Deconstructing Chronic Low Back Pain in the Older Adult: Shifting the Paradigm from the Spine to the Person

Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled ⇓, and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket ⇓. Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected. This issue of Pain Medicine contains the first in a series of articles on how to systematically and comprehensively rethink our approach to evaluating and designing management for older adults with chronic low back pain (CLBP). The series is entitled “Deconstructing Chronic Low Back Pain in the Older Adult: Step-by-Step Evidence and Expert-Based Recommendations for Evaluation and Treatment” and the article in this issue focuses on hip osteoarthritis (OA), an important potential contributor to CLBP in older adults.To understand how we might attempt to improve the care of older adults with CLBP, let us start by examining current approaches. Management of patients with CLBP often begins with a search for the cause of pain using spinal imaging. The vast majority of people with CLBP do not require imaging because they do not have “red flag” pathology, that is, serious disorders such as cancer or infection that require urgent treatment ⇓. Spinal imaging in the older adult who does not have red flags on history or physical examination will almost certainly reveal “abnormalities.” Imaging evidence of lumbar degenerative disc and facet disease is nearly ubiquitous in older adults, even those who are pain-free ⇓. An estimated 20% of older adults without neurogenic claudication have moderate to severe lumbar spinal stenosis on magnetic resonance imaging ⇓. …