1. SPINAL STENOSIS Jung U. Yoo, M.D. Professor and Chairman Department of Orthopedics and Rehabiliatation Oregon Health and Science University

2. STABILITY • ORDINARY ACTIVITIES MAY GENERATE OVER 1000LB OF FORCE

3. MOTION

4. NEUROPROTECTION • SPINAL CORD • NERVE ROOTS

5. PATHOPHYSIOLOGY • “Three-joint Complex” • a large tripod with the disc as the front support and two facet joints as the back supports • Any alteration in one of these joints can lead to damage to the others

6. STENOSIS

7. STENOSIS

8. FORAMINAL STENOSIS • Compresses the exiting nerve root

9. CANAL SHAPE • Round • Triangular • Trefoiled (15%) • Trefoiled & asymmetric

10. DEGENERATION & STENOSIS

11. PREVALENCE • Most common indication for spinal surgery in patients over 60 y.o. • 400,000 Americans are estimated to have spinal stenosis

12. STENOSIS • Narrowing of the spinal canal or neuroforamina • causing a symptomatic compression of the neural element.

13. SYMPTOMS • Neurogenic claudication • Radicular pain • Weakness • Sensory abnormalities • Back pain

14. PHYSICAL FINDINGS Physical Finding Literature Review • Limited lumbar extension 66-100% • Muscle weakness 18-52% • Sensory deficit 32-58% • Katz JN, et al: Diagnosis of lumbar spinal stenosis. Rheum. Dis. Clin. North Am. 20:471-483, 1994

15. NEUROGENIC CLAUDICATION • Cardinal symptom of lumbar stenosis • Progressive pain and/or paresthesia in the back, buttock, thigh and calves brought on by walking or standing, and relieved by sitting or lying down with hip flexion

16. POSTURE

17. AMBULATION

18. DIFFERENTIAL DIAGNOSIS • Vascular claudication • Osteoarthritis of hip or knee • Lumbar disc protrusion • Intraspinal tumor • Unrecognized neurologic disease • Peripheral neuropathy

19. FORAMINAL STENOSIS • Root symptoms • Unilateral • No claudication • Acute or chronic

20. LATERAL RECESS STENOSIS • Claudication • Radicular pain • Weakness is rare • Acute or chronic

21. CENTRAL STENOSIS • Varied presentation • Classically with neurogenic claudication • Some may only have back pain • Rarely painless progressive weakness

22. DIAGNOSTIC TESTS

23. X-RAY • Screening exam • Stenosis cannot be diagnosed

24. X-RAY • Instability such as scoliosis or listhesis

25. CT SCAN • Difficult to diagnose stenosis • Replaced by MRI • May be useful for those who cannot have an MRI

26. CT SCAN • Excellent bony detail

27. MRI • Non-invasive • Soft tissue visualization • Gold standard

28. MRI • Sagittal images • Visualization of foramen

29. MYELOGRAPHY • Excellent for intra-canal pathology • Poor for foraminal pathology • Replaced by MRI

30. MYELOGRAPHY • Invasive • 1% spinal headache • Recurrent stenosis • Inability to obtain MRI

31. MYELOGRAPHY

32. CT-MYELOGRAPHY • Excellent visualization of spinal canal

33. CT-MYELOGRAPHY • Excellent for recurrent stenosis • Invaluable in surgical planning

34. MRI • Expensive • Patient cooperation • Claustrophobia • Open MRI

35. EMG-NCS • Differentiation between neuropathy and radiculopathy • Acute active denervation vs. chronic denervation

36. TREATMENT

37. NONOPERATIVE RX • Rest • Analgesic • Oral steroid • Physical therapy • Bracing • Spinal injection

38. REST • Short term activity modification for acute pain • Long term activity modification is not recommended

39. ANALGESIC • NSAIDS • Tylenol • Narcotics • Neurontin

40. Oral Steroid • Effective for acute pain • Short duration therapy • ? Chronic or repeat tapering dose

41. PHYSICAL THERAPY • Avoid extension exercises acutely • William Flexion Exercises • Water aerobics • Strengthening of weak muscle groups

42. SPINAL INJECTIONS • Epidural steroid • Transforaminal root block • Facet joint injection

43. EPIDURAL STEROID • Commonly prescribed • 50% short-term efficacy • Not as selective • May not require fluroscope

44. TRANSFORAMINAL ROOT BLOCK • Highly selective • Diagnostic as well as therapeutic • Delivers medicine to the floor of spinal canal

45. FACET INJECTION • Facet for back pain • Not for radicular pain • May act as epidural in 40% of cases

46. SPINAL INJECTION • Most effective for acute pain • May not be indicated in cases of acute denervation or progressive motor loss

47. OPERATIVE TREATMENT • Decompression of neural element • Stabilization of unstable segment

48. “LAMINECTOMY”

49. DECOMPRESSION OF LATERAL RECESS • Undercutting the ventral aspect of the facet joints and the associated ligamentum flavum. • Medial facetectomy if necessary • The traversing nerve root underneath the facet joint must be visualized

50. FUSION • Sagittal instability • Scoliosis • Iatrogenic pars defect • Greater than 50% facet joint resection