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by Dr. David Borenstein, Medically Reviewed by Dr. C.H. Weaver M.D. 02/2022

Old Age and Back Pain

Older individuals are at risk of developing chronic low back pain as they age. The specific parameters that predict the development of this common ailment remain in question. Sakai and colleagues were intrigued with this clinical problem and designed a cohort study to identify those factors that were associated with the development of chronic low back pain.1

The authors enrolled 203 individuals with chronic low back pain, average of 79 years comprising 62.1% women, 37.9% men and an equal number of age-matched controls without back pain. Laboratory measurements included complete blood counts along with albumin, C-reactive protein, total cholesterol, creatinine, glomerular filtration rate, and 25-hydroxyvitamin D levels. Radiographic evaluation involved conventional radiography of the standing spine measuring the forward tilt of the spine, scoliosis, and instability with movement (spondylolisthesis). Body mass composition was assessed with a total body dual-energy absorptiometry (DXA) scan which measures bone mineral content as well skeletal mass index. Magnetic resonance imaging of the spine identified evidence of intervertebral disk degeneration along with any specific forms of back pain, such as infection or cancer.

The laboratory results found low vitamin D levels (hypovitaminosis D) in geriatric individuals with CLBP. (14.95 vs. 16.89). Another laboratory parameter that was increased in CLBP individuals was the red blood cell distribution width (RDW). RDW is an automated measure of the heterogeneity of red blood cell sizes due to inflammation and senescence of red blood cell precursors in the bone marrow.

Body composition in CLBP individuals was associated with lower extremity muscle mass, skeletal mass index, and cross sectional paraspinous muscle mass. In addition, lower extremity fat mass and body fat ratio were higher in CLBP individuals.

The presumption that CLBP individuals would have a greater degree of disk degeneration with MRI evaluation was not found. However, greater degrees of spinal forward bending (sagittal alignment) was present.

In the discussion, the authors comment on the significance of the high RDW. This finding is thought to be a marker of chronic inflammation in the elderly. Red blood cell size variation may reflect changes in the circulatory half-life of red blood cells that is shortened by chronic inflammation. Elevated RDW is also associated with increased risk of age-related disease and overall mortality risk.2 This increased level of inflammation may be mirrored in the sarcopenia (muscle loss) in the lower extremity first and then trunk muscles associated with the replacement with fat. Further evaluation is needed to determine if the loss of muscle is the cause or the effect of CLBP and disuse. Chronic inflammation may also be related to the aging of the immune system.

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Vitamin D has the potential of preventing falls in the elderly and modifying chronic pain perception. Low levels of vitamin D may predispose individuals to sarcopenia. In the results of the study, CLBP patients who had low vitamin D levels had muscle mass loss without associated loss of bone mineral density. This suggests that vitamin D could have effects on muscle mass and chronic pain perceptions independent of impact on the bony skeleton.

Of possible greatest importance is the presence of kyphosis (spinal sagittal alignment) which was significantly different in CLBP individuals compared to controls. The loss of trunk muscle mass allows for a forward tilt of the spine which is associated with decreasing vitality. The problem is that reversing this trend requires the renewal of muscles which have atrophied. Finding means of improving this general decline is essential.

References:

  1. Sakai Y et al. Clinical characteristics of geriatric patients with non-specific chronic low back pain Scientific Reports 2022;12:1286 https://doi.org/10.1038/s41598-022-05352-2
  2. Bazick H.S. et al. Red blood cell distribution width and all-cause mortality in critically ill patients. Crit Care Med 2011;39:1913-1921