Spinal Stenosis

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Spinal Stenosis

• Thomas M. Howard, MD
• Sports Medicine

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These Patients Consume

• Many appointments
• Many narcotic medications
• Many specialty appointments
• Ortho, Pain, Neurology, Neurosurgery, Physical
  Therapy
• TIME!!

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Lumbar Spine
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Epidemiology

• 12 mil visits/yr for LBP
• 3-4 will have spinal stenosis
• Usually age gt50
• Prevalence 1.7-8 annually

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Anatomy

• Three-joint complex
• Facet joints and disc
• Disc complex
• Nucleus pulposis and annulus fibrosis
• Ligamentum flavum
• Nerve roots

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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

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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

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Examination

• ROM
• Full forward flexion without sx
• Limited extension with pain
• DTRs
• Usually nl
• Strength
• EHL (L5), TA (L4), Peroneals (S1), Gastroc (S1),
  Quad (L3-4), Hip flexors (L2-3)
• Sensory

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Examination

• Vascular exam
• Pulses
• Pop, DP, PT
• Temp
• Trophic changes
• Consider ABI

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Differential Diagnosis

• Piriformis Syndrome
• Trochanteric Bursitis
• Hip OA
• Vascular Claudication
• SI Dysfunction

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Radiographs
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MRI
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CT Myelogram
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EMG
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Non-operative

• Medications
• Injections
• Physical Therapy
• Weight Management
• Lumbar stabilization and core strengthening
• Aerobic fitness
• Activity Modification
• Avoid repetitive bending, lifting, extension
  activities

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Medications

• Tylenol
• NSAIDs
• Narcotics
• Short acting
• Vicodin, Percocet, T3, Demerol, Dilaudid
• Sustained release
• MS Contin, Oxycontin, Methadone, Fentanyl
• Glucosamine Chondroitan

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Injections

• Epidural Steroid Injection
• Serial injections 1-3 on monthly basis
• 24-60 relief

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Surgery

• Laminectomy
• Remove bone between base of spinous process and
  facet-pedicle junction
• May require fusion and or posterior plates/screws
• Discectomy

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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 _at_ 4 yrs

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Poor Prognostic Factors

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

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Cervical Spine
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Epidemiology

• CSM is most common spinal disorder in gt55
• UK 23.6 of 585 pts with tetraparesis or paresis

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Anatomy

• Similar 3-joint complex
• Center of motion
• Flex C 5-6
• Ext C 6-7

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Pathophysiology

• Static compression
• Dynamic compression
• Ischemia
• Nerve root compression or cord problems (cervcial
  cord myelopathy)

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Static Compression

• Disc herniation
• Osteophytic spurring
• Vertebral body
• Zagoapophyseal joints

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Dynamic Compression

• Cervical Instability
• Ligamentum flavum buckling with extension
• Stretching over anterior oseophytes with flexion

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Symptoms

• Neck Pain
• Crepitus
• UE motor (atrophy) or sensory sx
• LE spasticity
• Gait disturbance
• Bowel/bladder sx

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Exam- UE

• C5-Deltoid, biceps
• C6- Biceps, wrist ext
• C7-elbow ext, wrist flex, finger ext
• C8- finger flexors
• T1-hand intrinsics

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Exam-LE

• Babinski
• Clonus
• Hyper-reflexia
• Spastic gait
• Abnormal Rhomberg
• Lhermittes sign

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Radiographs

• Cervical spondylosis
• Flex/ext views

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MRI

• Eval functional reserve and impingement of nerve
  and cord
• R/o myelopathy

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Differential Diagnosis

• Brachial Plexopathy
• Burner Syndrome
• ALS
• MS
• Polyneuropathy
• Cervical Spondylosis

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Non-surgical Management

• Medications
• Injections
• ESI, facet, trigger pts
• Activity modification
• Posture
• Strengthening
• Cervical Traction

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Surgical Management

• Anterior approach
• Discectomy and fusion
• Posterior approach for more advanced disease for
  laminectomy and posterior fusion

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Outcomes

• Non-op
• 1/3 improved
• 26 deteriorate
• Surgical
• 50 at best

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Prognostic Indicators

• Severe preop neuro def
• Abn cord signal or myelomalacia
• Severity of cord compression on plain film

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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