Spinal stenosis


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Spinal stenosis

  1. 1. SPINAL STENOSIS<br />
  2. 2. DEFINITION/INCIDENCE<br />Refers to narrowing of the spinal canal, nerve root canals, or intervertebral foramina due to spondylosisand degenerative disk disease.<br />Usually occurs in the cervical and lumbar spine; it seldom occurs in the thoracic spine.<br />About 5 of every 1000 Americans older than 50 years have symptoms of spinal stenosis. <br />with aging of the population prevalence of spinal stenosis will increase.<br />1/1000 > 65 in US underwent laminectomy, primarily for degenerative lumbar spinal stenosis <br />
  3. 3. ETIOLOGY<br />Is part of the aging process, and it is not possible to predict who will be affected. <br />No clear correlation exists between the symptoms of stenosis and race, occupation, sex, or body type. <br />2 forms: <br />Primary stenosisis congenital and relatively uncommon<br />patients are younger, no medical problems<br />2. Acquired stenosis is a degenerative condition. <br /> generally become symptomatic at age >50<br />
  5. 5. PRESENTATION<br />Usually occurs at the cervical and lumbar segments, resulting in 2 different clinical presentations:<br />cervical stenosis<br /> - usually present with cervical radiculopathy: radiating arm pain with numbness and paresthesia and occasionally, associated weakness<br /> - if the stenosis is severe enough, or if it is positioned centrally in the spine, patients may present with signs and symptoms of myelopathy (spinal cord dysfunction): finger numbness, clumsiness, and difficulty walking due to spasticity and loss of position sense. In more severe cases, the patients can have bowel and bladder control dysfunction. Upon examination, these patients have "long-tract signs" such as hyperreflexiaand clonus.<br />
  6. 6. PRESENTATION<br />2. lumbar stenosis<br /> - the classic presentation is radiating leg pain associated with walking that is relieved by rest. When patients bend forward, the pain diminishes (neurogenic claudication or pseudoclaudication). <br /> - the primary symptoms are discomfort, sensory loss, and weakness in the legs, reflecting involvement of spinal nerve roots within the lumbar spinal canal.<br /> - low back pain in LSS is not necessarily associated with the claudication symptoms. <br /> - rarely, patients with lumbar stenosis present with cauda equina syndrome (bilateral leg weakness, urinary retention due to atonic bladder). <br />
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  9. 9. In a study…<br />68 patients with strictly defined, myelographically proven, surgically confirmed lumbar spinal stenosis seen over a 30-month period <br /> - pseudoclaudication was the commonest symptom (94%) and was described by patients as pain (93%), numbness (63%), or weakness (43%)<br /> - bilateral in 68%<br /> - usually involved the entire leg rather than just the upper or lower leg (78 versus 15 and 6 %, respectively)<br /> - pain in a single nerve root distribution occurred in only 6 %<br /> - low back pain occurred in 65% and was described as mechanical and mild<br />
  10. 10. DIFFERENTIAL DIAGNOSIS<br />Peripheral vascular disease= vascular claudication<br />Nonspecific back pain from spondylosis without LSS<br />Distal polyneuropathy<br />The pain of osteoarthritis of the hips or knees<br />Spinal cord vascular malformations are rare<br />Inflammatory conditions involving the lumbosacral nerve roots or cauda equina: arachnoiditis, chronic inflammatory demyelinating polyneuropathy, sarcoidosis, carcinomatous meningitis, and a variety of infections (eg, cytomegalovirus, herpes simplex virus, herpes zoster virus, Epstein Barr virus, Lyme disease, mycoplasma, tuberculosis) <br />
  11. 11. WORK UP<br />the patient's history and physical examination are 2 of the most reliable means to establish the diagnosis.<br />imaging studies of the spine are absolutely necessary to establish the correct diagnosis.<br />The goal of spinal imaging is to localize the site and level of disease and to help differentiate between conditions in which patients require surgery and conditions in which patients recover following conservative treatment. <br />a new symptom of low back pain in an older individual (>50 years) or neurologic deficits consistent with disease of the lumbosacral spine are indications for a neuroimaging study<br />
  12. 12. IMAGING<br />Plain spine radiograph<br /> - is not the most sensitive imaging study to show stenosis from degenerative changes<br /> - it is useful in excluding fracture, spondylolysis, or neoplasm<br /> - the lateral view of the spine is the most useful <br /> - the flexion-extension views are very useful to show spinal instability<br />
  13. 13. IMAGING<br />MRI or CT myelogram<br /> - the imaging studies of choice<br /> - MRI is the first choice because CT myelogram is invasive. However, if a better delineation of the bony anatomy and the specific nerve root's involvement is necessary, a CT myelogram has the advantage over MRI<br />CT scan <br /> -alone is not as helpful, but it is a good alternative if MRI or CT myelogram is not possible<br /> - Osseous and calcified features are well outlined on CT scans <br />
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  15. 15. criteria used to define spinal stenosis vary<br /> - Intra spinal canal area of less than 76 mm2 and 100 mm2 to identify severe and moderate stenosis, respectively <br /> - Antero posterior diameters of less than 10 mm are also often used as a cutoff, but provide a less complete measure of anatomic disease. <br />radiologic spinal stenosis is a common incidental finding<br /> - 6-7% of asymptomatic adults<br /> - in adults over 60 yrs, the prevalence may be as high as 20-30%<br />There is no substantive relationship between the severity of radiologic findings and the severity of clinical symptoms or prognosis. Findings on neuroimaging must be carefully interpreted in the context of the clinical history and examination.<br />
  16. 16. TREATMENT<br />When a patient presents with signs and symptoms of myelopathy or cauda equina syndrome, urgent surgical decompression of the spinal cord or nerve roots is indicated. <br />Significant muscle weakness due to nerve root impingement is also a strong indication for surgical intervention.<br />Radicular pain is the most common symptom of spinal stenosis, and thus the most common indication for surgery. Usually, if the patient's quality of life is compromised because of pain and there are no effective or acceptable nonsurgical treatments, it is reasonable to recommend surgery.<br />For patients with LSS who do not have fixed or progressive neurologic deficits - conservative treatment <br />
  17. 17. Physical therapy<br />Physical therapy is the mainstay of conservative management, but evidence-based support in the literature is lacking<br />Goals of therapy include increased muscular stabilization and correction of posture<br />Stretching, strengthening, and aerobic fitness are usually recommended <br />Abdominal corsets or braces-their use is controversial <br />
  18. 18. symptomatic therapy may include acetominophen, NSAIDS, gabapentin<br />corticosteroid nerve-root injections reduce need for surgery in lumbar radicular pain due to nerve-root compression <br />epidural steroids may provide short-term pain relief <br />epidural steroid injection is associated with reduced short-term pain severity compared with physical therapy program<br />gabapentin may improve pain scores in patients with spinal stenosis<br />Medications<br />
  19. 19. Surgery<br />patients who do not have an adequate clinical response to conservative therapy and who are functionally disabled by their symptoms and for patients who have a progressive neurologic deficit <br />in patients with severe symptoms of lumbar spinal stenosis, decompressive surgery alone is effective approximately 80% of the time and medical/interventional treatment alone is effective about 33% of the time<br />decompressive laminectomy for spinal stenosis with radiculopathy might have benefit over nonsurgical therapy<br />surgery may be associated with some improved outcomes long-term<br />multilevel decompression requires general anesthesia, and significant blood loss is possible<br />
  20. 20. Intraspinous spacer implantation<br />
  21. 21. Laminectomy<br />
  22. 22. Laminectomy<br />