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1 REVIEW ARTICLE eissn: Korean J Clin Geri 2016;17(2): 노인요통관리 이동국 대구가톨릭대학교의과대학신경과학교실 Back Pain Management in the Older Person Dong-Kuck Lee Department of Neurology, Catholic University of Daegu School of Medicine, Daegu, Korea Low back pain (LBP) is a common problem in the geriatric population. The majority of cases are thought to be mechanical or idiopathic and benign nature, but its multiple causes and concerns regarding missed diagnosis of less common but more serious underlying pathological diagnoses mean many physicians find the assessment, investigation and treatment of chronic LBP in older adults challenging. Although back complaints are common among older people, limited information is available about the clinical course of the LBP and the identification of older persons at risk for the transition from acute back complaints to chronic LBP. Assessment must focus on identifying those with mechanical LBP and distingishing those from individuals with pathological disease. The limited role of imaging in those without pathological signs or symptoms reflect the complex nature of LBP. As always in those with chronic LBP, success in managing symptoms is likely to be achieved using a multidisciplinary approach with surgery reserved only for those with refractory symptoms. Key Words: Low back pain, Elderly 서론 최근의학의눈부신발달과각종생활여건의개선등으로인해평균수명이늘어남에따라인구중노령층이급격히증가하게되고따라서각종생활습관병과다양한통증증후군도급증하여노인들의삶의질을저하시키고있다. 특히임상에서흔히볼수있는노인요통은많은노인들의일상생활을힘들게한다. 노인요통은대부분양성이지만가끔위험한원인들도숨어있으므로신속하고적절한진단과치료가필요하다. 이종설에서 는많은노인들의일상생활을힘들게하는요통의여러가지임상적측면에대해간략하게정리해보고자하였다. 본론 1. 개괄 문헌상 1977년 Sarkin 1) 은노인에서흔히발생하는요통은대부분치료가능한병으로병력, 진찰, 영상검사, 및적혈구침강속도등을기준으로구분하면크게기계 Received: March 9, 2016 Accepted: May 23, Corresponding author: Dong-Kuck Lee Department of Neurology, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 47472, Korea Tel: , Fax: , dklee@cu.ac.kr Copyright C 2016 The Korean Academy of Clinical Geriatrics This is an open access article distributed under the term s of the C reative Com m ons Attribution N on-c om m ercial License ( licenses/by-nc/4.0) which perm its unrestricted non-comm ercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 52 Korean J Clin Geri 2016;17(2):51-58 적 (mechanical) 요통과병적 (pathological) 요통으로구분할수있다고했다. 기계적요통이란허리의조직은정상이지만전위 (displace) 되고긴장 (strain) 되어있으며여기에는인대 (ligament) 긴장, 척추간디스크전위, 손상, 섬유염 (fibrositis), 및척추협착증등이포함된다. 한편병리요통이란병리과정 (process) 이침윤되어생기는요통으로여기에는골다공증, 급성및만성염증, 일차성및전이성종양, 및골관절염등이포함된다고하였다. 1999년 Lachmann 등 2) 은요통은노인에서흔한증상으로노인들의좌식 (sedentary) 생활습관이기계적긴장에의한요통의선행인자이거나또는요통을악화시키는요인이된다고하였다. 또한임상의사들은가끔요통을일으키는심각한병도있다는것을항상염두에두고진료할것을강조하였다. 더불어노인요통에대한병력, 진찰, 원인, 위험한상황, 검사실검사, 영상검사, 약물및수술치료등에대해기술하였다. 2014년 Jones 등 3) 은노인요통은흔한증상으로대부분기계적, 원인불명, 또는양성이지만가끔있을수있는심각한원인이있는지규명하는것이중요하다고했다. 또한요통을단순한기계적요통, 신경뿌리병 (radiculopathy) 을동반한요통, 심각한병리를가진요통, 및척추병처럼보이는내장 (visceral) 병등으로구분하였다. 2. 역학일생중인구의평균 70% 이상에서요통과경부통증을호소한다고한다. 그러나노인들은요통이나경부통증이있어도표현을잘안하는경향이있으므로정확한상태를알기가힘들다. Hartvigsen 등 4) 은 70세이상연령층에서요통은 15%, 경부통증은 11%, 요통과경부통증이동시에있는경우는 11% 라고했다. 또한요통과경부통증의유병률은노인연령이점점더증가해도큰변화가없으며간헐적인증상을보이고남성보다는여성, 다른건강상문제가있는경우, 활동량이적은경우, 및평소건강상태가나쁜경우등에서더흔히생긴다고했다. 한편일반적으로노동력이왕성한연령층에서요통이가장흔히발생하므로 60대중반에서는요통의발생률이감소할것이라고생각해왔다. 그러나골관절염, 디스크퇴행, 골다공증, 및척추협착증등은연령이증가할수록유병률이증가하므로앞의생각과는모순이다. 연구결과양성요통은 60대이후연령이증가해도유병률은감소하지만중증요통은연령이증가하면급격하 게더증가한다고했다. 5) Hartvigsen 등 6) 은노인에서경부통과요통은흔한증상으로 70세이상의 10 20% 에서중등도이상의경부통과요통을가지고있으며특히노인여성에서이런증상이더흔히생긴다고했다. Weiner 등 7) 은만성요통을가진노인에서는생체역학및연조직병리가흔하며이런소견은간단한진찰만으로도상당한부분을평가할수있으므로의료진이좀더관심을기울이면불필요한의료비지출과환자의고통을줄일수있을것이라고했다. 일반적으로요통은노인에서더흔할것으로생각하고있으나 Fejer과 Leboeuf- Yde 8) 는 60세이상에서요통은중년보다더흔하지않다고했다. 그이유로는어떤세대에태어난연령층은신체적으로다른세대보다더튼튼하기때문에 cohort 연구에영향을줄수있으며나이가들면통증에대해내성이증가하고통증에대해적자생존상태가되므로통증을덜호소하게되고또한나이가들면통증을일으킬수있는심한일을더적게하게되는것등이있다고했다. 따라서아주노인이되면요통은더줄어들게된다고하였다. 그러나 Hoy 등 9) 은나이가들면서요통유병률은증가하며특히여성과 40 80세사이의연령층에서요통이더흔하다고했다. 한편 Ma 등 10) 은나이가들면요추추간판탈출증의빈도가줄어들며특히 80세이상에서더욱그러하고노인들은더여러군데에추간판탈출증이생긴다고했다. 3. 원인노인요통은허리에무리를주는생활양식과나이가들면서척추구조에생기는변화등이주요발병인자들이다. 요통은척추구조에생기는척추전방전위증 (spondylolisthesis), 척추협착증, 및골다공증성척추골절등같이기질적 (organic) 인원인에의한기질통과단순히연령에따른생리적변화에의해생기는기능적통증으로나눌수있다. 전자는정확한진단후적절한중재적시술 (intervention) 로치료하고후자는생활양식변화와치료운동등의관리가필요하다. 요통은기능장애, 불안정 (instability), 및재안정화 (restabilization) 단계를거쳐발생한다. 특히노인에서흔한척추협착증은척추체, 아치 (arch), 또는척추간추간판등에퇴행성변화가생겨척추관을압박하기때문에요통이생긴다. 척추협착증의가장흔한증상은파행 (claudication) 으로이것은장시간걷거나서있으면척추관에과도한동적 (dynamic) 부담

3 이동국 : 노인요통관리 53 이증가되기때문에발생하는것이다. 척추협착증을잘일으키는인자들로는연령에따라척추구조물에변화가생긴경우, 체간근육의약화로인해자세에변화가와서척추관에부담이생긴경우, 척추전방전위증처럼중년에시작되는분절성불안정, 및척추관절강직증성척추전방전위증이나과거척추수술같은것들이있다. 한편노인에서는골다공증에의해골량이줄어드므로비외상성골다공증성척추골절이잘생긴다. 이때갑자기심한통증이생기며골절이서서히안정되면서 2 3 개월지나서통증이감소한다. 그러나그후에도통증이지속되면척추체의가성관절증 (arthrosis) 을생각해보아야한다. 11) 만성요통은 65세이상노인에서흔히생겨일상생 활을불편하게하는증상이다. 대부분의요통은비특이적이다. 요통을일으키는대표적인병인섬유근통증후군, 고관절골관절염, 척추협착증, 궁둥구멍근 (piriformis) 근막통증증후군, 및엉치엉덩 (sacroiliac) 관절증후군등의정의와치료법은 Table 1과같다. 12) 한편복부대동맥동맥류도드물지만노인요통의원인중하나로사망률을높인다. 이병에서는요통외에도복통, 복부팽만, 및박동 (pulsation) 등도나타난다. 특히노인, 남성, 가족력, 고혈압, 흡연, 고콜레스테롤혈증, 관상동맥질환, 말초폐색질환, 및만성폐쇄호흡기질환등이있는경우에동맥류가잘생긴다. 복부초음파검사가저렴하고비침습적이므로가장흔히사용되지만복부 CT가가장정확한검사법이다. 13) Table 1. Chronic low back pain disorders queried by patient vignettes: definitions and treatment Condition Operational definition/physical findings Recommended treatment Fibromyalgia syndrome Hip osteoarthritis Lumbar spinal stenosis Myofascial pain of the piriformis muscle SI joint syndrome SI: sacroiliac. Chronic widespread pain plus palpable tenderness at 11 of 18 specific tender points Degenerative joint disease leading to pain and restricted hip range of motion, especially with internal rotation Degenerative spinal disease often associated with pain in lower back and neurogenic claudication, often radicular; may have associated weakness or numbness Examination often normal, except for diminished knee or ankle reflexes Magnetic resonance imaging has become standard evaluation, but has poor specificity; use only for surgical candidates Localized tenderness on deep palpation of piriformis muscle with reproduction of pain complaint and characteristic pain radiation pattern May have taut band in muscle, local twitch response with palpation Pain in and around the SI joint that can radiate to the thigh (most common), groin, lower leg, foot, abdomen Reproduction of pain in sacral sulcus on exam has high sensitivity, low specificity (combination of multiple maneuvers best for detection) Aerobic exercise Oral analgesics Tricyclic antidepressants Medication for associated symptoms (depression, fatigue) Multidisciplinary pain clinic referral for refractory cases Oral analgesics PT with evaluation for assistive device Consider joint injection Consider joint replacement for severe and refractory cases PT Oral analgesics Percutaneous electrical nerve stimulation (no controlled trials for lumbar spinal stenosis) Consider epidural corticosteroids (no controlled trials) Surgery for severe, refractory symptoms PT for gentle stretch, massage, and other modalities (e.g., transcutaneous electrical nerve stimulation) Trigger point injections Acupuncture Sparing use of systemic analgesics PT for stretching, strengthening, stabilizing pelvic and surrounding musculature Oral analgesics SI joint injection Correct leg length discrepancy, if present

4 54 Korean J Clin Geri 2016;17(2):51-58 노인척추에는골다공증성골절, 퇴행성척주측만증 (scoliosis), 및퇴행성척추전방전위증등이잘생겨요통을일으킨다. 14) 노인척추체압박골절은골다공증이있는사람에서더흔히발생한다. 심한골절일수록통증이심하고다양한합병증이동반되어일상생활을힘들게하여수명을단축시킨다. 척추골절후합병증으로는변비, 장폐색, 장기간활동저하, 심부정맥혈전증, 골다공증악화, 진행성근쇠약, 독립성저하, 신장감소, 척주후만 (kyphosis), 내부장기기능저하. 호흡부전, 만성통증, 자존심저하, 감정및사회활동장애, 요양원입원증가. 및사망등이있다. 15) 한편근막통증증후군도요통을일으키므로노인만성요통환자를진찰할때는단단한띠 (taut band) 나유발점 (trigger point) 같은근막통증증후군소견이있는지잘살펴야한다. 16) 4. 진찰노인요통에대한특별한진찰은없다. 일반적인병력청취후전신신체검진을하고나서신경학적진찰을통해운동, 감각, 심부건반사, 및보행기능등을평가하여진단한다. 특히신경뿌리병을알기위해서는다리를뻗쳐서들어올리는검사 (strait leg rasing test, SLRT) 가도움이된다 (Figure 1). 2) 5. 검사실검사기본적인혈액검사와소변검사후필요에따라근전도검사, 골밀도검사, 핵의학검사및암검사등을시행한다. 6. 영상검사노인척추질환에대한영상검사로는단순방사선촬영, CT, MRI, PET, 혈관촬영검사, 초음파검사, 및핵의학검사등이있으므로필요에따라취사선택한다. 요통 에대해즉시영상검사가필요한경우, 약 1개월정도치료후영상검사를해보는경우, 및영상검사가필요없는경우등에관한사항은 Table 2를참고하면된다. 특히외상성흉추, 요추, 및흉요추질환중성인에서최근 2주일이내의급성척추외상으로운동은정상이고통증과신경장애는없는경우, 가벼운외상후흉통이생긴경우, 또는가벼운꼬리뼈 (coccyx) 외상과꼬리뼈통증만있는경우등에서는응급영상검사가필요하지않다. 그러나최근낙상, 자동차사고, 충돌사고등으로인한급성척추외상, 중증외상으로인한흉통, 또는낙상후체중을감당하지못할정도의골반및엉치뼈 (sacrum) 외상등에서는반드시영상검사를하는것이좋다. 영상검사로는 CT나 MRI가좋으며골절이의심되지만영상검사로는애매한경우에는핵의학적뼈주사 (bone scan) 가도움이된다. 노인척추질환의진단에있어중요한점을정리하면다음과같다. 노인에서는관절염과퇴행성디스크질환이아주흔하다. 노인에서는심각한척추병은적지만혹시암, 감염, 말총 (cauda equina) 증후군, 또는심각한중증진행성신경질환이있는지잘살펴보아야한다. 만약위급한상황이라판단되면즉시영상검사를하거나척추전문가에게의뢰한다. 급성또는아급성요통을무시하고조속한시간내에영상검사를소홀히하다가큰병을놓칠수도있다. 척추골절이나관절염인경우를제외하고는단순촬영보다 CT나 MRI검사가근골격질환의진단에더유용하다. CT검사는뼈질환이나잠재골절을진단하는데좋고 MRI검사는연조직종괴나침습 (invasion) 을진단하는데유용하다. 특히 MRI검사는척추암, 감염, 골절, 말총증후군, 강직성척수염, 및기타염증성질환등의진단에좋다. 비특이적요통의수술전진단으로는 MRI검사가좋다. 척추전문영상의학의사의소견을가능한참고하는것이중요하다 ) Figure 1. Straight leg raising test. (A) The leg is raised until radicular symptoms are elicited. (B) The leg is lowered until pain is relieved and the foot is then dorsiflexed. Return of radicular symptoms with dorsiflexion indicates a positive test.

5 이동국 : 노인요통관리 55 Table 2. Suggestions for imaging in patients with low back pain (alone or with leg pain) Indicators for initial imaging Risk factors for cancer (multiple risk factors for cancer, or strong clinical suspicion for cancer) Risk factors for cancer (history of cancer with new onset of LBP) Imaging action Immediate imaging Radiography plus ESR* MRI (or CT if MRI not available) Risk factors for spinal infection (new onset of LBP with fever and history of intravenous drug use or recent infection) Risk factors for or signs of the cauda equina syndrome (urine retention, motor deficits at multiple neurologic levels, fecal incontinence, or saddle anesthesia) Severe neurologic deficits (progressive motor weakness) Weaker risk factors for cancer (unexplained weight loss or age >50 years) Risk factors for or signs of ankylosing spondylitis (morning stiffness that improves with exercise, alternating buttock pain, awakening because of back pain during the second part of the night, or younger age [20 to 40 years]) Risk factors for vertebral compression fracture (history of osteoporosis, corticosteroid use, significant trauma, or older age [>65 for men or >75 for women]) Signs and symptoms of radiculopathy (back pain with leg pain in an L4, L5 or S1 nerve root distribution or positive result on straight leg raise or crossed straight leg raise test) in patients who are candidates for surgery or epidural steroid injection Risk factors for or symptoms of spinal stenosis (radiating leg pain, older age, or pseudoclaudication) in patients who are candidates for surgery No criteria for immediate imaging and back pain improved or resolved within 1-month trial of therapy Previous spinal imaging with no change in clinical status Defer imaging after a trial of therapy (about 1 month) Radiography with or without ESR MRI (or CT if MRI not available) No imaging *Consider MRI if the initial imaging result is negative but a high degree of clinical suspicion for cancer remains. LBP: low back pain. 7. 요추적신호 (red flags) 요통을호소하는환자중골절에대한적신호로노인, 장기간스테로이드사용, 심한외상, 또는타박상이나찰과상등이각각있는경우에는 10 33% 에서골절가능성이증가하지만만약적신호가여러개같이있는경우에는골절위험이 42 90% 까지증가된다. 한편암에대한적신호로암병력이있는경우에는 7 33% 에서암가능성이증가하지만노인, 설명안되는체중감소, 또는한달간치료해도호전이없는경우등에서는암가능성이 3% 이하이다. 그외의적신호로외상, 골절, 척수병증 (myelopathy), 과거척추병력, 또는감염등이있다 (Table 3). 18,19) 8. 진단과감별진단다리통증유무를떠나서급성요통의진단흐름은 Figure 2를참고하면된다. 2) 특히노인요통의진단시 Table 3. Serious conditions presenting as low back pain O Osteomyelitis M Metabolic bone disease (eg. Paget s) I Infection (discitis, tuberculosis) N Neoplasm O Other (eg, epidural abscess, retroperitoneal bleed, abdominal aortic aneurysm) U Unstable angina S Spondylolisthesis, spondyloarthropathies 중요한점으로는 MRI나기타영상검사상위양성 (false positive) 소견이흔하다는것을숙지하고병력청취와진찰에집중해야한다. 결국임상증상과영상검사소견이항상일치하지는않다는것을잘알고있어야한다. 11) 노인요통의감별진단으로는염증, 감염, 암, 대사성원인, 압박골절, 또는혈관질환등이있으므로참고하여진단해야한다. 13) 특히노인요추추간판탈출 (lumbar

6 56 Korean J Clin Geri 2016;17(2):51-58 Figure 2. Algorithm for acute low back pain. GI: gastrointestinal, GU: genitourinary, IV: intravenous, NSAID: nonsteroidal anti-inflammatory drug, SLR: straight leg raising, UMN: upper motor neuron. disc herniation, LDH) 과요추협착증 (lumbar spinal stenosis, LSS) 의감별은중요하다. LDH에서는허벅지와정강이앞쪽의통증이흔하고 LSS에서는무릎뒤쪽통증이더흔하다. 또한 LSS에서는 Achilles 건반사가 LDH에서보다더감소된다. LDH에서는 SLRT에서양성률이 LSS 에서보다훨씬더높고몸통굴곡이더심하게제한된다. 20) 결국요통을진단하기위해서는요통이단순한비특이적요통인지, 신경뿌리 (radicular) 증후군인지, 또는심각한병리적문제를가지고있는상태인지를구분하여진단해야한다. 따라서적신호를나타내는요통인지에초점을두고감별진단하고치료후에도호전이없으면심리적인인자들도고려하여진단하며비특이적요통에무조건영상검사를하는것은바람직하지않다. 21) 9. 치료요통은급성또는아급성요통과만성요통에따라치료방침이다르다 (Table 4). 21) 일반적으로만성노인요통은우선보존적으로치료한다. 필요하면비스테로이드성항염제 (NSAIDs), 항우울제, 아편유사제, 또는근육이완제등을적절히선택하여쓰고경구투여가힘든경우에는정맥주사, 좌약, 또는피부를통하여약을쓴다. 그러나노인에서 NSAIDs를쓰다보면간, 신장, 및위장관합병증등이올수도있다는것을염두에두고치료해야 Table 4. Summary of common recommendations for treatment of low back pain Acute or Subacute Pain * Reassure patients (favourable prognosis). * Advise to stay active. * Prescribe medication if necessary (preferably time-contingent): first line is paracetamol; second line is nonsteroidal antiinflammatory drugs, consider muscle relaxants, opioids or antidepressant and anticonvulsive medication (as co-medication for pain relief). * Discourage bed rest. * Do not advise a supervised exercise programm. Chronic Pain * Discourage use of modalities (such as ultrasound, electrotherapy) * Short-term use of medication/manipulation * Supervised exercise therapy * Cognitive behavioural therapy * Multidisciplinary treatment 한다. 또한증상과진단에따라국소신경차단이나경막외 (extradural) 차단을하기도한다. 그러나이런방법은바늘이정확한위치에들어가지많으면효과가없고또한침습적이므로합병증이생길가능성이있다. 한편요추를안정시키기위해침대에서쉬게하고복대를하게한다. 그러나퇴행성척추병에서너무장기간쉬게하면근력약화가올수도있으므로잘관찰해야한다. 또한

7 이동국 : 노인요통관리 57 요추퇴행성척추전방전위증이나척주측만증 (scoliosis) 에서는특수한보조기 (brace) 를쓰기도한다. 특히척추체의골다공증성압박골절은위험하므로즉시척추전문가에게의뢰한다. 11,22,23) 만약노인요통이 1 2개월정도약물치료해도반응이없고증상이점점진행되며영상검사상증상과일치되는병변이있고또는보행시파행까지생기면수술적치료를고려해야보아야한다. 특히급성말총 (cauda equina) 증후군이나급성운동장애가있으면응급수술이필요하다. 그러나이미소변저류가있거나범람요실금 (overflow incontinence) 이있으면응급수술해도효과가적다. 따라서수술이너무늦으면돌이킬수없는변화가생겨예후가불량하므로신속한진단이필요하다. 한편노인척추질환을수술하려면젊은사람들과는다르게다양한문제점이발견된다. 뼈질의저하, 척수퇴행성변화, 또는흉부척주후만 (kyphosis) 와요부척주전만 (lordosis) 으로인한시상정렬 (sagittal alignment) 의변화등은수술을힘들게한다. 또한영양실조, 동반된다양한내과적질환들, 또는상처회복력저하등도수술에나쁜영향을미친다. 따라서노인척추질환은적응증을신중하게결정해야한다. 14,22) 특히노인척추압박골절은골절이안정상태인지아닌지를잘살펴보고치료방침을결정해야한다. 15) 한편노인요통은평소잘못된생활습관을조절하고자세교정, 허리, 복부, 및하지등에대한스트레칭, 및 다양한근육강화운동등을함으로써요통발생을줄일수있다 (Table 5). 2) 따라서약물치료와더불어물리치료를병행하고만약필요시수술을해야한다면수술전후재활의학과와협진하여요통을관리해야할것이다. 결국급성또는만성노인요통은척추치료및관리에대한다양한분야의전문가들의의견을수렴하여치료하는것이필요하다. 24,25) 결론 노인요통은임상에서흔한증상으로많은노인들이만성요통으로인해일상생활에큰불편을느끼며살고있다. 따라서노인환자를주로진료하는의료진들은요통의전반적인사항에대해평소숙지하고있어야한다. 노인요통의원인은대부분양성이지만외상, 골절, 암, 척수병, 복부동맥류, 척추염, 감염, 및과거척추수술병력이있는경우등에서는심각한문제를일으킬수도있으므로잘감별진단해야한다. 만성노인요통은대부분약물치료를하지만요추영상검사상증상과일치하는병변이있으며약물치료에반응이없고급성운동장애증상이있거나말총증후군등이있으면수술적치료를고려한다. 요통은평소생활습관을교정하고스트레칭과근력강화운동을포함한적절한운동을하면어느정도예방도가능하다. 특히수술전후에물리치료를포함한재활요법도유용하다. Table 5. Recommended body mechanics for the lower back 1. Sit in a firm chair that has a supportive back. Do not sit in a deep or overstuffed chair or couch 2. Sit with your knees 2 to 3 inches higher than your hips. Placing a thick book, such as a phonebook, under your feet may be helpful. 3. When driving, sit with your knees higher than your hips. 4. When standing, place one foot on a small stool and stand with your weight on both legs, maintaining good posture. 5. Sleep on your back or on your side, with a pillow under or between your knees. 6. Sleep with your arms relaxed at your sides. 7. To get out of bed, place your feet on the bed slowly, then log roll to your side. As you place your feet on the floor, start to sit up. 8. Do not lean over furniture to open or close windows. 9. Use a step stool when reaching for objects on high shelves. 10. When performing tasks such as brushing your teeth or shaving, bend your knees, keeping your back straight. 11. Push, do not pull, large objects when moving them. REFERENCES 1. Sarkin TL. Backache in the aged. S Afr Med J 1977;3: Lachmann E, Tunkel RS, Nagler W, Babayer M. New-onset low back pain in an elderly woman. JCOM 1999;6: Jones LD, Pandit H, Lavy C. Back pain in the elderly: a review. Maturitas 2014;78: Hartvigsen J, Christensen K, Frederiksen H. Back and neck pain exhibit many common features in old age: a populationbased study of 4, 486 danash twins years of age. Spine 2004;29: Dionne CE, Dunn KM, Croft PR. Does back pain prevalence really decrease with increasing age? A systemic review. Age Ageing 2006;35: Hartvigsen J, Frederiksen H, Christensen K. Back and neck pain in seniors-prevalence and impact. Eur spine J 2006;15: Weiner DK, Sakamoto S, Perera S, Breuer P. Chronic low back pain in older adults: prevalence, reliability, and validity

8 58 Korean J Clin Geri 2016;17(2):51-58 of physical examination findings. J Am Geriatr Soc 2006;54: Fejer R, Leboeuf-Yde C. Does back and neck pain become more common as you get older? A systemic literature review. Chiropr Man Therap 2012;20: Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systemic review of the global prevalence of low back pain. Arthritis Rheum 2012;64: Ma D, Liang Y, Wang D, Liu Z, Zhang W, Ma T, et al. Trend of the incidence of lumbar disc herniation: decreasing with aging in the elderly. Clin Interv Aging 2013;8: Yamamoto H. Low back pain due to degenerative disease in elderly patients. JMAJ 2003;46: Cayea D, Perera S, Weiner DK. Chronic low back pain in older adults: What physicians know, What they think they know, and what they should be taught. J Am Geriatr Soc 2006;54: Hocaoglu S, Kaptanoglu E, Hocaoglu S. Low-back pain in geriatric patients. J Clin Rheumatol 2007;13: Kanter AS, Asthagiri AR, Shaffrey CI. Aging spine: challenges and emerging techniques. Clin Neurosurg 2007;54: Old JL, Calvert M. Vertebral compression fractures in the elderly. Am Fam Physician 2004;69: Lisi AJ, Breuer P, Gallagher RM, Rodriguez E, Rossi MI, Schmader K, et al. Deconstructing chronic low back pain in the older adult- step by step evidence and expert-based recommendations for evaluation and treatment. Pain Med 2015; 16: Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med 2009;169: Taylor JA, Bussieres A. Diagnostic imaging for spinal disorders in the elderly: a narrative review. Chiropr Man Therap ;20: Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RWJG, Vet HCD, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013;347:f Rainville J, Lopez E. Comparison of radicular symptoms caused by lumbar disc herniation and lumbar spinal stenosis intheelderly. Spine2013;38: Koes BW, Tulder MV, Lin CWC, MAcedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19: Harden N, Whitfield P, Moore A. The management of degenerative lumbar spine disease. ACNR 2005;4: Kuijpers T, Middelkoop MV, Rubinstein SM, Ostelo R, Verhagen A, Koes BW, et al. A systematic review on the effectiveness of pharmacological interventions for chronic nonspecific low-back pain. Eur Spine J 2011;20: Macedo LG, Bostick GP, Maher CG. Exercise for prevention of recurrence of nonspecific low back pain. PhysTher 2013; 93: Van Tulder M, Koes B. Low back pain. In: McMahon SB, Koltzenburg M, Tracey I, Turk DC, eds. Wall and Melzack s Text book of pain. 6th ed. New York: Elsevier, 2013;

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical