Lumbar canal stenosis

Causes of Stenosis
• Degenerative spondylo-listhesis
• Facet subluxation and hypertrophy
• Pagets disease
• Tumour
• Facet joint cyst
• Congenital- achondroplasia
• Scoliosis with lateral shift
 Differential Diagnosis
• Vascular Claudication
• Hip OA
• Lumbar disc protrusion
• MS
• Tumour
• AV malformation
• Peripheral Neuropathy
Zones of nerve compression in Spinal
Stenosis
 Types of Stenosis

• Central: No pain, but legs ‘slow’ on walking

• Lateral recess: Unilateral leg pain, increased

on walking.
 Diagnosis

Congenital Stenosis Traumatic Stenosis

Infectious Stenosis
 Diagnosis

Degenerative Stenosis
JT. Right L45 Facet Joint Cyst.
Severe Right sided leg
pain and Low back
pain
Treated with
decompression
surgery
65/M. Pagets Disease causing stenosis. Long
standing LBP. Neurogenic claudication
distance 50 yards
 Symptoms
• 70% also have back pain
• Leg pain worse on walking and standing and
eased on sitting or bending forwards
• Can cycle or walk leaning forwards on a trolley
• Gradually Progressive
• Increased on walking on hard surfaces , down
an incline and in high heels
 Tandem Stenosis

• In 15-20% of patients both cervical and

lumbar stenosis are present
• Hoffman Sign positive.
• Heel-Toe gait – poor balance.
• Usually operate on the neck first
 Signs
• Minimal!!
• One of the hallmarks of these patients is that
they have no spinal tenderness, a full range of
movement, SLR is normal and there is no
neuro-deficit.
• Diagnosis is purely in the history
 Spinal Stenosis- what’s new?
• Diagnosis often missed as no positive
examination findings
• Diagnosis on history: difficulty walking with
cramps in legs, eased on sitting
• Epidural injections- short term relief
• Surgery- Now never do a laminectomy alone-
alters the biomechanics
• Always add dynamic stabilization- excellent
outcomes
 When to refer?

• Pain uncontrolled in primary care

• Walking getting progressively worse

• Surgery is straight forward

• No increase in surgical risk due to age.
 Treatment
• Conservative
-Rest, analgesics, anti-
inflammatories, oral
steroids, antispasmodics,
physiotherapy, weight
loss, steroid injections
 T
reatment- Laminectomy and Dynamic Stabilization( my
preferred option)
 Complications and Outcomes of Surgery

• 2-4% risk of infection, CSF leak , and Neural Injury

• No death, or paralysis in 17 years of practise in
over 4000 cases
• Surgery has become safer, outcomes better and
recovery quicker
• 80% better on average
• Increased age alone does not result in increased
risk of surgery
 Dynamic Stabilization

• 29 elderly patients with degenerative scoliosis.

Decompressive laminectomy and dynamic
stabilization without fusion. (Dynesis)
• 54 month mean follow up. Oswestry score
improvement of 51.6%. 51.7% improvement in
VAS leg pain, and 57.8% for VAS back pain.

Sivestre M, Lolli F, Bakaloudis G. Dynamic stabilization for degenerative

lumbar scoliosis in elderly patients. Spine 2010 Jan
 Dynamic Stabilization
• 100 patients. Decompression and pedicle
screw based dynamic stabilization (Cosmic)
• Improved disability scores. ODI pre-op of 51,
and post-op of 21.
• Improvement in pain. VAS pre-op 6.5 and
post-op 2.1.
• SF-36 outcomes were also improved.
Stoffel M, Behr M, Reinke A, Meyer B. Pedicle screw-based dynamic
stabilization of the thoracolumbar spine with the Cosmic-system: a
prospective observation. Achta Neurochirurg 2010 May