Back pain in the elderly – non-surgical options

In this episode of PodMD, experienced Brain and Spinal Surgeon Dr Ameya Kamat will be discussing the topic of back pain in the eldery – non-surgical options, including how the approach in managing pain is different for these patients, the risks of leaving it untreated, the non-surgical options, the role of complementary therapies, when a GP should refer and more.


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  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Ameya Kamat

    Dr Ameya Kamat is an experienced Brain and Spinal Surgeon, specialising in the surgical treatment of conditions involving the brain, spine, and peripheral nerves. Dr Kamat consults at various locations across Victoria, including Mulgrave and Moorabbin.

    Dr Kamat embarked on his medical career by receiving his Fellowship in Neurosurgery in 2019. He furthered his studies by earning a Masters in Medicine (Neurosurgery) degree in Cape Town, South Africa in 2020. Following this, Dr Kamat then pursued a Complex Spine Fellowship at Macquarie University Hospital in Sydney, where he honed his skills. In recognition of his accomplishments, Dr Kamat was awarded a Fellowship of the Royal Australasian College of Surgeons in 2023.

    Today, we’ll be discussing the topic of back pain in the elderly – non-surgical options.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Ameya, thanks for talking with us on PodMD today.

    Ameya : Thank you for having me, good to be here!

    Question 1
    The topic of today’s discussion is back pain in the elderly: non-surgical options. Ameya, can you give us a brief overview about back pain in elderly patients?

    Ameya: Absolutely. Back pain is very common in the elderly. Essentially starts in your mid to late 40s and gets personally worse over time. And once you hit 65-70-80 often back pain is running your major complaints. It usually happens due to degenerative disc or joint disease in the spine and it can be debilitating. It can affect your lifestyle, it can affect your sleep and it can affect your mood. It can affect your mental health and at the end of the day nobody wants to live in pain and if you’re dating back pain, you’re on medication all the time. You just not feeling good about life in general and something that needs to be done about it.

    Question 2
    How does the approach to managing back pain differ in elderly patients compared to younger patients?

    Ameya: Yeah. So in younger patients, it’s usually like an acute disc prolapse or a muscle strain often is like the most common thing. In elderly people, it’s usually a joint problem or it could be a disc problem. It it’s not as common to have a musculoskeletal injury or like a muscle strain in the elderly compared to younger people because young people are a lot more active, they participate in a lot more things like sport and they’re hiking. And they have young children who they’re lifting. They’re moving house. So they’re picking up heavy boxes and moving furniture around because elderly don’t do that as often.

    The best way to approach this, though, is firstly a thorough history and examination to ask the time of onset. It happens suddenly it’s most likely something that acute, like a muscle strain or just pull-ups. It was happening gradually overtime and getting worse. That’s probably more a degenerative picture if it’s something that’s associated with everything, like weight loss and night sweats or pain, that doesn’t settle when you’re lying down. Now you’re starting to worry about things like infection or cancer. So these things are like, really important.

    It’s also good to know, you know, if they’ve had any bladder or bowel issues. Because the nerves are go to your blood and bowel could be compressed and that’s quite. Serious. And you also want to know if there any numbness or weakness in the arms or legs. You also want to know if the pain radiates down the arms or legs and these are all good factors to actually or good things that I actually ask them to see if you can differentiate what the potential causes are.

    Question 3
    What are the major risks of leaving this untreated?/strong>

    Ameya: So it can be very serious. Depends, of course, where the compression of your spine is. If that is the cause of it, it can lead to limb numbness, limb weakness, it can lead to paralysis. Can lead to bladder or bowel issues, mood problems, sleep disturbances, being hooked on medication, on pain medication just to get over the pain. So yeah, leaving back pain or neck pain untreated does have long standing negative consequences, unfortunately.

    Question 4
    What are the main non-surgical treatment options?

    Ameya: So I always recommend actively modification. I believe that you know, like lifting heavy objects or bending your back to your objects from the ground or repetitive, twisting, bending, climbing, jumping, heavy lifting, these things can all aggravate or even like reduce the healing capacity off the injury. Things like weight loss cause you know, like having a large pendulous abdomen does put lots of pressure on your spine. Smoking accelerates the degenerate process, so quitting smoking is really, really important.

    I always recommend patients see a physiotherapist for range of motion exercises and core strengthening. Having a very strong core is really important, especially around the abdomen. The lower back those muscles, the stronger they are, the better the biomechanical stability of your spine in general, even these days, most of the procedures we try and do are muscle sparing because we don’t like damaging muscle anymore.

    Things like Pilates, acupuncture, these are very useful in helping with pain and there are procedures like where we can give a cortisone injection which reduces the swelling around the nerve. So although all these are very good non-surgical treatment options that we always try first to try and avoid surgery, surgery is always the last thing we should be doing for patients especially with back pain or leg pain.

    Question 5
    Have there been any developments in the treatment of elderly patients in the last years or are there any in trials or development now?

    Ameya: Absolutely. We’re definitely moving away from doing these big massive complex spine procedures, you know, like over the last 20 years, they’ve been so many patients who’ve had lots of spinal instrumentation and now they’re coming back with lots of complications. I’m not saying spinal instrumentations a bad thing, but it should only be reserved for people who actually need it. So I always start off with non-surgical or noninvasive procedures, things like caudal epidural injections are very useful where essentially we inject a high volume of steroid and local anesthetic into like the tailbone area and what that does is it pushes fluid up towards the lumbar spine and coats all those nerves and joints with a combination of steroid and local anesthetic. And patients get really good pain relief for between, you know, three months and and a year even.

    We also have a procedure called radiofrequency ablation. Essentially the small joints and the spine called your facet joints are massive pain generators. And as we get older, these joints become more arthritic, they get inflamed, they carry more fluid, and then they generate pain. So there are some small nerves that that essentially transmit pain from these joints to the brain and radio frequency ablation is, is is a simple day procedure that takes about 20-30 minutes. And we can literally zap those nerves and extend them. And gives patients really good pain relief. Doesn’t take all the pain away, but it certainly takes the edge off it. And and, you know, makes it more tolerable. And they can have pain relief for between a year and two years even. So that’s something we we always do.

    And then with regards to more invasive stuff, as I said earlier, you know, over last 20 years, spinal fusion has been. The big thing lots of people have been getting it unnecessarily and you know in in the right patient, a spinal fusion is a great operation, but this should be only performed when absolutely required. Simple spinal decompression seem to work really well as well. So we always try and avoid, you know, doing anything too big first up there is another thing to endoscopic spine surgery and we’re now we’re using little cameras to try and you know, decompress nerves and and decreasing the rate of spinal fusion as well. And that’s certainly the biggest development I think in terms of the last year or two, we’re also using things like you know, navigation where we watch where all our metalware is going and if we need to do a fusion. There’s robotic surgery as well, but that, that’s all stuff that that’s the very high end sort of stuff that the very few patients actually require.

    Question 6
    What if non-surgical options are failing?

    Ameya: Yeah. So this would depend on the precise problem. Firstly to go under the knife at all, you should be at the close to end of your tether. You should, you know, if you if people start to niggle, surgery is not necessarily for you. You also need to be in the right mental frame of mind to undergo. Surgery. But I always say you know, if non surgical options are failing, we do have minimally invasive procedures like radiofrequency ablation, minimally invasive spine options like endoscopic spine surgery or you’re doing small spinal decompression procedures that really do help with pain. So there are tons of options out there and I always try and tailor an option to each individual patient’s unique need. There’s several options there, they really are, and no two people have the exact same problem.

    Question 7
    What role do complementary therapies, like acupuncture or massage, play in the management of chronic back pain among the elderly?

    Ameya: Yes, these actually very useful because what happens is the thing called the gate theory, where once we have an injury or something that causes pain, the pain generator fibers transmit these impulses to the brain. With things like massage and acupuncture, they result in different fibres being used, which are actually faster than the pain fibres. So you almost trick your body into feeling those sensations before the pain actually reaches your brain. So that’s where things like acupuncture and massage dry needling come in.

    Question 8
    When should a GP refer?

    Ameya: I think GP should refer if a patient has unrelenting back pain or especially if they have back pain that’s associated with leg pain or neck pain that’s associated with arm pain where you get electric shock like sensations going down your arms and leg. If patients get numbness in their arms or legs, weakness in their arms or legs or bladder or bowel problems, these are all really big reasons to refer and refer early. I agree that the majority of these patients resolve on their own, and in fact always scored 75 to 90% of patients with these acute problems, especially the young like the younger patients, resolve in about 12 weeks. However, getting patients seen early has its major advantages as well

    Question 9
    What role does the GP play in the treatment of the back pain in the elderly?

    Ameya: Yeah. So the GP is your main gatekeeper in terms of patients come and see their GP first. The vast majority of patients will always go and see their GP before seeing the ED doctors or specialists or anything of that sorts, so I would always encourage GP’s to push patients to, to modify the activities, modify their lifestyle, quit smoking, lose weight, you know, encouraging active lifestyle. That’s very, very important. Performing a thorough neurological examination also is imperative because sometimes subtleties can be missed. And performing that examination will help you pick up those small nuances.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on back pain in the elderly: non-surgical options?

    Ameya: Sure. Yeah. I think that the first one is that you know, just because you’re getting old doesn’t mean you need to be living in pain. You know, we always say as as we all get older, you know, I’m getting old. My neck is a bit sore. My back’s a bit sore and listen, if it’s a tiny little niggle that isn’t troubling you too much. Fair enough. But if it’s really affecting your lifestyle, affecting your mood, affecting your sleep, affecting your mental health, requiring you to take several medications, you should get it checked out. That’s why, like the most important thing.

    The second thing to know is not all forms of back and neck pain require surgery. Sometimes we can just see a patient, refer them to the ideal physio or occupational therapist or planning instructor to do certain things to help with that. So surgery. Yes, it’s an option in many cases, but it’s not necessary in all cases.

    And the third thing is referring patients early. I mean as we get older, there are other things that that could cause pain as well in your back you know things like cancers, infections and things along those lines. So someone has unrelenting pain, the pain it’s worse at night. Pain that doesn’t resolve with lying down. It’s always good to get it checked out. It’s most likely nothing, but if it is something diagnosing early is always the key.

    Thanks for your time and the insights you’ve provided.

    Ameya: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.