7. Physical examination
■ Vital signs : BP 147/80 PR 92 RR 20T 37.2
■ HEENT : no pale, anicteric sclerae, pharynx & tonsil not injected, no lymphadenopathy
■ Respi : Clear both lung
■ CVS : normal S1S2, no murmur
■ Abdomen : soft, not tender
■ Skin : normal
8. Physical examination
Back & Extremities
■ Loss of lordosis at lumbosacral junction, mild muscle atrophy, normal gait
■ No point of tenderness, no palpable stepping along spine
■ Limit ROM on extension due to pain
■ Motor
Rt Lt
L2 V V
L3 V V
L4 IV V
L5 III III
S1 V V
9. Physical examination
■ Sensory : decrease pinprick sensation at L5 dermatome both side
■ Reflex : 2+ all, absent Babinski sign
■ PR : good sphincter tone, Bulbocavernosus reflex positive
■ SLRT negative
13. MRI
1. Lumbar spondylosis with scoliosis, causing
- Grade I anterolisthesis of L2 over L3
- Severe L2/3 to L4/5 spinal canal stenosis with cauda equina nerve roots
compression, and tortuosity of the cauda equina roots above the stenotic level.
- Narrowing left L3/4, bilateral L4/5 neural foramina with possible left L3 and
bilateral L4 exiting nerve roots compression.
- Suspected bilateral S1 traversing nerve roots compression.
2. Mild to moderate vertebral height loss of L3-L5 vertebral bodies without marrow
edema, possible old osteoporotic fracture.
16. Spinal stenosis
■ Abnormal narrowing of the central canal, the lateral recesses or the
intervertebral foramina to the point where the neutral element are compromised.
22. ■ Anatomic classification
– central stenosis
■ cross sectional area < 100mm2 or <10mm A-P diameter on axial CT
■ caused by ligamentum hypertrophy directly under the lamina posteriorly, and
the bulging disc anteriorly
■ presents with nonspecific root compression or symptoms of lower nerve root
(at L4/5 level the root of L5 affected)
– lateral recess stenosis (subarticular recess)
■ associated with facet joint arthropathy and osteophyte formation(overgrowth
of superior articular facet)
■ presents with symptoms of descending nerve root (at L4/5 level the root of L5
affected)
23. ■ Anatomic classification
– foraminal stenosis
■ occurs between the medial and lateral border of the pedicle
■ exiting nerve root compressed by ventral cephalad overhang of the
superior facet and the bulging disc
■ present with symptoms of exiting nerve root(at L4/5 level the root of
L4 affected)
– extraforaminal stenosis
■ located lateral to the lateral edge of the pedicle
■ lateral disc herniation causes impingement of the existing nerve root
24. Presentation
■ Symptoms
– back pain
– referred buttock pain
– Claudication
■ pain worse with extension (walking, standing upright)
■ pain relieved with flexion (sitting, leaning over shopping cart, sleeping in fetal
position)
– leg pain (often unilateral)
– weakness
– bladder disturbances
– recurrent UTI present in up to 10% due to autonomic sphincter dysfunction
– cauda equina syndrome (rare)
25.
26. Presentation
■ Physical Exam
– Kemp sign
■ unilateral radicular pain from foraminal stenosis made worse by extension of
back
– Straight leg raise (tension sign)
■ is usually negative
– Valsalva test
■ radicular pain not worsened byValsalva as is the case with a herniated disc
– normal neurologic exam
■ patients may have no focal deficits, as exam often takes place with patient
seated and symptoms may be reproducible or exacerbated only with lumbar
extension or ambulation
27. Imaging
■ Radiographs
– standing AP and lateral may show
■ nonspecific degenerative findings (disk space narrowing, osteophyte formation)
■ degenerative scoliosis
■ degenerative spondylolisthesis
– flexion/extension radiographs may show
■ segmental instability and subtle degenerative spondylolisthesis
28. Imaging
■ MRI
– central stenosis with a thecal sac < 100mm2
– obliteration of perineural fat and compression of lateral recess or foramen
– facet and ligamentum hypertrophy
29. Imaging
■ CT myelogram
– more invasive than MRI
– findings include
■ central and lateral neural element compression
■ bony anomalies
■ bony facet hypertrophy
30. Treatment
■ Non-operative
– rest, หลีกเลี่ยงการก้มๆเงยๆ
– NSAIDs, low dose tricyclic anti depressant
– Back muscle exercise
– Brace and lumbar support
– Epidural steroid injection (