Spinal Stenosis 2
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Spinal Stenosis
Thomas M. Howard, MD
Sports Medicine
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These Patients Consume:
Many appointments Many narcotic medications Many specialty appointments
– Ortho, Pain, Neurology, Neurosurgery, Physical Therapy
TIME!!
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Lumbar Spine
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Epidemiology
12 mil visits/yr for LBP
3-4% will have spinal stenosis
Usually age >50 Prevalence 1.7-8%
annually
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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
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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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Radiographs
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MRI
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CT Myelogram
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EMG
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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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Cervical Spine
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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
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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