis
Lymes, HSV, HZV< EBV, mycoplasma, TB
Lumbar DJD
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Exam:
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Palpate back
Observe movment
Neurological Exam
Lumbar DJD
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Evaluation:
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Back pain alone of recent onset: NSAID, opiate,
follow up in 4 weeks – if still present X ray and
ESR – if abnormal MRI
Back pain with neruo findings in patient >50: pain
relief – opiate, NSAID not as helpful: if pain only
– treat and if not better in 4 weeks – MRI: If
weakness – MRI and refer.
Bowel, bladder, ED, sensory level – MRI
H/O fever, cancer, weight loss - MRI
Lumbar
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Treatment modalities
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Physical Therapy : No proven benefit, no
standard treatment protocol, but everyone does it
and patients like it
Injections: may give short term benefit
Surgery: depends on the problem – helps in a
young back, dicy at best in an old back
Hip DJD
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DD: Trochanteric Bursitis, Gluteusmedius Bursitis, DJD,
fracture
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Take Home: Hip Joint Pain is anterior groin pain
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There are 18 bursas in the hip joint and they can all hurt
Trochanteric Bursitis is lateral thigh pain
Lateral Cutaneous Femoral Nerve Pain – not influenced by
movement
Anterior hip or groin pain – usually DJD but r/o osteonecrosis,
abdominal pathology such as hernia, or L2-3 nerve root
Posterior pain is almost never the hip – lumbar, SI Joint or
Leriche’s syndrome (vascular disease causing buttock, hip,
thigh claudication)
Hip DJD
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Exam:
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FABERE Test
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Flex
Abduct
Externally Rotate
Extend
Internal and External Rotation
Palpation
Hip DJD
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Treatment:
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Injections can be your best friend
Knee Pain
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Medial: meniscal, medial ligament,
Anserine bursitis
Lateral: meniscal, lateral ligament, iliotibial
band syndrome
Anterior: Patellofemoral syndrome, Patellar
bursitis, Patellar tendonopathy ( jumpers
leg ) Osgood Schlutter – tibial pain
Posterior:Arthritis, Bakers Cyst,
Valgus Movement testing Medial Collateral Ligament
Varus movement, testing lateral collateral ligament