Lumbar Stenosis Pablo Pazmi ño, MD Curitiba, Brazil
Lumbar Spinal Stenosis <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Classification </li></ul><ul><l...
Spinal Stenosis:  <ul><li>The term &quot;stenosis&quot; itself is derived from the Greek word  stenos,  which means narrow...
Epidemiology <ul><li>Disease of the older population </li></ul><ul><li>Increase in median age from 32.9 years in 1990 to 3...
Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements....
Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements....
Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements....
Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements....
Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements....
Foramen <ul><li>On the diagram 2 is </li></ul><ul><li>the nerve exiting the spine through a hole called the Foramen </li><...
PLL  Posterior Longitudinal Ligament This is a ligament that sits against the bone and thickens with arthritis It is a Den...
PLL Anatomy <ul><li>Epidural space anterior to PLL is filled by AIVVP: Anterior Internal Vert Ven Plexus and adipose tissu...
Ligamentum Flavum:  Posterior Epidural Region Yellowish 80% Elastin fibers Spans between the adjacent laminae and fills th...
Nerve root organization  This is how the nerves are arranged within the thecal sac
Facet Joints <ul><li>Essential for control of normal motion and based on orientation control anteroposterior slippage  </l...
Mechanics of Neural Arch <ul><li>Torsion: Axial rotation 1-2 º CW /CCW, more with cartillage thinning (apophyseal jts) </l...
Diurnal Changes Diurnal changes in fluid content, disc height, and disc bulge.  19mm variation, from 1.5mm ht of each lumb...
Morphometric Data: Variable Shapes of Central Lumbar Canal <ul><li>A. Round </li></ul><ul><li>B. Triangular </li></ul><ul>...
Spinal Stenosis Normal is on Top Left Stenosis is on Bottom Right
Normal AP >12mm and Cross Sectional Area 77+/- 13mm2   Schonstrom Spine JOR ’88:13 <ul><li>AP Diameters Decrease L1 to L3 ...
Pathophysiology This is an “Axial View” Look at the Arthritis/Stenosis that develops
Extension <ul><li>Shortens spinal canal </li></ul><ul><li>Broadens Nervous tissue </li></ul><ul><li>Shortens and broadens ...
Flexion Foraminal size increases in flexion, and decreased in extension. Nondegenerated foramina>>Degenerated foramina For...
3 Joint Complex: Kirkaldy-Willis 1978  <ul><li>Tripod:   Disc, Facets where a change in one joint leads to abnl stresses i...
Fibrous border of NP coalesces with AF and after 2nd decade indistinct. Next as disk degenerates its unable to absorb load...
Disc Degenerative Cycle: A remodeling process in response to mechanical alterations.  Occurs initially in the more mobile ...
Etiological Theories <ul><ul><li>VASCULAR:  Dynamic component </li></ul></ul><ul><ul><li>  MECHANICAL </li></ul></ul><ul><...
Theories for Stenosis VASCULAR <ul><li>Impair proper vascular and nutritional supply to the nerve root you will contribute...
Mechanical <ul><ul><li>Collapse disc height: overriding of articular surfaces, narrowing of neuroforamen in cross section ...
Mechanical Theory:   Intraneural edema formed as a result of compression injury leads to an intraneural compartment syndro...
Remember this slide ? This  is the Foramen  (The Nerve’s hole where it exits) <ul><li>On the diagram #2 is </li></ul><ul><...
Notice the Fibrosis/Scarring that develops with time inside the Foramen This is what happens with Stenosis with time !!!!
Mechanical and Vascular Theories:   Decrease in Cross Sectional Area Neurogenic claudication began with venous congestion ...
Degenerative Spinal Stenosis:  Etiology due to altered mechanical forces <ul><li>Osteophyte formation </li></ul><ul><li>(9...
Presentation <ul><li>Age : Mid 50’s –Early 60’s </li></ul><ul><li>Females  present with greater frequency </li></ul><ul><l...
Differential Diagnosis <ul><li>Peripheral Neuropathy </li></ul><ul><li>Vascular Disease: starts distally with cramping, ca...
Comparison of Neurogenic and Vascular Claudication in Spinal Stenosis Symptom or Sign Neurogenic Claudication Vascular Cla...
Physical Exam No definitive signs or findings Gait:  Posture:  LB:  ROM:  Neurologic exam :  Tension signs  Pulses and tro...
Plain films <ul><li>Radiographs usually reveal findings consistent with degeneration of the lumbar spine, such as  </li></...
CT MRI Findings <ul><li>CT&MRI </li></ul><ul><li>1. Identify location, degree of stenosis  (15% trefoil) </li></ul><ul><li...
Myelography Through 1980’s <ul><li>Hourglass constriction at one or more levels </li></ul><ul><li>Scans in extension, hype...
Transition to MRI occurred in 90’s <ul><li>Accuracy of MRI and CT combined was 92.5%  Modic AMJR ’86:147 </li></ul><ul><li...
Reading CT/MRI Disc: Herniated Vertebrae: Endplate, Osteophytes Facets: Orientation, Arthroses, Synovial Cysts, Capsular h...
Central Stenosis <ul><li>Present with neuronal claudication, and pathology can entail single-level or multi-level involvem...
Lateral stenosis <ul><li>Largely accounts for radiculopathic symptoms and entails the lateral recess and the intervertebra...
MRI <ul><li>Useful indicator of significant foraminal stenosis is absence of well defined perineural fat signal of parasag...
Axial T1 MRI shows disc and osteophyte protruding in the foramen, which obliterates the fat anterior to the Nroot
Axial MRI can show Central and Lateral recess stenosis by Lig flavum hypertrophy and facet hypertrophy <ul><li>Disc bulgin...
MRI better for LRStenosis: T1 parasagittal scans show the N root cmprs or deformed by disc/ facet subluxation with lig fla...
Remember this slide ? This  is the Foramen  (The Nerve’s hole where it exits) <ul><li>On the diagram #2 is </li></ul><ul><...
Foraminal Stenosis <ul><li>Here you can see how the nerve can be pinched within the foramen (the nerve’s hole through whic...
 
 
 
Conservative Treatment Options <ul><li>Early stages intermittent symptoms (neural inflammation) </li></ul><ul><li>Activity...
Conservative Therapy <ul><li>Avoid Narcotic medications and muscle relaxants (depression/sedation) </li></ul><ul><li>Suppo...
The Natural Course of Lumbar Spinal Stenosis Johnsson CORR ’92:279 <ul><li>There are No well designed, long-term, prospect...
Natural Course of NonOperative versus Operative Treatment
Operative Treatment This condition will not progress to paralysis or bowel/bladder dysfunction, if activities are curtaile...
One year Outcomes Surgical procedures increase the relative odds of definite improvement 2.6 fold compared with nonop  Atl...
Surgical Decompression  Divided into decompressive procedures With and Without a fusion
Results <ul><li>Good to excellent outcomes 72%.  </li></ul><ul><li>Keep in mind there are no randomized clinical trails co...
Laminectomy Bilateral Laminectomy : Lamina and Lig Flavum are removed on both sides of stenotic level(s) to the lateral re...
Decompression without arthrodesis is the preferred treatment unless instability or structural abnormalities are present. <...
Multiple Stenotic Levels <ul><li>“ It is wise to decompress all stenotic levels but to do so in a limited fashion” McCullo...
Indications for Fusion
Fusion Procedures <ul><li>ALIF  Anterior Lumbar Interbody Fusion </li></ul><ul><li>PLIF  Posterior Lumbar Interbody Fusion...
Role of Fusion <ul><li>Rigid vs Semirigid </li></ul><ul><li>Overall fusion rate 65% Noninstrumented </li></ul><ul><li>77% ...
Comorbidity <ul><li>Complications are more frequent with </li></ul><ul><ul><li>Advancing age </li></ul></ul><ul><ul><li>In...
Correlation with excellent outcome <ul><li>Preoperative duration of symptoms of less than 4 years </li></ul><ul><li>No pre...
Case <ul><li>79 yo male complains of Right sided> Lsided leg back, mild back pain, weakness. </li></ul><ul><li>Has noted d...
 
Degenerative Discs: Blackened, Bone on bone, decreased in height
L3 4 Stenotic Canal (Triangular shape)
L 4 5 Stenosis trefoiled/triangular canal Synovial cyst
L5 S1
1/14/06  Patient underwent multilevel decompression surgeries <ul><li>L3 L4 Hemi laminectomy for facet cyst, foraminotomie...
Surgical Procedures <ul><li>Surgery should be a last resort, when conservatives measures fail. </li></ul><ul><li>In some c...
Dr Pazmiño: Orthopaedic Spine  Dr Lauryssen: Neurological  Spine
Minimally Invasive  <ul><li>All our procedures are performed in a minimally invasive manner. </li></ul><ul><li>All patient...
Iguacu Falls. Brazil
<ul><li>Thank you for your time. </li></ul><ul><li>If you know someone who could benefit from a consultation for Lumbar Pa...
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Lubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MD

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This video explains Lumbar Stenosis. When arthritis begins to encroach around the spinal cord and neural elements this is called Lumbar Stenosis. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Stenosis/Arthritis feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1

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Lubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MD

  1. 1. Lumbar Stenosis Pablo Pazmi ño, MD Curitiba, Brazil
  2. 2. Lumbar Spinal Stenosis <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Classification </li></ul><ul><li>Anatomy & Morphometrics </li></ul><ul><li>Mechanics of the Neural Arch and Stenosis </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Physical Exam </li></ul><ul><li>Imaging </li></ul><ul><li>Treatment Options </li></ul><ul><ul><li>Conservative </li></ul></ul><ul><ul><li>Operative </li></ul></ul>
  3. 3. Spinal Stenosis: <ul><li>The term &quot;stenosis&quot; itself is derived from the Greek word stenos, which means narrow. </li></ul><ul><li>Narrowing of the spinal canal, lateral recess, or the foramen that leads to neural compression, producing radiculopathy or neurogenic deficit. </li></ul>
  4. 4. Epidemiology <ul><li>Disease of the older population </li></ul><ul><li>Increase in median age from 32.9 years in 1990 to 35.3 in 2000 now 37.6 </li></ul><ul><li>34.9 million >65yo </li></ul><ul><li>Degenerative lumbar spinal stenosis is seen primarily in patients older than 60, with an average age of 73 at presentation. </li></ul><ul><li>Females are predominantly affected, with reported female-to-male ratios ranging from 3:1 for all types of stenosis </li></ul><ul><li>First appearace of disc degeneration is in 3 rd decade females, males 2 nd decade Miller Spine ’88:13 </li></ul>
  5. 5. Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements. </li></ul><ul><li>The degree and location of stenosis produce the different clinical presentations. </li></ul><ul><li>Centrally </li></ul><ul><li>Lateral recess: Subarticular(anterior SAF) </li></ul><ul><li>Entrance Zone </li></ul><ul><li>C. Foraminal : Between pedicles </li></ul><ul><li> Midzone </li></ul><ul><li>D. Extraforaminal: Lateral to pedicle </li></ul><ul><li> Exit Zone </li></ul>
  6. 6. Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements. </li></ul><ul><li>The degree and location of stenosis produce the different clinical presentations. </li></ul><ul><li>Centrally </li></ul><ul><li>Lateral recess: Subarticular(anterior SAF) </li></ul><ul><li>Entrance Zone </li></ul><ul><li>C. Foraminal : Between pedicles </li></ul><ul><li> Midzone </li></ul><ul><li>D. Extraforaminal: Lateral to pedicle </li></ul><ul><li> Exit Zone </li></ul>
  7. 7. Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements. </li></ul><ul><li>The degree and location of stenosis produce the different clinical presentations. </li></ul><ul><li>Centrally </li></ul><ul><li>Lateral recess: Subarticular(anterior SAF) </li></ul><ul><li>Entrance Zone </li></ul><ul><li>C. Foraminal : Between pedicles </li></ul><ul><li> Midzone </li></ul><ul><li>D. Extraforaminal: Lateral to pedicle </li></ul><ul><li> Exit Zone </li></ul>
  8. 8. Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements. </li></ul><ul><li>The degree and location of stenosis produce the different clinical presentations. </li></ul><ul><li>Centrally </li></ul><ul><li>Lateral recess: Subarticular(anterior SAF) </li></ul><ul><li>Entrance Zone </li></ul><ul><li>C. Foraminal : Between pedicles </li></ul><ul><li> Midzone </li></ul><ul><li>D. Extraforaminal: Lateral to pedicle </li></ul><ul><li> Exit Zone </li></ul>
  9. 9. Anatomy <ul><li>Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements. </li></ul><ul><li>The degree and location of stenosis produce the different clinical presentations. </li></ul><ul><li>Centrally </li></ul><ul><li>Lateral recess: Subarticular(anterior SAF) </li></ul><ul><li>Entrance Zone </li></ul><ul><li>C. Foraminal : Between pedicles </li></ul><ul><li> Midzone </li></ul><ul><li>D. Extraforaminal: Lateral to pedicle </li></ul><ul><li> Exit Zone </li></ul>
  10. 10. Foramen <ul><li>On the diagram 2 is </li></ul><ul><li>the nerve exiting the spine through a hole called the Foramen </li></ul><ul><li>From here the nerve will provide sensation and strength to the legs </li></ul>
  11. 11. PLL Posterior Longitudinal Ligament This is a ligament that sits against the bone and thickens with arthritis It is a Denticulated flat broad attachment at level of disc and has a narrower course across midportion of concave posterior wall of the vertebral body Sagitally oriented deep layer connects periosteum along vert body, T/Y shaped in transverse sections. Vertical T dissappears at disc level Dual aspect Proprioceptive function Suspensory ligament for dural sac
  12. 12. PLL Anatomy <ul><li>Epidural space anterior to PLL is filled by AIVVP: Anterior Internal Vert Ven Plexus and adipose tissue </li></ul><ul><li>Medial Venous Plexus: segmental </li></ul><ul><li>Lateral Longitudinal vein of the anterior cmpt </li></ul><ul><li>Batson’s Plexus: lies ventral and laterally from the deep PLL layers </li></ul>
  13. 13. Ligamentum Flavum: Posterior Epidural Region Yellowish 80% Elastin fibers Spans between the adjacent laminae and fills the interlaminar space. The capsular part of the ligament is thinner than the interlaminar portion. 2 Layered aspect: firmly attached, diverge caudally at the upper rim of laminae, superficial thickness 2.5-3.5mm / 1mm deep OlszewskiSpine ’96:21 Tented recess filled with homog epid adipose adherent at the apex of the ligament.
  14. 14. Nerve root organization This is how the nerves are arranged within the thecal sac
  15. 15. Facet Joints <ul><li>Essential for control of normal motion and based on orientation control anteroposterior slippage </li></ul><ul><li>Compromised facets will alter the distribution of mechanical forces throughout the spine </li></ul>
  16. 16. Mechanics of Neural Arch <ul><li>Torsion: Axial rotation 1-2 º CW /CCW, more with cartillage thinning (apophyseal jts) </li></ul><ul><li>Flexion: Capsular ligaments of Apophy Jts resist. In full flexion 40% resistance (Disc 30%,Supra Intersp lig 20%,LF 10%) </li></ul><ul><li>Failure: SSLig  CLig  Disc </li></ul><ul><li>Compression: </li></ul><ul><ul><li>Flattened (erectsitting /lifting)  all resisted by disc. </li></ul></ul><ul><ul><li>Lordotic (erect std)facet tips contact laminae of subadj vertebrae and bear 1/6 th cmpr force </li></ul></ul><ul><ul><li>(Extension)Disc narrowing 70% cmprs transmitted across apophyseal joints </li></ul></ul>
  17. 17. Diurnal Changes Diurnal changes in fluid content, disc height, and disc bulge. 19mm variation, from 1.5mm ht of each lumbar disc. Sleep: loading on discs reduced and discs absorb fluid and increase vol Absorbed fluid is expelled during day with loading through Creep/Walking: Lose height, increase bulge
  18. 18. Morphometric Data: Variable Shapes of Central Lumbar Canal <ul><li>A. Round </li></ul><ul><li>B. Triangular </li></ul><ul><li>C. Trefoiled: architectural form having the appearance of a trifoliate leaf ,3 lobed arcs arranged in a circle (15-25% @L5). Dvlpmtnl: Small midsagittal, interpedicular diameter continues to increase up puberty. Shallow  Trefoil </li></ul><ul><li>D. Trefoiled and Asymmetric: Lumbar roots prone to compression in the lateral recess, not a certainty Lee Spine ’80:13 </li></ul>
  19. 19. Spinal Stenosis Normal is on Top Left Stenosis is on Bottom Right
  20. 20. Normal AP >12mm and Cross Sectional Area 77+/- 13mm2 Schonstrom Spine JOR ’88:13 <ul><li>AP Diameters Decrease L1 to L3 </li></ul><ul><li> Increase L3 to L5 </li></ul><ul><li>Transverse diameters increase L1 to L5 </li></ul><ul><li>Cross Sx Areas Decrease L1 to L2 </li></ul><ul><li>Constant L2-L4 </li></ul><ul><li>Marked Increase L5 </li></ul><ul><li>A fair amount of Left- Right Asymmetries. Suggests an asymmetric lever arms for muscles. </li></ul><ul><li>Tropism of the facet jts, pedicles, laminae and vertebral bodies influence the size and shape of canal. </li></ul>
  21. 21. Pathophysiology This is an “Axial View” Look at the Arthritis/Stenosis that develops
  22. 22. Extension <ul><li>Shortens spinal canal </li></ul><ul><li>Broadens Nervous tissue </li></ul><ul><li>Shortens and broadens ligamentum flavum, </li></ul><ul><li>Posterior disc protrusion causes nterference of circulation of C Equina and Nerve roots) </li></ul><ul><ul><li>Brieg Biomechanics of CNS, 1960 </li></ul></ul>
  23. 23. Flexion Foraminal size increases in flexion, and decreased in extension. Nondegenerated foramina>>Degenerated foramina Foramina open 24% during flexion and closed 20% during extension Less significant changes with lateral bending and axial rotation Stenotic spines: Flexion increases SAC by reducing disc bulge, stretching ligamentum flavum, Panjabi Spine’83:4
  24. 24. 3 Joint Complex: Kirkaldy-Willis 1978 <ul><li>Tripod: Disc, Facets where a change in one joint leads to abnl stresses in the others (Usually disc Videman showed in only 20% facet degen preceeds) </li></ul><ul><li>Disc degeneration: </li></ul><ul><ul><li>Anteriorly: Bulging Annulus fibrosus: narrows central anterior spinal canal </li></ul></ul><ul><ul><li>Posteriorly: Facets develop bony osteophytes, hypertrophy and ligament buckling </li></ul></ul>
  25. 25. Fibrous border of NP coalesces with AF and after 2nd decade indistinct. Next as disk degenerates its unable to absorb load at the nucleus pulposus. The force is redirected unequally down the annulus fibrosus, causing it to tear circumferentially and these combine and expand radially to the periphery of the endplate. Dessication, degeneration, cavitation and calcium deposition. Due to mechanical changes the disc space collapses Collapse leads to posterior fissuring and bulging along PLL
  26. 26. Disc Degenerative Cycle: A remodeling process in response to mechanical alterations. Occurs initially in the more mobile segments then progress cephalad <ul><li>Unstable phase: </li></ul><ul><li>Alters kinematics of motion segment. Assoc with disc height rdxn, ligamentous laxity, and facet jt degeneration. </li></ul><ul><li>Remodeling phase: </li></ul><ul><li>Osteophyte formation re-stabilizes motion segment, stenosis ensues </li></ul>Dysfunction  Instability  Restabilization
  27. 27. Etiological Theories <ul><ul><li>VASCULAR: Dynamic component </li></ul></ul><ul><ul><li> MECHANICAL </li></ul></ul><ul><ul><li>Diverse presentation of signs and symptoms because of variability in size of Lumbar spinal canal, size of Nerve roots, and induced pressures. </li></ul></ul><ul><ul><li>Degenerative processes in spine result in mechanical, compression, ischemia, altered metabolism, and neural inflammation. </li></ul></ul>
  28. 28. Theories for Stenosis VASCULAR <ul><li>Impair proper vascular and nutritional supply to the nerve root you will contribute to edema, fibrosis, inflammation, ischemia, and altered metabolic processes. Dynamic/brought on by activity </li></ul><ul><ul><li>Vertebral Venous HTN : Arnoldi CORR ’76:115 </li></ul></ul><ul><ul><li>Arterial Hypovascular Vaso Nervorum: Intersection of central and radicular within Cauda Equina and Spinal Nerve Roots </li></ul></ul><ul><ul><li>3. Dorsal Root ganglion extensive vascular network,increased permeability and metabolic fcn. Parke Spine ’85:10 , JBJS ’81:63A </li></ul></ul>
  29. 29. Mechanical <ul><ul><li>Collapse disc height: overriding of articular surfaces, narrowing of neuroforamen in cross section and impingement on exiting nerve root. </li></ul></ul><ul><ul><li>Stenotic canal reduces further while walking. Epidural pressures increase 20mm Hg with each step, due to complex rotary sp segment mvmts during walking that in turn reduces cross section. </li></ul></ul><ul><ul><li>Takahaski Spine ’95:20 </li></ul></ul>
  30. 30. Mechanical Theory: Intraneural edema formed as a result of compression injury leads to an intraneural compartment syndrome. Venous congestion at 5-10mmHg ◙ Rate dependent: More pronounced after rapid than slow onset compression ◙ Long standing edema leads to intraneural fibrotic scar ◙ This delays long convalescence scenario ◙ Impairs nutrition Olmarker Spine ’89:14
  31. 31. Remember this slide ? This is the Foramen (The Nerve’s hole where it exits) <ul><li>On the diagram #2 is </li></ul><ul><li>the nerve exiting the spine through a hole called the Foramen </li></ul><ul><li>Keep this in mind for the next slide !!!!!!!!!!!!!!!!!!!!!!!!!! </li></ul>
  32. 32. Notice the Fibrosis/Scarring that develops with time inside the Foramen This is what happens with Stenosis with time !!!!
  33. 33. Mechanical and Vascular Theories: Decrease in Cross Sectional Area Neurogenic claudication began with venous congestion of the nerve root and DRG. With increasing compression motor and sensory deficits occurred and blockage of axoplasmic flow (50-75%). Constriction of more than 50% was the critical point that resulted in loss of Cortical evoked potentials, neurologic deficits and histologic abnormalities. Delamarter JBJS ’90A:110
  34. 34. Degenerative Spinal Stenosis: Etiology due to altered mechanical forces <ul><li>Osteophyte formation </li></ul><ul><li>(90%M >50, 100%F>60) </li></ul><ul><li>Disc Bulging </li></ul><ul><li>Facet Jt Hypertrophy </li></ul><ul><li>Lamella subluxation </li></ul><ul><li>Ligamentous thickening </li></ul><ul><ul><ul><ul><li>Naylor JBJS ’79:61B </li></ul></ul></ul></ul>
  35. 35. Presentation <ul><li>Age : Mid 50’s –Early 60’s </li></ul><ul><li>Females present with greater frequency </li></ul><ul><li>Symptoms exacerbation of symptoms with standing and walking, and improve with lying down, sitting or leaning on a shopping cart or kitchen counter . </li></ul><ul><li>Neurogenic Claudication </li></ul><ul><li>Radicular Symptoms 5th Lumbar root is most often involved. (75%) Sensory,motor,and reflex changes </li></ul><ul><li>Pain burning, numbness, tingling, heaviness, cramping and weakness of both lower extremities (One) </li></ul><ul><li>Leg Pain (Not back pain: common but not cause for seeing MD) Radiates to the buttocks and thighs and progressively radiates below the knees to the feet. </li></ul>
  36. 36. Differential Diagnosis <ul><li>Peripheral Neuropathy </li></ul><ul><li>Vascular Disease: starts distally with cramping, calf pain and progresses proximally </li></ul><ul><li>Lumbar Disc Disease </li></ul><ul><li>Osteoarthritis of other joints (SI,hip,knee,lumbar, etc.) </li></ul><ul><li>Myelopathy from cord compression </li></ul>
  37. 37. Comparison of Neurogenic and Vascular Claudication in Spinal Stenosis Symptom or Sign Neurogenic Claudication Vascular Claudication Distal pulses Normal Diminished or absent Skin changes None Mottled or atrophic Loss of pretibial hair growth Positional change Pain improved with lumbar flexion (eg, sitting, stooping) Pain unaffected by lumbar posture Walking distance Variable Fixed distance before onset Increased pain with increased distance ambulated Relationship of pain to cessation of ambulation
  38. 38. Physical Exam No definitive signs or findings Gait: Posture: LB: ROM: Neurologic exam : Tension signs Pulses and trophic changes: Radiologic imaging studies confirm stenosis, clarify Forward flexed posture with limited pelvis rotation Forward flexed, coronal imbalance No specific tenderness, spasm (HNP) Pt tenderness overf SI jts/Sciatic Notch Good forward flexion, painful extension Often normal L4-5 Level Commonly: Weakness EHL, Tib Ant SLR often negative Reflex testing unreliable, absent/hypoactive common, hyperactive reflexes and long tract signs prompt search for compressive lesion (SLR,Naffziger,Kemp,Cram)are often negative unless Foraminal involvement Vascular
  39. 39. Plain films <ul><li>Radiographs usually reveal findings consistent with degeneration of the lumbar spine, such as </li></ul><ul><li>Disc space narrowing </li></ul><ul><li>Endplate sclerosis </li></ul><ul><li>Formation of osteophytes </li></ul><ul><li>Facet joint hypertrophy and arthritis </li></ul><ul><li>Degenerative scoliosis or spondylolisthesis </li></ul><ul><li>Settling of spinous processes </li></ul><ul><li>Instability </li></ul>
  40. 40. CT MRI Findings <ul><li>CT&MRI </li></ul><ul><li>1. Identify location, degree of stenosis (15% trefoil) </li></ul><ul><li>2. Absolute stenosis lateral recess diameter <3mm, relative 3-5mm </li></ul><ul><li>3. Sagittal absolute <10 , relative <12 </li></ul><ul><li>Ciric JNeurosurgery ’80:5 </li></ul><ul><li>Verbeist JBJS B’77:59 </li></ul><ul><li>4. Cross sectional area <100mm2 absolute stenosis </li></ul><ul><ul><li>Bolender JBJS ‘85: 67A </li></ul></ul><ul><ul><li>5. The critical height of the intervertebral foramen is believed to be 15 mm and posterior disc height of 3 mm. N Root compression 80% when below </li></ul></ul>
  41. 41. Myelography Through 1980’s <ul><li>Hourglass constriction at one or more levels </li></ul><ul><li>Scans in extension, hyperextension </li></ul><ul><li>High sensitivity and specificity </li></ul><ul><ul><li>Bell Spine ’84:9 </li></ul></ul><ul><ul><li>False positives 24% in asymptomatic pts </li></ul></ul>
  42. 42. Transition to MRI occurred in 90’s <ul><li>Accuracy of MRI and CT combined was 92.5% Modic AMJR ’86:147 </li></ul><ul><li>Helps differentiate nondiscogenic lumbar radiculopathy An SUSCTMRI ’93:14 </li></ul><ul><li>Older population higher incidence of false + </li></ul><ul><li>Over 60% of pts >60yo have degen changes,sten </li></ul>
  43. 43. Reading CT/MRI Disc: Herniated Vertebrae: Endplate, Osteophytes Facets: Orientation, Arthroses, Synovial Cysts, Capsular hypertrophy, Tropism, Subluxation Nerve Root entrapment Foramina Lateral Recess Thecal Sac: Degree of deformity Canal: Trefoil, round, etc Instraspinal Masses Fat: Prominent epidural fat, epidural lipomatosis Ligamentum Flavum
  44. 44. Central Stenosis <ul><li>Present with neuronal claudication, and pathology can entail single-level or multi-level involvement. </li></ul><ul><li>Thecal sac can be compressed laterally, anteriorly and/or posteriorly, and circumferentially. </li></ul><ul><li>Lateral compression may result from medial hypertrophy of the facet. </li></ul><ul><li>Posterior disk protrusion may account for anterior central stenosis, whereas alterations of the ligamentum flavum may contribute to posterior compression . </li></ul><ul><li>Circumferential or Multi-directional combination of compressive forces upon the thecal sac. </li></ul>
  45. 45. Lateral stenosis <ul><li>Largely accounts for radiculopathic symptoms and entails the lateral recess and the intervertebral foramen. </li></ul><ul><li>The incidence of lateral nerve root entrapment is 8 to 11% in stenotic patients. </li></ul><ul><li>Unrecognized foraminal stenosis accounts for 60% of failed back patients with persistent postoperative symptoms. </li></ul>
  46. 46. MRI <ul><li>Useful indicator of significant foraminal stenosis is absence of well defined perineural fat signal of parasagittal T1 weighted images </li></ul><ul><li>Blk Arrows DRG </li></ul><ul><li>White Arrowhead A radicular vein anterior </li></ul>
  47. 47. Axial T1 MRI shows disc and osteophyte protruding in the foramen, which obliterates the fat anterior to the Nroot
  48. 48. Axial MRI can show Central and Lateral recess stenosis by Lig flavum hypertrophy and facet hypertrophy <ul><li>Disc bulging, compromises canal anteriorly </li></ul><ul><li>Hypertrophy of the facets and lig flavum indents the Subarachnoid space posteriorly </li></ul>
  49. 49. MRI better for LRStenosis: T1 parasagittal scans show the N root cmprs or deformed by disc/ facet subluxation with lig flavum impingement on N root <ul><li>L4-5 Level: MRI T1 Parasagittal scan </li></ul><ul><li>The nerve (black circle/ dot) is being pinched within the foramen </li></ul>
  50. 50. Remember this slide ? This is the Foramen (The Nerve’s hole where it exits) <ul><li>On the diagram #2 is </li></ul><ul><li>the nerve exiting the spine through a hole called the Foramen </li></ul>
  51. 51. Foraminal Stenosis <ul><li>Here you can see how the nerve can be pinched within the foramen (the nerve’s hole through which it must exit) </li></ul>
  52. 55. Conservative Treatment Options <ul><li>Early stages intermittent symptoms (neural inflammation) </li></ul><ul><li>Activity modification </li></ul><ul><li>Staying in shape physically/aerobically </li></ul><ul><li>Avoid longterm bedrest </li></ul><ul><li>Avoid certain activities : bending,twisting, lifting, unnecessary walking…..Usually eases pain </li></ul><ul><li>PTherapy: stretching and isometrically strengthening atrophied muscles </li></ul><ul><li>Modalities: heat, U/S, Whirlpool, massage </li></ul>
  53. 56. Conservative Therapy <ul><li>Avoid Narcotic medications and muscle relaxants (depression/sedation) </li></ul><ul><li>Support grps and antidepressant meds (help insomnia, clinical depression, neurogenic pain) </li></ul><ul><li>Anti-inflammatory meds </li></ul><ul><li>Calcitonin </li></ul><ul><li>Bracing </li></ul><ul><li>Epidural steroids and oral steroid ‘dose packs’ relieve pain and inflammation and allow aerobic conditioning and incr fcn </li></ul><ul><li>All temporary not a cure for stenosis, and gives indication of severity </li></ul>
  54. 57. The Natural Course of Lumbar Spinal Stenosis Johnsson CORR ’92:279 <ul><li>There are No well designed, long-term, prospective studies describing the true nature of stenosis </li></ul><ul><li>There also are No single randomized trials which compared surgery vs conservative. </li></ul><ul><li>The largest and best study followed 32 patients preselected for surgery, at 4yr period had no proof of severe deterioration and unchanged stenosis. (Non randomized comparison design) </li></ul><ul><li>Immediate operation should be advised only if neurologic symptoms devolop or if pain is intolerable </li></ul>
  55. 58. Natural Course of NonOperative versus Operative Treatment
  56. 59. Operative Treatment This condition will not progress to paralysis or bowel/bladder dysfunction, if activities are curtailed symptoms may generally relieve This ultimately is about the Quality of life and level of function/activity desired by the patient Significant ability to walk/stand due to claudicant leg pain.
  57. 60. One year Outcomes Surgical procedures increase the relative odds of definite improvement 2.6 fold compared with nonop Atlas Spine ’96: 21 Maine observational cohort study: Although improvement 55% nearly twice as good 28% improvement by conservative.
  58. 61. Surgical Decompression Divided into decompressive procedures With and Without a fusion
  59. 62. Results <ul><li>Good to excellent outcomes 72%. </li></ul><ul><li>Keep in mind there are no randomized clinical trails comparing surgical and conservative treatment. </li></ul><ul><li>We can offer two types of procedures </li></ul><ul><li>Limited Procedures </li></ul><ul><ul><li> Single level Hemilaminectomy </li></ul></ul><ul><ul><ul><ul><li>Hemilaminotomy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Laminoplasty </li></ul></ul></ul></ul><ul><ul><li>Global Procedures </li></ul></ul><ul><ul><ul><ul><li>Multilevel bilateral laminectomy with bilateral facetectomies and formainotomies </li></ul></ul></ul></ul>
  60. 63. Laminectomy Bilateral Laminectomy : Lamina and Lig Flavum are removed on both sides of stenotic level(s) to the lateral recess. Proceed Caudal to Cranial. Decompressed until lateral edge of the nerve root is decompressed Preserve Pars Interarticularis- to minimize instability by inadvertent sacrifice of superior facet. If disc herniation: Discectomy is performed,then consider arthrodesis. Finally lateral decompression of the foraminae(probe foramen dorsal and ventral to Nerve root, and rtrxn 1cm medially).
  61. 64. Decompression without arthrodesis is the preferred treatment unless instability or structural abnormalities are present. <ul><li>One or Two level stenosis: Laminectomy preferred with care to minimize damage to pars and facets. </li></ul><ul><li>If more than one facet jt sacrificed at any segmental level then prophylactic fusion to minimize risk of subsequent spinal instability if disc and posterior structures violated </li></ul>
  62. 65. Multiple Stenotic Levels <ul><li>“ It is wise to decompress all stenotic levels but to do so in a limited fashion” McCulloch: Mastercases in Spine Sx </li></ul><ul><li>Multilevel laminotomies are preferred to laminectomy </li></ul><ul><li>These can be unilateral or bilateral </li></ul><ul><li>Unless there is instability there is no need for fusion </li></ul>
  63. 66. Indications for Fusion
  64. 67. Fusion Procedures <ul><li>ALIF Anterior Lumbar Interbody Fusion </li></ul><ul><li>PLIF Posterior Lumbar Interbody Fusion </li></ul><ul><li>Posterior fusion </li></ul><ul><li>Posterolateral (Intertransverse or bilateral lateral) fusion </li></ul><ul><li>Noninstrumented </li></ul><ul><li>Instrumented </li></ul><ul><ul><li>Nonsegmental Instrumentation </li></ul></ul><ul><ul><li>Segmental (Pedicle Screw) Instrumentation </li></ul></ul>
  65. 68. Role of Fusion <ul><li>Rigid vs Semirigid </li></ul><ul><li>Overall fusion rate 65% Noninstrumented </li></ul><ul><li>77% Semirigid fixation </li></ul><ul><li>95% Rigid fixation </li></ul><ul><li>Overall trend for better clinical outcome with increasing rigidity of fixation </li></ul><ul><li>Grob Humke JBJS ’95:77 </li></ul>
  66. 69. Comorbidity <ul><li>Complications are more frequent with </li></ul><ul><ul><li>Advancing age </li></ul></ul><ul><ul><li>Increased complexity of diagnosis </li></ul></ul><ul><ul><li>Comorbid conditions </li></ul></ul><ul><li>Katz, Lipson JBJS’91:73 </li></ul>
  67. 70. Correlation with excellent outcome <ul><li>Preoperative duration of symptoms of less than 4 years </li></ul><ul><li>No preoperative low back pain </li></ul><ul><li>No significant comorbidities </li></ul><ul><li>Katz, Lipson JBJS’91:73 </li></ul>
  68. 71. Case <ul><li>79 yo male complains of Right sided> Lsided leg back, mild back pain, weakness. </li></ul><ul><li>Has noted difficulty with walking long distances which brings on his pain </li></ul><ul><li>Has relief of pain while lying supine </li></ul><ul><li>Has no difficulty while shopping, which he loves to do as long as he can use a shopping cart </li></ul>
  69. 73. Degenerative Discs: Blackened, Bone on bone, decreased in height
  70. 74. L3 4 Stenotic Canal (Triangular shape)
  71. 75. L 4 5 Stenosis trefoiled/triangular canal Synovial cyst
  72. 76. L5 S1
  73. 77. 1/14/06 Patient underwent multilevel decompression surgeries <ul><li>L3 L4 Hemi laminectomy for facet cyst, foraminotomies </li></ul><ul><li>Lumbar hemilaminectomy for Herniated Nucleus Pulposus L5 S1 </li></ul><ul><li>Patient doing well. Stayed in the hospital for 3 days, passed a course of therapy, noticed resolution of leg pain & back pain. </li></ul>
  74. 78. Surgical Procedures <ul><li>Surgery should be a last resort, when conservatives measures fail. </li></ul><ul><li>In some cases surgery needs to be done sooner than later, or even urgently, depending on the physical exam, history, neural deficits, and size of the herniation. </li></ul>
  75. 79. Dr Pazmiño: Orthopaedic Spine Dr Lauryssen: Neurological Spine
  76. 80. Minimally Invasive <ul><li>All our procedures are performed in a minimally invasive manner. </li></ul><ul><li>All patients receive a plastics closure and are followed closely afterwards </li></ul>
  77. 81. Iguacu Falls. Brazil
  78. 82. <ul><li>Thank you for your time. </li></ul><ul><li>If you know someone who could benefit from a consultation for Lumbar Pain/Stenosis please refer them to our online website or call toll free to schedule an appointment </li></ul><ul><li>1-8SPINECAL-1 </li></ul><ul><li>www.beverlyspine.com </li></ul><ul><li>www.santamonicaspine.com </li></ul>

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