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Musculoskeletal Aging Dorothy D. Sherwood, MD, FACP 4/19/2012 Overview Pathobiology Clinical Presentation and Treatment of: Cervical Spine Lumbar Spine Hip Knee Pathobiology of DJD Degeneration of Cartilage 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 AGE! 50 to 80% of people over 60 have symptomatic DJD Obesity Genetics Injuries Crystal arthopathies Vitamin D deficiency Cervical Spine Disease Anatomy: 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 80 to 90 % of non-traumatic cervical pain is due to DJD – but DD included Rheumatoid Arthritis Spondyloarthritis Polymyagia Rheumatica Bone Mets/Cord Tumor Infection Multiple Sclerosis Cervical DJD 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 Cervical Spondylosis – DJD Cervical Spondylitic myelopathy: weakness, impaired coordination, gait impairment, bowel or bladder incontinece, babinsky 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 Physical Exam: Cervical ROM Muscle palpation Strength, reflexes, sensory, gait, upper motor neuron signs Maneuvers: Spurling, Elvey, Upward Traction Imaging: 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 Treatment: Motor findings: refer to Neurosurgeon of choice Sensory findings: respond well to time… Steroid taper TCA Gabapentin Narcotics If safe, NSAID is always indicated ( but not if you are using a steroid taper ) NSAID and Elderly Renal Toxicity GI Toxicity 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 Pathophysiology Loss of Interverterbral disc with degeneration Loat on the Facets Facet hypertrophy Ligament hypertrophy Lumbar DJD Terminology: Spondylosis: arthritis Spondylolisthesis: slippage – Grade 1 to 4 Sondylolysis: fracture of the pars interarticularis Spinal Stenosis; squeezing the cord Radiculopathy: nerve root compression Lumbar Clinical Presentation: Pain Sensory Loss Weakness Neruogenic Claudication Bowel, Bladder incontinece, Erectile Dysfunction – Cauda Equina or Conus Medullaris Syndrome ( compression at T11) Lumbar DJD DD: Vascular Distal polyneuropathy DJD hip and knee SI Joint pain Inflammatory conditions Arachnoiditis Chronic Demylinating Polyneuropathy Sarcoidosis Carcinomatous meiningitis Lymes, HSV, HZV< EBV, mycoplasma, TB Lumbar DJD Exam: Palpate back Observe movment Neurological Exam Lumbar DJD Evaluation: 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 Treatment modalities 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 DD: Trochanteric Bursitis, Gluteusmedius Bursitis, DJD, fracture Take Home: Hip Joint Pain is anterior groin pain 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 Exam: FABERE Test Flex Abduct Externally Rotate Extend Internal and External Rotation Palpation Hip DJD Treatment: Injections can be your best friend Knee Pain 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