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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

Spinal Stenosis

Thomas M. Howard, MD

Sports Medicine

these patients consume
These Patients Consume:
  • Many appointments
  • Many narcotic medications
  • Many specialty appointments
    • Ortho, Pain, Neurology, Neurosurgery, Physical Therapy
  • TIME!!
epidemiology
Epidemiology
  • 12 mil visits/yr for LBP
  • 3-4% will have spinal stenosis
  • Usually age >50
  • Prevalence 1.7-8% annually
anatomy
Anatomy
  • Three-joint complex
    • Facet joints and disc
  • Disc complex
    • Nucleus pulposis and annulus fibrosis
  • Ligamentum flavum
  • Nerve roots
pathophysiology
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
symptoms
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
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
examination9
Examination
  • Vascular exam
    • Pulses
      • Pop, DP, PT
    • Temp
    • Trophic changes
  • Consider ABI
differential diagnosis
Differential Diagnosis
  • Piriformis Syndrome
  • Trochanteric Bursitis
  • Hip OA
  • Vascular Claudication
  • SI Dysfunction
non operative
Non-operative
  • Medications
  • Injections
  • Physical Therapy
  • Weight Management
  • Lumbar stabilization and core strengthening
  • Aerobic fitness
  • Activity Modification
    • Avoid repetitive bending, lifting, extension activities
medications
Medications
  • Tylenol
  • NSAID’s
  • Narcotics
    • Short acting
      • Vicodin, Percocet, T3, Demerol, Dilaudid
    • Sustained release
      • MS Contin, Oxycontin, Methadone, Fentanyl
  • Glucosamine Chondroitan
injections
Injections
  • Epidural Steroid Injection
    • Serial injections 1-3 on monthly basis
    • 24-60% relief
surgery
Surgery
  • Laminectomy
    • Remove bone between base of spinous process and facet-pedicle junction
    • May require fusion and or posterior plates/screws
  • Discectomy
prognosis
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
poor prognostic factors
Poor Prognostic Factors
  • Prolonged duration of sx
  • Severe sx
  • Psychosomatic disorders
  • Sphincter disturbances
  • Insurance or medical-legal issues
  • Poor self-assessment of health
epidemiology22
Epidemiology
  • CSM is most common spinal disorder in >55
  • UK 23.6% of 585 pts with tetraparesis or paresis
anatomy23
Anatomy
  • Similar 3-joint complex
  • Center of motion
    • Flex C 5-6
    • Ext C 6-7
pathophysiology24
Pathophysiology
  • Static compression
  • Dynamic compression
  • Ischemia
  • Nerve root compression or cord problems (cervcial cord myelopathy)
static compression
Static Compression
  • Disc herniation
  • Osteophytic spurring
    • Vertebral body
    • Zagoapophyseal joints
dynamic compression
Dynamic Compression
  • Cervical Instability
  • Ligamentum flavum buckling with extension
  • Stretching over anterior oseophytes with flexion
symptoms27
Symptoms
  • Neck Pain
  • Crepitus
  • UE motor (atrophy) or sensory sx
  • LE spasticity
  • Gait disturbance
  • Bowel/bladder sx
exam ue
Exam- UE
  • C5-Deltoid, biceps
  • C6- Biceps, wrist ext
  • C7-elbow ext, wrist flex, finger ext
  • C8- finger flexors
  • T1-hand intrinsics
exam le
Exam-LE
  • Babinski
  • Clonus
  • Hyper-reflexia
  • Spastic gait
  • Abnormal Rhomberg
  • Lhermitte’s sign
radiographs30
Radiographs
  • Cervical spondylosis
  • Flex/ext views
slide31
MRI
  • Eval functional reserve and impingement of nerve and cord
  • R/o myelopathy
differential diagnosis32
Differential Diagnosis
  • Brachial Plexopathy
  • Burner Syndrome
  • ALS
  • MS
  • Polyneuropathy
  • Cervical Spondylosis
non surgical management
Non-surgical Management
  • Medications
  • Injections
    • ESI, facet, trigger pts
  • Activity modification
  • Posture
  • Strengthening
  • Cervical Traction
surgical management
Surgical Management
  • Anterior approach
  • Discectomy and fusion
  • Posterior approach for more advanced disease for laminectomy and posterior fusion
outcomes
Outcomes
  • Non-op
    • 1/3 improved
    • 26% deteriorate
  • Surgical
    • 50% at best
prognostic indicators
Prognostic Indicators
  • Severe preop neuro def
  • Abn cord signal or myelomalacia
  • Severity of cord compression on plain film
summary pearls
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
ad