Back Pain From Fractures In Older People

Back pain is very common in older people, and as each decade goes by people have an increased number of chronic pain problems.

Most older people with back pain have a long history of back pain since they were much younger. This may have been due to disc or joint problems and the result of work or other physical activity.

Back pain which occurs for the first time when a person is over 55 years of age should always be taken more seriously as the likelihood of underlying illness is higher than in younger people.

However, it is quite common for older people to develop pain problems which have no underlying serious medical cause. Arthritic back joints may become painful after an injury or overuse, stenosis may develop and limit the ability to walk far, and stenotic changes can give a form of sciatica.

But these are not the only possibilities. Because our bones become weaker with age it is possible for back pain to develop from small internal fractures in the vertebrae. Back pain is not just an inevitable part of getting older, there is always an underlying reason.

Compression fractures

Our bones are designed to resist compression, the force which gravity and our bodyweight imposes on us. This is fine when we are younger and it is quite difficult to fracture our vertebrae without trying hard such as falling from a height or having a car crash

When we get older, especially for women over 50, our bones gradually lose some of their substance every year, becoming gradually weaker and less resistant to compression. In some of us this loss of bone mass is much faster than in others, putting us at risk from fractures at some point in our future.

If our bones become very brittle, even everyday activities can put us at risk of developing spinal compression fractures. Trivial activities such as lifting something, missing a kerb, slipping or even having a cough or sneeze can fracture the vertebrae.

Spinal Collapse

When a number of small spinal fractures occur over time, the effects begin to become apparent. The hairline fractures add up to a degree of vertebral collapse. This means that the shape of the spinal bone alters as part of it collapses down in a manner which is apparent on xray.

These minor individual fractures can all add together to change the shape and function of the spine. If you have had this problem you may have noticed a loss of height compared to younger adults you know well. People can lose two or three inches in height at times.

This kind of fracture pattern occurs most commonly in the front part of the vertebra, where there is less internal bracing, and is called anterior compression fracture. This process wedges the vertebra and if several bones are affected this causes a kyphosis in the thoracic area. This is an increased front to back curve which give a stooped forward posture. Compression fractures seem to have their greatest postural affect in the thoracic area although their occur in other parts of the spine.

When the wedging process occurs in the upper thoracic vertebrae, the change in spinal curvature known as a dowager’s hump appears. This is more properly know as a cervico-thoracic kyphosis and is observable in more elderly women with osteoporotic spinal changes.

Diagnosis of spinal compression fractures

About 60% of these fractures may not be diagnosed because many people attribute their new pains to arthritic changes and the pains which go with being older. If not diagnosed, the osteoporotic process can continue, putting the person at future increased fracture risk as well as leaving them in pain. Osteoporosis treatment is relatively successful and significantly reduces the chances of further fractures.

Consequences of spinal compression fractures

Continual spinal pain, which can be very severe and sharp, can disable a person functionally, leading to depression, medication intake, breathing problems and further fractures not just in spinal bones. The consequences of osteoporotic fracture are very serious for many thousands of elderly people every year. Fracturing the hip is one of the most common problems in very elderly people and for a large minority this signals the end of their independent life.

Who is at risk of osteoporotic spinal fracture?

There are two main groups:

People diagnosed with a kind of cancer which spreads to the bones, such as lymphoma or multiple myeloma. An unexpected fracture after a trivial activity may be the first indication that a tumour is affecting the person. In these cases a radio-isotope bone scan is often performed to check for any further risk areas.
People with osteoporosis. Since you have to lose 30% of your bone mass before it becomes evident on xray, there may be nothing to indicate you have this problem until you get the pain of a microfracture.

Risk factors for osteoporosis

These include race, sex, bodyweight, smoking, and hormonal changes:

White and Asian women are at greatest risk
The risk rises quickly in women over 50 and continues to rise with age
Low bodyweight means thin women have a higher risk
If you had an early menopause, before your late forties for example
Smokers lose bone thickness faster than nonsmokers. Yes, it’s just another of those annoying reasons why you should give up!

The frequency of osteoporosis

Over age 50 years, studies have shown that osteoporosis affects about 20% of white and asian women, 10% of hispanic women, 5% of black women and 5% of men. People who develop spinal compression fractures show a 23% increase in their mortality, so the situation is serious.

How do I know if I have a compression fracture?

Symptoms which might indicate a spinal fracture are:

Sudden onset of severe back pain, often for no apparent reason or after a light activity. Lifting one end of a piano did it for one lady but this level of effort is not required.
The pain is worse when you are weight bearing, for example standing or walking.
Lying down tends to relieve the pain to some extent.
The pain makes bending and twisting difficult to manage.
You notice you have lost height.
You notice the development of a deformity in your spine, it has come hunched to some extent.

The pain can typically start with a minor back strain during an normal activity such as lifting some groceries, bending over to pick something up or jarring yourself by slipping or missing your step.

Osteoporosis pain can vary

Everyone feels pain differently and this needs to be taken into account by your doctor when he is diagnosing you. However, the typical pain of spinal fracture is sudden, severe, sharp and disabling. People are significantly distressed by it and it limits their activities dramatically. As the bone heals over two or three months, the pain will usually subside. Sometimes pain will remain even after the fracture has healed successfully.

Referred pain can confuse the issue, with some people getting abdominal pain rather than spinal, which can be misleading. Obvious severe spinal pain is not always present. Some people may have mild pain over a long period developing into a chronic back pain, other may notice the development of the spinal curve in the thoracic area and this alerts them to a potential problem.

Multiple compression fractures

If the osteoporosis is severe enough there may be many fractures, leading to significant change in the person’s spine:

Height loss occurs with each minor fracture of a spinal bone and eventually the change in stature will be obvious.
The kyphosis or hunched back develops, throwing the balance of the whole spine out of kilter, causing lumbar, thoracic and neck pain.
The shortening of the spine can compress the stomach, causing it to bulge and give digestive difficulties.
The shortening of the spine means the rib cage can impinge on the pelvic bones at the side, causing pain.
Breathing problems may occur if the spine becomes badly curved forward as this compresses the lungs and can seriously affect breathing.

The advice overall is to see a doctor about the possibility of having osteoporosis or spinal fractures if you are an older person, particularly if you have high risk factors or symptoms.