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 3-4% will have spinal stenosis Usually age >50 Prevalence 1.7-8% annually

Anatomy
Three-joint complex Facet joints and disc

Disc complex Nucleus pulposis and annulus fibrosis Ligamentum flavum

Nerve roots

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
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
ROM
Full forward flexion without sx Limited extension with pain

DTRs
Usually nl

Strength
EHL (L5), TA (L4), Peroneals (S1), Gastroc (S1), Quad (L3-4), Hip flexors (L2-3)

Sensory

Examination
Vascular exam Pulses
Pop, DP, PT

Temp Trophic changes

Consider ABI

Differential Diagnosis
Piriformis Syndrome

Trochanteric Bursitis
Hip OA Vascular Claudication SI Dysfunction

Radiographs

MRI

CT Myelogram

EMG

Non-operative
Medications

Injections
Physical Therapy Weight Management Lumbar stabilization and core strengthening Aerobic fitness Activity Modification Avoid repetitive bending, lifting, extension activities

Medications
Tylenol NSAIDs Narcotics Short acting
Vicodin, Percocet, T3, Demerol, Dilaudid

Sustained release
MS Contin, Oxycontin, Methadone, Fentanyl

Glucosamine

Chondroitan

Injections
Epidural Steroid

Injection
Serial injections 1-3 on monthly basis 24-60% relief

Surgery
Laminectomy Remove bone between base of spinous process and facet-pedicle junction May require fusion and or posterior plates/screws

Discectomy

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

Prolonged duration of sx

Severe sx
Psychosomatic disorders

Sphincter disturbances
Insurance or medical-legal issues Poor self-assessment of health

Cervical Spine

Epidemiology
CSM is most common

spinal disorder in >55 UK 23.6% of 585 pts with tetraparesis or paresis

Anatomy
Similar 3-joint

complex Center of motion

Flex C 5-6 Ext C 6-7

Pathophysiology
Static compression Dynamic

compression Ischemia Nerve root compression or cord problems (cervcial cord myelopathy)

Static Compression
Disc herniation

Osteophytic spurring

Vertebral body Zagoapophyseal joints

Dynamic Compression
Cervical

Instability Ligamentum flavum buckling with extension Stretching over anterior oseophytes with flexion

Symptoms
Neck Pain Crepitus UE motor

(atrophy) or sensory sx LE spasticity Gait disturbance Bowel/bladder sx

Exam- UE
C5-Deltoid, biceps

C6- Biceps, wrist

ext C7-elbow ext, wrist flex, finger ext C8- finger flexors T1-hand intrinsics

Exam-LE
Babinski Clonus Hyper-reflexia

Spastic gait
Abnormal

Rhomberg Lhermittes sign

Radiographs
Cervical

spondylosis Flex/ext views

MRI
Eval functional

reserve and impingement of nerve and cord R/o myelopathy

Differential Diagnosis
Brachial Plexopathy

Burner Syndrome
ALS MS Polyneuropathy Cervical Spondylosis

Non-surgical Management
Medications Injections ESI, facet, trigger pts Activity

modification Posture Strengthening Cervical Traction

Surgical Management
Anterior approach

Discectomy and

fusion Posterior approach for more advanced disease for laminectomy and posterior fusion

Outcomes
Non-op 1/3 improved 26% deteriorate Surgical 50% at best

Prognostic Indicators
Severe preop

neuro def Abn cord signal or myelomalacia Severity of cord compression on plain film

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