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Spinal Stenosis

Spinal Stenosis

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Spinal Stenosis

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  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