spinal stenosis 2

Spinal Stenosis

Thomas M. Howard, MD

Sports Medicine

These Patients Consume:

Many appointments Many narcotic medications Many specialty appointments

– Ortho, Pain, Neurology, Neurosurgery, Physical Therapy

TIME!!

Lumbar Spine

Epidemiology

12 mil visits/yr for LBP

3-4% will have spinal stenosis

Usually age >50 Prevalence 1.7-8%

annually

Anatomy Three-joint complex

– Facet joints and disc

Disc complex– Nucleus pulposis and

annulus fibrosis

Ligamentum flavum Nerve roots

Pathophysiology Facet arthropathy and

osteophytic growths Hypertrophy of

ligamentum flavum HNP and disc spurring Degenerative

spondylolithesis Underlying effect is not

mechanical but more decreased CSF flow and local ischemia

Symptoms Post h/o HNP, chronic LBP, surgery, old injury C/o burning, cramping, numbness, tingling or

fatigue Back Pain 95% Leg pain 71%

– 15% thighs only– Often bilateral

Leg weakness 33 % Pseudoclaudication 94% Pain relieved by sitting or lying

Examination ROM

– Full forward flexion without sx

– Limited extension with pain

DTR’s– Usually nl

Strength– EHL (L5), TA (L4),

Peroneals (S1), Gastroc (S1), Quad (L3-4), Hip flexors (L2-3)

Sensory

Examination

Vascular exam– Pulses

• Pop, DP, PT

– Temp– Trophic changes

Consider ABI

Differential Diagnosis

Piriformis Syndrome Trochanteric Bursitis Hip OA Vascular Claudication SI Dysfunction

Radiographs

MRI

CT Myelogram

EMG

Non-operative

Medications Injections Physical Therapy Weight Management Lumbar stabilization and core strengthening Aerobic fitness Activity Modification

– Avoid repetitive bending, lifting, extension activities

Medications Tylenol NSAID’s Narcotics

– Short acting• Vicodin, Percocet, T3,

Demerol, Dilaudid

– Sustained release• MS Contin, Oxycontin,

Methadone, Fentanyl

Glucosamine Chondroitan

Injections

Epidural Steroid Injection– Serial injections 1-3 on

monthly basis

– 24-60% relief

Surgery

Laminectomy– Remove bone between

base of spinous process and facet-pedicle junction

– May require fusion and or posterior plates/screws

Discectomy

Prognosis

Surgery– Metanalysis of 74 studies

• 64% with good to excellent outcomes

– Katz, et al. Spine 1996- 88 pts followed for 7 yrs

• 3-5 yrs 52% free of severe pain, 30% in severe pain, and 17% re-operated

• 7-10 yrs 30% in severe pain and 24% re-operated

Non-surgical– 52% improved @ 4 yrs

Poor Prognostic Factors

Prolonged duration of sx Severe sx Psychosomatic disorders Sphincter disturbances Insurance or medical-legal issues Poor self-assessment of health

Cervical Spine

Epidemiology CSM is most common

spinal disorder in >55 UK 23.6% of 585 pts

with tetraparesis or paresis

Anatomy Similar 3-joint

complex Center of

motion– Flex C 5-6

– Ext C 6-7

Pathophysiology Static compression Dynamic

compression Ischemia Nerve root

compression or cord problems (cervcial cord myelopathy)

Static Compression Disc herniation Osteophytic spurring

– Vertebral body– Zagoapophyseal

joints

Dynamic Compression Cervical

Instability Ligamentum

flavum buckling with extension

Stretching over anterior oseophytes with flexion

Symptoms Neck Pain Crepitus UE motor

(atrophy) or sensory sx

LE spasticity Gait disturbance Bowel/bladder sx

Exam- UE C5-Deltoid, biceps C6- Biceps, wrist

ext C7-elbow ext, wrist

flex, finger ext C8- finger flexors T1-hand intrinsics

Exam-LE Babinski Clonus Hyper-reflexia Spastic gait Abnormal

Rhomberg Lhermitte’s sign

Radiographs Cervical

spondylosis Flex/ext views

MRI Eval functional

reserve and impingement of nerve and cord

R/o myelopathy

Differential Diagnosis Brachial Plexopathy Burner Syndrome ALS MS Polyneuropathy Cervical Spondylosis

Non-surgical Management Medications Injections

– ESI, facet, trigger pts

Activity modification

Posture Strengthening Cervical Traction

Surgical Management Anterior approach Discectomy and

fusion Posterior approach

for more advanced disease for laminectomy and posterior fusion

Outcomes Non-op

– 1/3 improved

– 26% deteriorate

Surgical– 50% at best

Prognostic Indicators Severe preop

neuro def Abn cord signal

or myelomalacia Severity of cord

compression on plain film

Summary & Pearls Abn gait consider cord problems When evaluating cervical discs look at

the LE for UMN signs Surgery is best to be avoided Step-wise approach to pain management Use your Pain Specialist Serial exams Know your myotomes and dermatomes