Clinical Case: Lower Back Pain in an Older Woman - Clinical Pain Advisor

Clinical Case: Lower Back Pain in an Older Woman

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  • Figure. Anteroposterior radiograph of the lumbar spine.

An 80-year-old woman presents to the office with a complaint of back pain that radiates to her lower extremities; the pain in her extremities intensifies with standing and walking. To help relieve the leg pain, she feels the need to flex her trunk forward while walking, otherwise known as the shopping cart sign. Radiographic examination of her lumbar spine is ordered and shows degenerative scoliosis with a 25° convex curve to the right side (Figure), as well as lateral listhesis at L3-L4 and L4-L5.

Degenerative scoliosis is a lateral curvature of the spine that is typically seen in elderly patients with degenerative disc disease and lumbar facet arthritis.1 Although adult-onset idiopathic scoliosis generally involves the thoracic spine, degenerative scoliosis commonly involves the lumbar spine.1...

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Degenerative scoliosis is a lateral curvature of the spine that is typically seen in elderly patients with degenerative disc disease and lumbar facet arthritis.1 Although adult-onset idiopathic scoliosis generally involves the thoracic spine, degenerative scoliosis commonly involves the lumbar spine.1

The etiology of degenerative scoliosis is unclear. Multiple factors such as low body mass index, osteoporosis, degenerative disc disease, facet arthritis, facet tropism, and lateral listhesis are thought to contribute to the disease.1 Scoliosis may develop due to an asymmetrical collapse of the disc space and facet degeneration that leads to a lateral and rotational deformity of the lumbar spine in the coronal plane.  The same degenerative cascade can lead to kyphosis and/or lordosis in the sagittal plane.1,2

The patient in the case presents with classic symptoms of degenerative scoliosis and spinal stenosis that are the cause of her lumbar radiculopathy. Chronic lower back pain with intermittent leg pain are the most common symptoms. Patients may also complain of a change in their body shape as the deformity progresses. Pain that is improved with forward bending of the spine is associated with spinal stenosis caused by scoliosis. Factors that are associated with curve progression include a Cobb angle >30°, lateral listhesis of >6 mm, and significant vertebral body rotation.2 Coronal curves of <30° rarely progress.1,2

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.

References

1. Koerner JD, Reitman CA, Arnold PM, Rihn J. Degenerative lumbar scoliosis. JBJS Rev. 2015;3(4):01874474-201504000-00004.

2. Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus. 2010;28(3):E1.

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