ALTC Interview with Dr. Kaliq Chang

ALTC Interview with Dr. Kaliq Chang
March 1, 2017

An increasing amount of attention is being given to the significant economic and political consequences of looming demographic changes, which are expected to lead to greater challenges for medical care in terms of care delivery, cost, and maintaining quality of life for aging individuals.1 Adults may soon—and some currently do—expect to live to 100 years old, and they hope to be able to perform all of the usual activities of daily living up to that age. 

In order to assist the aging population in this goal, attention must be given to every aspect and probable degenerative condition of aging. How to care for the spine of an aging adult, as well as managing pain associated with spinal disorders in order to preserve quality of life,1 is an area in need of greater notice.

According to experts, degeneration of the spine begins in the third decade of life, eventually leading to progressive disc height loss and ligamentous/capsular hypertrophy, or thickening. As degeneration progresses, bony and soft tissue failure can develop, leading to a variety of spinal conditions. Osteoporosis, for one, is a large problem for the growing population of older adults as it leads to decreased bone strength and, thus, bone fractures including spinal fractures. According to one report, vertebral fractures are present in about 25% of postmenopausal women, with rates increasing dramatically with age.2 

In an effort to understand the factors that contribute to the gradual deterioration of the spine, Annals of Long-Term Care: Clinical Careand Aging spoke with Kaliq Chang, MD, an interventional pain management specialist board-certified in anesthesiology at Atlantic Spine Center, a nationally recognized leader for endoscopic spine surgery with several locations in New Jersey and New York City. Dr Chang discussed the most common spinal conditions that professionals should be mindful of in older adults and what steps clinicians can take to prevent and treat them.

As adults reach the age of 65 years and older, what are the most common types of spine-related conditions? Less common? What prior medical events or illnesses can be markers for early or more advanced spinal conditions?

In older adults who have isolated low back and/or neck pain, more than half of [these cases] are due to degenerative facet joint arthritis, which is a type of osteoarthritis that affects the parallel column of joints that connect the individual vertebra of the spine behind the spinal canal. Other common causes of back/neck pain are also largely a result of the aging process, with degenerative spine changes including spinal stenosis (narrowing of the central tube housing the spinal cord and spinal nerves), spondylolisthesis (misalignment of one vertebra over another), and/or neural foraminal stenosis (narrowing of the tunnels where the spinal nerves exit the spine). Any or all of these conditions can cause pain, which may also radiate to the arms or legs due to irritation or compression of the spinal nerves.

There are other common causes of back pain in the elderly. Sudden, sharp back pain can be a result of a vertebral compression fracture, especially in those who have advanced osteoporosis. This can be treated and fixed with minor surgery if diagnosed early enough. Another less common cause can be a spinal tumor, whether primary or metastatic. Both of these conditions can be diagnosed and evaluated with x-rays and magnetic resonance imaging. Infection, especially if the patient has recently had a spine procedure, is another possible condition that necessitates prompt diagnosis and treatment.

As stated above, osteoarthritis and degenerative changes of the spine are the cause of the most common spine conditions in the elderly. In my experience, genetics and family history seem to be the most common denominator. However, obesity, smoking, certain occupations (sports, excessive driving, lifting, or sitting in front of a computer), or a history of previous trauma are also common reasons for the acceleration of the degenerative process.

How are the most common as well as less common types of aging spine conditions treated? Can any of the conditions be reversed or repaired?

The treatment for degenerative changes of the spine leading to pain starts with lifestyle and ergonomic adjustments such as sleep positions, appropriate desk and chair height, and proper lifting technique. Then anti-inflammatory medications and physical therapy or chiropractic care are utilized. The next steps include interventional pain management techniques, such as facet joint nerve blocks for facet arthritis or epidural steroid injections for sciatic-like pain. 

The majority of patients will have tolerable pain after a series of these conservative treatments, but some may require surgery for relief. Most conditions can be treated with same-day, minimally invasive surgery, although some may require much more extensive surgery. Certain conditions, such as spinal stenosis or sciatic-like pain (radiculopathy), are more easily treated with surgery, while others, such as facet osteoarthritis, are not.

Vertebral compression fractures can be treated within 6 months of the occurrence of the fracture with kyphoplasty, which is a minimally invasive, same-day procedure where cement is injected into the fractured vertebral body, which, in almost all cases, relieves pain and stabilizes the bone from further collapse (avoiding the dangerous “hunchback” shape of the spine).

Spinal tumors, whether primary or metastatic, need to be evaluated by an oncologist as soon as they are detected. Standard interventional pain management techniques may help with the pain symptoms, but treatment using a complement of chemotherapy, radiation, and surgery will likely be recommended to address the tumors directly.

Infection of the spine, if not treated promptly, can lead to the obliteration of the spinal canal or nerves and/or septic shock. Fortunately, an extensive course of antibiotics and removal of spinal hardware (if applicable) are able to treat most infections.

What kinds of related or associated comorbidities can spinal conditions contribute to that makes treatment more complex?

Other conditions involving the spine can accelerate the development or complicate the treatment of these conditions. Some of these include ankylosing spondylitis, idiopathic scoliosis, rheumatoid arthritis, previous spine surgery, and cancer.

Medical conditions unrelated to the spine can also complicate treatment. Osteoporosis, for example, can cause or accelerate many of the above conditions, so proper treatment through a primary care provider or endocrinologist can help prevent progression of these conditions. Obesity also makes treatment of these conditions difficult, so proper dieting and appropriate exercise can help immensely. Smoking is well known to exacerbate all pain syndromes, so cessation is highly recommended.

What are the best ways that older adults with little-to-no spinal problems can prevent problems or strengthen back muscles?

Proper sleep bedding and positions go a long way in helping to prevent or reduce back or neck aches. A firm mattress and a pillow that allows your neck to lie in a neutral position are very important for neck and back stability. Also, sleeping with a pillow under the knees when lying supine or with a pillow between the knees when on the side can help reduce stress on the lower back.

Ergonomics at home and work are extremely important as well. When sitting at a computer desk, avoid slouching of the back and stooping of the neck. Make efforts to raise the computer monitor to eye level and adjust seat height to facilitate optimal positioning. When lifting heavy objects, be sure to bend at the knees and not at the waist, and push rather than pull as much as possible.

A strong core is essential to preventing spine injury, so static exercises that strengthen and tone the abdominal, lower back, and neck muscles are very effective. Yoga and pilates (within reasonable limits) can also be helpful in creating and maintaining flexibility and strength of the spine and core.

What could older adults specifically in long-term care facilities do to prevent or ease existing spinal issues?

For those whose mobility is limited, staying out of bed as much as possible is the main priority. Walking alone can improve flexibility, strength, and blood flow to the spine and intervertebral discs, which can help prevent injury. A morning and evening walk can easily be incorporated into a daily routine, before or after meals. Age-appropriate yoga or core-strengthening classes can build upon a foundation of daily walking.

What steps can geriatricians and other health care professionals in the long-term care field take to prevent and treat spinal problems in older adults?

Proper daily exercise, treatment of osteoporosis, and cessation of smoking are the most high-yield steps that geriatricians and other health care professionals in the long-term care field can take to help treat and prevent spine conditions in older adults. Additionally, the prompt diagnoses of conditions such as vertebral fractures and infections can significantly reduce pain and even save lives. Older adults with sudden severe back pain and/or fever should be taken to urgent or emergent care as soon as possible.

  1. Schwab, FJ. Spine Aging. Orthospine website. Accessed January 10, 2017.
  2. University of Twente, Department of Biomechanical Engineering. Aging Spine. University of Twente website. Accessed January 10, 2017.