1 / 37

Spinal Stenosis

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

marionc
Download Presentation

Spinal Stenosis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Spinal Stenosis Thomas M. Howard, MD Sports Medicine

  2. These Patients Consume: • Many appointments • Many narcotic medications • Many specialty appointments • Ortho, Pain, Neurology, Neurosurgery, Physical Therapy • TIME!!

  3. Lumbar Spine

  4. Epidemiology • 12 mil visits/yr for LBP • 3-4% will have spinal stenosis • Usually age >50 • Prevalence 1.7-8% annually

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

  6. 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

  7. 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

  8. 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

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

  10. Differential Diagnosis • Piriformis Syndrome • Trochanteric Bursitis • Hip OA • Vascular Claudication • SI Dysfunction

  11. Radiographs

  12. MRI

  13. CT Myelogram

  14. EMG

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

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

  17. Injections • Epidural Steroid Injection • Serial injections 1-3 on monthly basis • 24-60% relief

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

  19. 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

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

  21. Cervical Spine

  22. Epidemiology • CSM is most common spinal disorder in >55 • UK 23.6% of 585 pts with tetraparesis or paresis

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

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

  25. Static Compression • Disc herniation • Osteophytic spurring • Vertebral body • Zagoapophyseal joints

  26. Dynamic Compression • Cervical Instability • Ligamentum flavum buckling with extension • Stretching over anterior oseophytes with flexion

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

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

  29. Exam-LE • Babinski • Clonus • Hyper-reflexia • Spastic gait • Abnormal Rhomberg • Lhermitte’s sign

  30. Radiographs • Cervical spondylosis • Flex/ext views

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

  32. Differential Diagnosis • Brachial Plexopathy • Burner Syndrome • ALS • MS • Polyneuropathy • Cervical Spondylosis

  33. Non-surgical Management • Medications • Injections • ESI, facet, trigger pts • Activity modification • Posture • Strengthening • Cervical Traction

  34. Surgical Management • Anterior approach • Discectomy and fusion • Posterior approach for more advanced disease for laminectomy and posterior fusion

  35. Outcomes • Non-op • 1/3 improved • 26% deteriorate • Surgical • 50% at best

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

  37. 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

More Related