Lumbar Stenosis

1
Lumbar stenosis
2
Definition
Lumbar canal stenosis is the narrowing of the
spinal canal or the tunnels through which nerves
and other structures com- municate with that
canal. Narrowing of the spinal canal usually
occurs due to changes associated with aging that
decrease the size of the canal, including the
movement of one of the vertebrae out of
alignment. The narrowing of the spinal canal or
the side canals that protect the nerves often
results in a pinching of the nerve root of the
spinal cord. The nerves become increasingly
irritated as the diameter of the canal becomes
narrower.
3
Prevalation
Prevalence of LSS increase with age and is
particularly high in subjects aged 7079 years,
irrespective of gender.
The incidence of Lumbar spinal stenosis (LSS) in
the United States has been estimated at 8-11 of
the population.
As the baby boomers age, an estimated 2.4
million Americans will be affected by LSS by
2021. With the first wave of baby boomers just
qualifying for Medicare, this condition will
undoubtedly have an impact on government
healthcare spending.
As correlated factors, an advanced age (60 years
or older), diabetes mellitus, urological
disorders, osteoarthritis and spinal fractures as
comorbidities, and depressive symptoms, were
associated with LSS.
4
Causes and Risk factors
While some people are born with a small spinal
canal, most Lumbar spinal stenosis occurs when
something happens to reduce the amount of space
available within the spine. Causes of spinal
stenosis may include Overgrowth of bone Wear and
tear on your spinal bones can prompt the
formation of bone spurs, which can grow into the
spinal canal. Paget's disease, a bone disease
that usually affects adults, also can cause bone
overgrowth in the spine. Herniated disks The soft
cushions that act as shock absorbers between your
vertebrae tend to dry out with age. Cracks in a
disk's exterior may allow some of the soft inner
material to escape and press on the spinal cord
or nerves. Thickened ligaments The tough cords
that help hold the bones of your spine together
can become stiff and thick over time. These
thicker ligaments can bulge into the spinal
canal. Tumors Abnormal growths can form inside
the spinal cord, within the membranes that cover
the spinal cord or in the space between the
spinal cord and vertebrae. Spinal injuries Car
accidents and other major trauma can cause
dislocations or fractures of one or more
vertebrae. Displaced bone from a spinal fracture
may damage the contents of the spinal canal.
Swelling of adjacent tissue immediately following
back surgery also can put pressure on the spinal
cord or nerves.
5
Causes and Risk factors
Some medical conditions can cause spinal
stenosis.These include
The risk of developing spinal stenosis increases
if

• Osteoarthritis and bony spurs that form as we age
  
• Inflammatory spondyloarthritis (e.g., ankylosing
  spondylitis)
• Spinal tumors
• Paget's Disease

• You were born with a narrow spinal canal
• You are female
• You are 50 years old or older
• You've had a previous injury or surgery of the
  spine

6
Symptoms

• Many people, especially those older than age 50,
  have some narrowing of the spinal canal but don't
  have symptoms. Symptoms occur when the nerve
  roots get squeezed.
• Leg pain
• The most common symptom is leg pain that happens
  when you walk or stand and feels better when you
  sit. You feel pain in your legs, because the
  nerve roots that pass through the lower spine
  extend to the legs.
• People often have leg pain when the spine is
  extendedwhen they are standing straight or
  leaning backward, for example.
• And they often feel better when the spine is
  flexedwhen they are sitting, walking uphill,
  riding a bicycle, or leaning over a grocery cart,
  for example.
• People with severe stenosis may have a habit of
  leaning forward in a stooped position to relieve
  pain.
• Other symptoms may include
• Numbness, weakness, and cramping in the legs,
  feet, or buttocks. Stiffness in the legs and
  thighs.
• Low back pain.
• In severe cases, loss of bladder and bowel
  control.

7
Diagnostic
Your doctor will begin by letting you relate the
history of how your symptoms began and how they
progressed. You will be asked a series of
questions and a physical examination then carried
out that is directed primarily at your lower
back, and nerve function in your legs. Your
doctor will check your balance, test your
gait. X-rays may be requested and will in some
patients show signs of degenerative changes in
the disc spaces or facet joints. Bending x-rays
of the neck may show a small degree of slip
slide between the neck vertebrae. Magnetic
resolution imaging MRI of the neck may be
ordered. MRI pictures allow your NASS doctor to
visualize structures that may be impinging on the
spinal cord or the nerve branches. In some
patients, injection of dye into the spinal cord
myelogram may be required and this is followed
by CT scans computerized tomography.
Electrical testing of the nerves and spinal cord
is requested in some patients. Electromyogram
EMG and nerve conduction studies help
distinguish cervical radiculopathy from other
nerve problems in the arm and forearm such as
carpal tunnel syndrome. Somatic sensory evoke
potentials SSEP are electrical tests that study
signal conduction through the spinal cord and may
be ordered in some patients with cervical
myelopathy.
8
Non-surgical treatment
Typical lumbar stenosis treatments include one or
a combination of the following Activity
modi?cation Patients are usually more comfortable
when flexed forward. For example, many patients
can ease leg pain and discomfort when walking by
leaning forward on a cane, walker or shopping
cart. Exercise This treatment will be
recommended as part of treatment for most people
with lumbar spinal stenosis. A targeted program
of spinal stenosis exercises with guidance from a
physical therapist or doctor can prevent further
debilitation arising from inactivity.
Modifications to exercises can be made to ensure
patient comfort. For example, stationary biking
can be a beneficial treatment option because
patients are sitting and positioned in a
flexed-forward position while exercising.
9
Non-surgical treatment
Non-steroidal anti-inflammatory drugs
(NSAIDs) Since inflammation is a common component
of spinal stenosis, anti-inflammatory drugs, such
as ibuprofen (e.g. Advil), naproxen (e.g. Aleve)
or Cox-2 Inhbitors (e.g. Celebrex), may be an
effective lumbar stenosis treatment.
Epidural injections This treatment will be
recommended as part of treatment for most people
with lumbar spinal stenosis. A targeted program
of spinal stenosis exercises with guidance from a
physical therapist or doctor can prevent further
debilitation arising from inactivity.
Modifications to exercises can be made to ensure
patient comfort. For example, stationary biking
can be a beneficial treatment option because
patients are sitting and positioned in a
flexed-forward position while exercising.
When the (usually elderly) patient can no longer
walk sufficiently to care for himself or herself
(such as to go shopping for essentials), then
lumbar spinal stenosis surgery is usually
recommended. Surgery for lumbar stenosis is
mainly designed to increase a patients activity
tolerance, so he or she can do more activity with
less pain.
10
Treatment - surgery

• Typically, surgeons use 2 surgical techniques for
  spinal stenosis surgery.
• Decompression The surgeon will remove tissue
  pressing against a nerve structure, which makes
  more room in the spinal canal (for the spinal
  cord) or in the foramen (for the nerve roots).
• Stabilization The surgeon works to limit motion
  between vertebrae.
• Decompression Surgery for Spinal Stenosis
• To remove the tissue that's pressing on a nerve,
  your spine surgeon may perform one of the
  following types of surgery.
• Foraminotomy If part of the disc or a bone spur
  (osteophyte) is pressing on a nerve as it leaves
  the vertebra (through an exit called the
  foramen), a foraminotomy may be done. Otomy means
  "to make an opening." So a foraminotomy is making
  the opening of the foramen larger, so the nerve
  can exit without being compressed.
• Laminotomy Similar to the foraminotomy, a
  laminotomy makes a larger opening, this time in
  your bony plate protecting your spinal canal and
  spinal cord (the lamina). The lamina may be
  pressing on your nerve, so the surgeon may make
  more room for the nerves using a laminotomy.
• Laminectomy Sometimes, a laminotomy is not
  sufficient. The surgeon may need to remove all or
  part of the lamina, and this procedure is called
  a laminectomy. This can often be done at many
  levels without any harmful effects.
• Also, a laminoplasty can be performed to preserve
  bony anatomy.
• Indirect decompression is a variation of
  decompression surgery where pressure is relieved
  by spreading the bones apart instead of removing
  bone. This can be done with instrumentation
  (hardware), such as interspinous process devices
  or interbody cages. Even artificial discs can
  accomplish some indirect decompression by
  restoring the height between adjacent vertebrae.

11
Treatment - surgery
Stabilization Surgery for Spinal Stenosis Not
everyone who has surgery for spinal stenosis will
need stabilization, which is also known as spinal
fusion. It's especially helpful in cases where
one or more vertebrae has slipped out of the
correct position, which makes your spine unstable
(and painful). In these cases, the bones slipping
can pinch nerves. The need for stabilization also
depends on how many vertebrae your surgeon needs
to work on. For example, if he or she needs to
remove the lamina (using a laminectomy) in
multiple vertebrae, your spine may be unstable
without those structures. You'll need to have
spinal fusion to help stabilize your spine.
Spine stabilization surgery has been common for
many years. It can be done alone or at the same
time as a decompression surgery. In spine
stabilization, the surgeon creates an environment
where the bones in your spine will fuse together
over time (usually over several months or
longer). The surgeon uses a bone graft (usually
using bone from your own body) or a biological
substance (which will stimulate bone growth).
Your surgeon may use spinal instrumentationwires,
cables, screws, rods, and platesto increase
stability and help fuse the bones. The fusion
will stop movement between the vertebrae,
providing long-term stability