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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

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Spinal stenosis l.jpg

Spinal Stenosis

Thomas M. Howard, MD

Sports Medicine


These patients consume l.jpg
These Patients Consume:

  • Many appointments

  • Many narcotic medications

  • Many specialty appointments

    • Ortho, Pain, Neurology, Neurosurgery, Physical Therapy

  • TIME!!



Epidemiology l.jpg
Epidemiology

  • 12 mil visits/yr for LBP

  • 3-4% will have spinal stenosis

  • Usually age >50

  • Prevalence 1.7-8% annually


Anatomy l.jpg
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


Examination l.jpg
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


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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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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

  • NSAID’s

  • 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 @ 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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Epidemiology

  • CSM is most common spinal disorder in >55

  • 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

  • Lhermitte’s 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


Outcomes l.jpg
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


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