spinal claudication [compatibility mode]
Post on 12-Jan-2016
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Spinal Claudication
Presentation and Management
Neil W Valentine FRCS
Presentation
Age 50 +Male : Female >5 : 1Usually manual workersLimited walking capacityStoop / sit / lean forward to relieve symptoms“heavy” or “tired” legs
ClaudicationSpinal : Vascular
Relieved by flexingUphill often not badCycling easy
Relieved by standingUphill badCycling bad
Examination
Diagnosis depends on historyOften no signsStooped gaitCan’t extend
Mechanism of symptom production- speculative
Effect of movementDegenerative spondylolisthesis“watershed” vascular zoneObstruction to CSF circulationArterial insufficiencyVenous engorgementIncarcerated segment
Pathogenesis
Pre-existing narrow canalDisc bulge(s)Facet hypertrophy / degenerationLigament hypertrophy / degeneration
SpinalStenosis
Canal configurations
Pathogenesis
Anatomy
Pathology
TreatmentNon - Operative
Restriction of activityPhysiotherapyAnti – inflamatoriesLumbar supportEpidural steroidCalcitonin
Often of limited benefit
X - rays
Investigation
MyelogramCombined CT / myelogramNerve conduction / EMG’sMRI
Myelogram
CT
CT myelography
MRI
TreatmentOperative
Multi – level laminectomyLateral recess decompressionNerve root decompressionStabilise and fuse if required
Posterior Hypertrophy
Multilevel decompression
Multilevel flavectomyRoot decompressionsDoes not destabilise
Central Decompression
Partial facetectomy
Lateral Recess Decompression
Subtotal Facetectomy
Root Decompression
TreatmentStabilisation and fusion
Remains unresolvedFacets disruptedPrevious instabilityPrevious decompression
Stabilisation (fusion)
Stabilisation (fusion)
Problems
Generally aged patient groupVery extensive surgery – 3 hours +High constitutional risksDifficulty in reconstructing porotic bone
Possible Developments
Limited decompressionSpinous process distraction
“X-stop”
Limited Decompression
Multi – level flavectomyLateral recess decompressionPreserve facetsNo need for stabilisation
X - stop
Complications
Dural tear 8.5%Neurological complications up to 10%“Old” nerves don’t recover as well as “young” nervesNeck problems
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