Edward P Abraham, MD, FRCSC, Associate Professor of Surgery, Department of Orthopaedics, Dalhousie University Medical School, Saint John Campus, Saint John NB Canada Canada East Spine Centre, Horizon Health Network.
	Hamilton Hall, MD, FRCSC, Professor, Department of Surgery, University of Toronto, Executive Director, Canadian Spine Society, Toronto, ON.

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Abstract: In spite of the slightly increased incidence of infections, malignancies and systemic illnesses affecting the older spine, about 90% of back pain in the elderly, as in younger patients, is mechanical. This article covers several of the common problems: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity and osteoporotic compression fractures. Treatment is both non-operative and surgical and the decisions about which to choose and therefore when to refer depend as much on the age and functional capacity of the patient as upon the specific pathology.

Key Words: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity, osteoporotic fractures, imaging.

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The diagnosis of neurogenic claudication is made on the history of intermittent leg dominant pain brought on by activity, usually walking, and relieved by rest in flexion, usually by sitting down. The physical examination while the patient is at rest is often normal.

Mechanical back pain associated with disc degeneration is seldom an indication for surgery and can usually be adequately managed through a combination of education, activity modification, general fitness and exercises selectively tailored to improve the pain-producing positons and movements.

Disc herniation producing acute sciatica is uncommon in the older patient and the diagnosis should be made with caution. True radicular pain is constant and leg dominant. Referred, intermittent leg pain frequently accompanies back dominant pain and should not be treated as sciatica.

Enduring spine surgery is a major challenge for the elderly patient. The decision to operate must be made after comprehensive consultation, emphasizing the prolonged recovery and weighing the potential benefits against the inevitable risks, including the risk to life.

Osteoporotic vertebral body compression fractures frequently occur without a recognized history of trauma. The pain, often in the thoracic or upper lumbar area, appears suddenly, is aggravated by movement (particularly bending forward) and is reduced but not eliminated by lying down. The acute phase can last several weeks but usually subsides without specific treatment. Multiple compression fractures over time will produce a kyphotic spine.

Back pain in the elderly should be managed with a minimum of medication. Mechanical pain can usually be controlled with the appropriate mechanical measures and additional analgesia is not required. Recourse to pain medication as a first line of treatment is not recommended and when employed should be limited to non-narcotic formulations. With the possible exceptions of acute sciatica and recent vertebral compression fractures, opioids should not be used.

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Angela M. Cheung, MD, PhD, FRCP(C), CCD, Director, Osteoporosis Program, University Health Network and Mount Sinai Hospital; Associate Director, Women’s Health Program, University Health Network; Associate Professor, University of Toronto, Toronto,ON.

Osteoporosis is common in postmenopausal women and older men. There are various efficacious therapies for the treatment of osteoporosis and the prevention of osteoporotic fractures in Canada. First-line therapies include alendronate, risedronate and raloxifene; all of these are oral antiresorptive therapies. In this article, we review new drug therapies currently or soon to be available in Canada, such as bone formation therapies (parathyroid hormone and strontium ranelate) and intravenous infusions (such as zoledronic acid), and compare them to existing therapies.
Key words: osteoporosis, osteoporotic fractures, parathyroid hormone, strontium, zoledronic acid.