1 / 55

Spinal Stenosis / Neurogenic Claudication

Spinal Stenosis / Neurogenic Claudication. Chris Dowding Half Day Feb 16 2012. Low Back Pain. About ¾ of all individuals will experience low back pain at some time in their lives; usually, it resolves in a matter of weeks.

Download Presentation

Spinal Stenosis / Neurogenic Claudication

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/NeurogenicClaudication Chris Dowding Half Day Feb 16 2012

  2. Low Back Pain • About ¾ of all individuals will experience low back pain at some time in their lives; usually, it resolves in a matter of weeks. • Low back pain is the leading cause of disability in people younger than 50 years of age. • LBP - M=F • Peak incidence between 35 and 50 years of age • Primary causes of low back pain • Muscle strain or ligament sprain • Facet joint arthropathy • Discogenic pain or Annular tears • Spondylolisthesis • Spinal stenosis

  3. Anatomy

  4. What is Spinal Stenosis? • First described by Verbiest 1954 • 7 patients with syndrome of the following: • Lumbar canal narrowing • Neurogenic spinal claudication • Radicular pain • Motor weakness in lower limb

  5. Definition • Spinal Stenosis • Narrowing of the spinal canal, resulting in a clinical syndrome of leg dominant pain • Primary subtypes • Central canal stenosis • Subarticularstenosis (area under facet joints) • Neural foramina stenosis • Symptoms are caused by compression of the nerve roots • Results in neurogenicclaudication

  6. Definition • Neurogenicclaudication • Discomfort or pain that radiates from the spinal area into the buttocks and frequently into thigh and lower leg

  7. Pattern 4

  8. Claudication

  9. Claudication

  10. Claudication

  11. Etiology • Spinal Stenosis • Narrowing of spinal canal due to: • Degenerative • (most common) • Developmental • Congenital disorders • Post traumatic • Steroids • Post-surgical • Certain disorders

  12. Degenerative Stenosis • Narrowing is secondary to arthritis • Typically following order • Disc degeneration • Facet osteoarthritis • Flavum hypertrophy • Symptoms develop around 60 yo

  13. Intervertebral Joints Two Components: 1. Outer rim of fibrocartilage called the annulus fibrosus (attaches to cartilaginous end plate) • Connects vertebral bodies in a fibrocartilaginous joint (no capsule, little motion) 2. Facet (Zygapophyseal) joints

  14. Intervertebral Disks • Fibrocartilaginous • Collagen, water, Proteoglycans • Annulus Fibrosus • Obliquely oriented collagen • Type I collagen • Outer rim contains free nerve endings • Central Nucleus Pulposus • 88+% water, high polysaccharide content • No blood vessels or nerves • Type II collagen

  15. Intervertebral Disks • Function • spinal motion and stability. • Disk is avascular. • Nutrients fluid via diffusion through pores in the hyaline cartilage end plates • As Disks ages • Decreased water content, increased collagen.

  16. Disk Degeneration • Begins roughly third decade of life. • Characterized by a decline in proteoglycan concentration with resultant loss of hydration and a decreased number of viable cells • L4-5 and L5-S1 are the disks that typically degenerate first

  17. Degenerative Disks • Disk height decreases, resulting in alteration of the segmental spinal biomechanics • Increasing wear on facet joints • The precise cause(s) of disk degeneration are unclear, and there are several potential contributors • Comorbidities like diabetes, vascular insufficiency, and smoking are potentially associated with disk degeneration • There appears to be a genetic component to disk degeneration

  18. Degenerative Stenosis • Loss of disc height •  Infolding of flavum •  Increased stress across facets •  Facet OA and hypertrophy •  Osteophytesand capsule thickening •  Cysts

  19. Degenerative Stenosis • Spondylolithesis (+/- spondylolysis) • Can result in stenosis • Back pain is primary symptom • Neurogenicclaudication is secondary

  20. Developmental Stenosis • Narrowing of canal due to growth disturbance of posterior elements • Congenitally short pedicles • Often present in 20’s

  21. Presentation • Constellation of symptoms • Leg pain • Difficulty ambulating • Comfortable sitting • Pain with prolonged walking • Neurologic deficits

  22. History • Age • Pain • Location • Timing • Characteristics • Aggravating or relieving factors? • Previous therapy? • PMHx • Social History/Occupation • Meds/Allergies • Functional Inquiry • How far can you walk? • Can they bike?

  23. Red Flags Night sweats Fever Weight loss Bowel/Bladder History of cancer Immunosuppression Saddle anaesthesia Sexual dysfunction Age > 60 History of IVDU Chronic infections Rest/night pain

  24. Physical Exam • Vitals • Inspect • Gait • Leg length • Trendelenburg test • Spinal alignment • Palpate • Spinous processes • Paraspinal muscles • Greater trochanters

  25. Physical Exam • ROM • Spine flexion, extension, rotation, lateral bend • Hip flexion, extension, rotation • Pain with etxension, relieved by flexion • Neuro • Strength • Sensation • Reflexes • Half of patients with symptomatic stenosis have motor or sensory deficits • Usually mild

  26. Neurologic Examination

  27. Special Tests • Romberg maneuver • Patient stands with eyes closed • Look for unsteadiness, wide based stance • Indicates damaged proprioception

  28. Imaging • Lumbar x-rays • +/- spondylolithesis • Extent of disc narrowing • Foramina osteophytes • CT/MRI • Can illustrate reductions in cross sectional diameter of central canal or foramina • Useful for pre-op planning or assessing candidacy for epidural injections • Large number of people may have radiologic findings but are asymptomatic

  29. Location of stenosis • Centrally • Lateral recess & neural foramina • Degeneration of • Disk • Facets (hypertrophy) • Synovial cysts • Joint capsule • Thickening of ligamentumflavum • Osteophytes

  30. Identifying the cause • Differential is broad • Some non-spinal causes to keep in mind • Vascular claudication • Hip arthritis • Diabetes (peripheral neuropathy)

  31. Vascular Claudication • Cramping/tightness in calf • PVD (skin ulcers, trophic changes) • Diminished pulses • Relieved by cessation of activity • Versus neurogenic (flexion or sitting down) • Capable of activity while flexed • shopping cart • Cycling • walking uphill

  32. Hip Arthritis • Groin pain • Referred pain in thigh • increased with activity • Internal rotation diminished • XR - OA

  33. Diabetes Glove & stocking distribution Not affected by activity level

  34. Conservative Management • Physical therapy • Abdominal strengthening • Biking • Brace/corset • Slight lumbar flexion • Limit hours worn per day • Avoid atrophy • Pain pyramid • Tylenol • NSAIDS • Narcotics

  35. Conservative Management • Epidural injections • Theory is that compression of nerve roots causes inflammation and thus symptoms • Cortocosteroids to reduce inflammation • Evidence is not convincing one way or another • Although this practice is increasing

  36. Natural History? • Natural course of disease • Pain / function of patients with lumbar stenosis • remains unchanged in majority patients • After one year of non-op management the majority of patients will be neither worse nor better • Rapid decline uncommon • Therefore prophylactic treatment non indicated • Improvement is also uncommon • If patient is miserable at baseline, non-op management may not be appropriate

  37. Surgical indications Progressive neurologic deficit Intractable pain Persistent impairment and functional limitation Confirmation by imaging LBP is not alleviated with surgery!

  38. Lumbar Stenosis:So when should we operate? • Goals of surgery • Decompress central canal and neural foramina • Options • Laminectomy ** • Partial facetectomy ** • Lumbar arthrodesis • +/- Instrumentation • Interspinous distraction • MIS

  39. Algorithm? Edward N. Hanley Jr., MD, Spinal Stenosis, Charlotte

  40. Treatment – Spinal Stenosis • Maine lumbar spine study • 119 patients • 67 treated surgically • 52 treated nonsurgically • After 4 years 70% of surgically treated and 52% of nonsurgically treated reported that their predominant pain was better. • Satisfaction 63% of surgically treated and 42% of nonsurgically treated. • Atlas et al. Spine. 2000.

  41. Malmivaara2007 • Design • RCT • 4-university hospitals • 94 patients • Surgical • Laminectomy 10 patients also had transpedicular fusion • Outcome • Oswestry Disability Index (0-100) • Intensity of pain (0-10) • Walking ability – self-reported • 6,12&24 months

  42. Malmivaara2007 • Inclusion Criteria • Back pain radiation to lower limb/buttock • Fatigue loss sensation aggravated by walking • Persistent pain without progressive neurologic dysfunction • SAC (sagital) < 10 mm • Duration of symptoms > 6 months • Signs & symptoms correspond to segmental radiographs • Severity of disease to justify surgical/non-surgical rx

  43. Malmivaara2007 • Exclusion • Severe LSS intractible pain • Progressive neurologic dysfunction • Mild LSS with clinical signs feeble enough to exclude surgical treatment • Spondylolysis and spondylolytic disease • Earlier back operation due to stenosis • Herniated disc during last 12 months • Another spinal disorder • Intermittent claudication due to PVD • Severe OA of L/E • Neurologic disease with impaired function of L/E • Psych • Alcoholic

  44. Malmivaara2007 • Randomization: • Central office computer generated blocks variable size for each hospital • Physician phoned central office after baseline exam, questionnaire completed

  45. Malmivaara2007 • Intervention • Surgical group • Segmental decompression • Facetectomy • Instability treated at surgeon discretion • Fusion of lumbar spine +/- instrumentation • Degenerative listhesis warranting procedure • Brochure for nature of disease, symptoms and activities • Non-operative group • Physiatrist followed throughout • Physiotherapist followed • Exercises • Brochure for nature of disease, symptoms and activities

  46. Malmivaara2007 • Walking ability • Reported & measured • No significant difference between 2 groups

  47. Malmivaara2007 • Conclusion • Those undergoing surgery reported greater improvement over non-operative treatment • Benefit diminished over time • Issues • Longer f/u needed • Surgical treatment differed • Selected bias from exclusion criteria • Screened for those who may benefit from surgery

  48. Weinstein 2008 • SPORT Trial • “Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis” • Inclusion • 12 weeks of symptoms typical to stenosis • Exclusion • Spondylolithesis

  49. Weinstein 2008 • 2 cohorts • A) randomization • Op vs non-op • B) observational • Elective op vs. elective non-op • Outcomes • Bodily pain and physical function • SF-36 • Modified Oswestry disability index • 6 weeks, 3 months, 6 months, 1 year, 2 years

More Related