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 .

cramping. chronic LBP. 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 . surgery. old injury  C/o burning. numbness.Symptoms  Post h/o HNP.

Hip flexors (L2-3)  Sensory . Gastroc (S1). Peroneals (S1). Quad (L3-4).Examination  ROM – Full forward flexion without sx – Limited extension with pain  DTR’s – Usually nl  Strength – EHL (L5). TA (L4).

DP.Examination  Vascular exam – Pulses • Pop. 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. extension activities . lifting.

Dilaudid – Sustained release • MS Contin.Medications  Tylenol  NSAID’s  Narcotics – Short acting • Vicodin. Oxycontin. Fentanyl  Glucosamine Chondroitan . Methadone. Demerol. Percocet. T3.

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 .

Spine 1996. et al. and 17% re-operated • 7-10 yrs 30% in severe pain and 24% re-operated  Non-surgical – 52% improved @ 4 yrs . 30% in severe pain.88 pts followed for 7 yrs • 3-5 yrs 52% free of severe pain.Prognosis  Surgery – Metanalysis of 74 studies • 64% with good to excellent outcomes – Katz.

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 .

6% of 585 pts with tetraparesis or paresis .Epidemiology  CSM is most common spinal disorder in >55  UK 23.

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 .

finger ext  C8. biceps  C6. wrist flex. wrist ext  C7-elbow ext.Biceps.Exam.finger flexors  T1-hand intrinsics .UE  C5-Deltoid.

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 .

facet.Non-surgical Management  Medications  Injections – ESI. 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 .

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