Lumbar spinal stenosis is a common condition among older adults causing lower back and leg pain. It results from the narrowing of the spinal canal which compresses the nerves and blood vessels. Key features include neurogenic claudication pain that worsens with standing or walking and is relieved by bending forward. Treatment involves non-operative options like medication, injections and physical therapy initially. For those with more severe symptoms, open decompressive laminectomy is currently the gold standard surgical treatment, though minimally invasive techniques are gaining popularity due to lower complication rates. Proper patient selection and postoperative rehabilitation are important for achieving good long-term outcomes.

1. LUMBAR SPINAL STENOSIS
Dr A. E. Bassey

2. Outline
• Introduction
• Anatomy
• Classification
• Pathophysiology
• Differential diagnoses
• Clinical features
• Investigation
• Treatment
• Post-operative care
• Outcome factors
• Complications
• Current trends
• Conclusion
• References

3. Introduction
• Lumbar spinal stenosis is a clinical syndrome of buttock or lower extremity
pain, with or without low back pain, resulting from diminished space for
neurovascular elements in the spinal canal
• It is one the commonest conditions for which patients see a physician, or
lose days from work, causing a heavy burden to the healthcare system as
the economy by way of productivity losses
• Prompt diagnosis and appropriate treatment are essential to obtaining
outcomes that are satisfactory to both patient and attending surgeon

4. Introduction
• Age-associated condition
• Population-based study in Japan:
• 40-49yrs – 1.7-2.2%
• 70-79yrs – 10.3-11.2%
• Commonest indication for spine surgery in >65yrs
• Commoner in women

5. Anatomy
• Five lumbar vertebrae
• Consecutive vertebrae articulate anteriorly via a primary cartilaginous
joint, and posteriorly via 2 synovial joints (facet joints)
• Each vertebra has broadly, a vertebral body and vertebral arch

9. Anatomy
• Supporting ligaments:
• Supraspinous ligament
• Interspinous ligament
• Ligamentum flavum

12. Anatomy
• IV disc
• Has central gel-like nucleus pulposus
• 85% water
• Mostly Type II collagen
• Surrounded by concentric rings of fibrocartilage

13. Classification

14. Classification
• Anatomically, classified into:
• Central stenosis
• Lateral recess stenosis
• Foraminal stenosis

15. Pathophysiology
• Intervertebral disc changes
• Changes in nucleus pulposus
• Dehydration
• Reduced chondroitin sulfate:Keratin sulfate ratio
• Changes in Annulus fibrosus
• Facet joint changes
• Degeneration, capsular hypertrophy, osteophyte formation
• Intervertebral foramen changes
• Ligamentum flavum changes
• Spinal instability

16. Pathophysiology
• Factors causing symptoms are
• Neural compression
• Vascular compromise
• Inflammatory mediators
• ? Demyelination

17. Differential diagnosis
• Mechanical low back pain
• Lower limb arthritis
• Vascular claudication
• Peripheral neuropathy

18. Clinical features
• History
• Neurogenic claudication is the hallmark feature of LSS – present in 90% of those with
symptomatic LSS
• Low back pain
• Severe neurologic deficits are uncommon
• Medical co-morbidities
• Examination
• Observation – sit, stand, ambulate with trunk flexed forward
• Lumbar extension provokes symptoms
• Neurologic exam is most times normal – mostly due to recess stenosis
• Assymetric DTRs
• Sensorimotor deficits in L5
• Nerve root tension signs are usually not present
• Remember to
• Screen hip and knee
• Check for stocking-type hypoaesthesia
• Check for vascular insufficiency

19. Investigation
• Xray
• MRI
• CT myelogram
• EMG, SSEPs, NCS

22. MRI

23. MRI

24. Treatment
• Non-operative
• Operative

25. Treatment
• Rationale for non-operative treatment
• In terms of natural history, most cases of LSS run a benign course with rapid
or catastrophic neurologic deterioration occurring rarely
• Non-operative gives acceptable outcomes in the long term – measuring
walking distance, pain control etc
• Early vs delayed surgery yielded similar outcomes
• Findings from the SPORT Trial
• Largest Level I study comparing non-operative therapy and decompressive laminectomy
for LSS
• Outcome measures - bodily pain and physical function on the SF-36 health status
questionnaire and the modified Oswestry Disability Index
• At 2yrs, surgical treatment had significantly better outcomes that non-op
• At 5yrs, the surgery group still had better parameters, but the difference was no longer
statistically significant, except for indices such as SF-36 bodily pain and physical function,
ODI

26. Treatment
• Based on these, some experts recommend attempting non-operative
treatment first, for mild to moderate stenosis.
• Despite all of these, open decompressive laminectomy is currently
considered the GOLD standard treatment modality for lumbar spinal
stenosis
• The factors guiding treatment choice should include
• Severity of pain
• Patient’s functional status
• Presence of co-morbidities
• Patient’s preference

27. Treatment
• Non-operative treatment
• Drug therapy
• PCM is ineffective compared to placebo (Williams et al – 2014, Machado et al
- 2015)
• NSAID use should be discouraged due to
• Inflammation is not core pathophysiology
• Age-related comorbidities can be aggravated
• Pure analgesics, eg opioids, are useful (remember sedation and risk of falls)
• Gabapentin has been shown to be useful – improved walking distance,
decreased pain scores, recovery of sensory deficits (Yaksi et al – 2007, Kaye et
al - 2014)
• Other drugs – pregabalin, TCAs, duloxetine – have not been studied in LSS
• Recommendation – Start gabapentin. If low back pain is present add opioid

28. Treatment
• Physical therapy
• Aim of PT
• Reduce lordosis
• Reduce extension forces on spine
• Increase abdominal core strength
• Other benefits – improve mood, mutual support, weight control
• Flexion-based lumbar stabilization exercises
• Stationary cycle
• Elliptical trainers
• Aquatic exercises
• Use of lumbar corset in slight flexion also beneficial

29. Treatment
• Epidural corticosteroid injection
• This is presumed to quell the inflammatory reaction resulting from stenosis
• It may be caudal, interlaminar or transforaminal
• Evidence in support of benefits of single injection is lacking,
• Multiple reports abound extolling the benefits of a multiple injection
regimen, with effects lasting up to 2 years (Hoogmartens et al – 1987, Botwin
et al – 2002, Delport et al – 2004)

30. Surgical treatment
• Ultimately, the main indications for surgical therapy are the patient’s desire and
failed non-operative management.
• Surgical treatment being current gold standard is reinforced by
• A recent Cochrane review stating “moderate and high quality evidence for non-operative
treatment is lacking and thus prohibits recommendations for guiding clinical practice.”
(Ammendolia et al – 2013)
• Non-operative treatment is therefore currently based on experience and training guided by
limited clinical outcome data
• Proper patient selection is critical to achieving a good outcome. The ideal patient
has features of neurogenic claudication, which are relieved by lumbar flexion
activities. This was echoed by Deen and colleagues
• Surgical decompression is usually done on an elective basis, except there’s rapidly
progressing neurologic deficit

31. Surgical treatment
• Techniques of surgical decompression
• Laminectomy +/- Arthrodesis
• Laminotomy
• Fenestration
• Laminoplasty
• MicroEndoscopic Decompressive Laminotomy
• InterSpinous Process devices
• Even though open Decompressive laminectomy is considered to gold
standard for treatment of LSS, current evidence is still insufficient to decide
which technique is most effective (Cochrane reviews – Gibson et al – 2005,
Overdevest et al - 2015).

32. Surgical treatment
• Open decompressive laminectomy
• Involves removal of posterior osseoligamentous structures
• Where symptoms are predominantly radicular, laminectomy alone is done
• Indications for laminectomy and fusion are:
• Neurogenic claudication with significant LBP component
• Neurogenic claudication + instability/spondylolisthesis
• LSS with degenerative scoliosis
• Revision decompressive laminectomy

34. Surgical treatment
• Open laminotomy
• Done in those with primarily lateral recess stenosis
• Aims to preserve much of the posterior structures with advocates claiming
improved stability and lower complication rates
• Approaches
• Unilateral laminotomy
• Bilateral laminotomy
• Unilateral laminotomy for bilateral decompression
• Thome & colleagues (2005) prospectively compared unilateral laminotomy for
bilateral decompression, bilateral laminotomy and open laminectomy
• Walking distance, pain control, pt satisfaction all similar
• Dural tear commonest complication
• BL had lowest complication rate

36. Surgical treatment
• Celik & colleagues (2010) went further to compare bilateral laminotomy and
open laminectomy
• Adequate decompression achieved in both groups on CT/MRI
• BL – much lower complication rate
• BL – nonsignificant trend to superior walking distance, pain control, ODI
• Fenestration
• Decompression is done through a 5mm hole in subjacent pars
• No outcome reports yet

38. Surgical treatment
• Laminoplasty
• Distraction laminoplasty – used to decompress central and lateral recess
stenosis
• Expansive lumbar laminoplasty – Sangwan & colleagues (2008) reviewed 25
patients who had ELL. There was an average of 124% increase in AP spinal
canal diameter. Some experts however feel it fails to properly address lateral
recess stenosis

41. Surgical treatment
• MicroEndoscopic Decompressive Laminotomy
• Minimally invasive approach to decompressive laminotomy
• Unilateral approach permits bilateral decompression
• Yagi et al (2009) & Mobbs et al (2014) prospectively compared MEDL
and open laminectomy
• Similar outcomes
• MEDL had significantly lower perioperative morbidity – intraop blood loss,
muscle damage, opioid requirement for pain, time to mobilization, length of
stay
• MEDL had lower complication rate

43. Post-operative care
• Ambulate all patients ASAP, if possible on same day as surgery. If there was
a dural tear that was repaired then ambulate after 48hrs
• If fusion done apply LS orthotic for 6wks. If fusion involves sacrum and
bone quality is questionable, apply LS orthotic with thigh extension
• The patient should avoid bending and twisting movements, and lifting
heavy objects for 6-12 weeks
• First post op visit is at 2-3 weeks, if decom alone was done, subsequent
visits would be at 3 moths and 1 year
• If fusion was done subsequent visits are at 6wks, 3 months, 6 months, 1
year and annually till 5 years

44. Outcome factors
• Good outcome factors
• Predominant leg pain
• Higher disability
• Neuroforaminal stenosis
• Neurologic deficit
• Poor outcome factors
• Smoking
• Occupational lifting
• Symptoms lasting >12 months

45. Complications
• Lumbar spinal stenosis
• LL muscle weakness
• Bladder/dysfunction
• Depression
• Decompressive surgery
• Dural tear
• Infection
• Instability
• DVT/PE

46. Current trends
• Use Interspinous Process spacers
• Principle – they are inserted into interspinous space and used to distract
adjacent interspinous processes, thus increasing spinal canal and foraminal
capacity.
• The patient likely to benefit is one who has neurologic claudication that is
relieved within 5 minutes of sitting down, and no more than grade I
spondylolisthesis
• It should not be used in poor bone due to risk of fractures
• Wu et al (2014) & Hong et al (2015) in their metanalyses compared ISP and
open decompression – outcomes were similar, but the ISP group had
significantly higher reoperation rates

47. Conclusion
• As populations age, incidence of LSS is likely to rise.
• Our healthcare system needs to be empowered via capacity-building and
infrastructural development to care for victims of this ubiquitous, disabling
and costly disease.
• Surgical decompression still remains the gold standard of care.
• A thorough history and physical examination, as well as use of appropriate
imaging are indispensable to determining those who stand to benefit from
invasive procedures.

48. THANK YOU

49. References
• Apley’s System of Orthopaedics and Fractures, 10th Ed (2018), pp524 – 527
• Rothman-Simeone and Herkowitz The Spine, 7th Ed (2018), pp1019 – 1057
• Weinstein JN, Tosteson TD et al Surgical versus nonsurgical therapy for lumbar
spinal stenosis. N Engl J Med. 2008 Feb 21;358(8):794-810.
• Watters WC, Baisden J, Gilbert TJ, et al. Degenerative lumbar spinal stenosis: an
evidence-based clinical guideline for the diagnosis and treatment of degenerative
spinal stenosis. Spine J. 2008;8:305-310.
• Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-
back pain: a double-blind, randomized controlled trial. Lancet. 2014;384:1586-
1596.
• Machado GC, Maher CG, Ferreira PH, et al. Eicacy and safety of paracetamol for
spinal pain and osteoarthritis: systematic review and meta-analysis of
randomized placebo controlled trials. BMJ. 2015;350h:1225.
• Thomé C, Zevgaridis D, Leheta O, et al. Outcome after less-invasive
decompression of lumbar spinal stenosis: a randomized comparison of unilateral
laminotomy, bilateral laminotomy, and laminectomy. J Neurosurg Spine.
2005;3(2):129-141.

50. References
• Yaksi A, Ozgonenel L, Ozgonenel B. he eicacy of gabapentin therapy in patients with
lumbar canal stenosis. Spine. 2007;32:939-942.
• Kaye AD, Rivera Bueno F, Katalenich B, et al. The effects of gastroretentive gabapentin
(Gralise) on spinal stenosis patients with radicular pain. Pain Physician. 2014;17:169-178.
• Hoogmartens M, Morelle P. Epidural injection in the treatment of spinal stenosis. Acta
Orthop Belg. 1987;53:409-411.
• Delport EG, Cucuzzella AR, Marley JK, et al. Treatment of lumbar spinal stenosis with
epidural steroid injections: a retrospective outcome study. Arch Phys Med Rehabil.
2004;85:479-484.
• Ammendolia C, Sturber KJ, Rok E, et al. Nonoperative treatment for lumbar spinal
stenosis with neurogenic claudication. Cochrane Database Syst Rev. 2013;(8):CD010712.
• Gibson JN, Waddell G. Surgery for degenerative lumbar spondylosis: updated Cochrane
Review. Spine. 2005;30:2312-2320.
• Overdevest GM, Jacobs W, Vleggeert-Lankamp C, et al. Effectiveness of posterior
decompression techniques compared with conventional laminectomy for lumbar
stenosis. Cochrane Database Syst Rev. 2015;(3):CD010036.

51. References
• Celik SE, Celik S, Göksu K, Kara A, Ince I. Microdecompressive laminotomy with a 5-year
follow-up period for severe lumbar spinal stenosis. J Spinal Disord Tech. 2010;23(4):229-
235.
• Sangwan SS, Kundu ZS, Walecha P, et al. Degenerative lumbar spinal stenosis—results of
expansive laminoplasty. Int Orthop. 2008;32(6):805-808
• Yagi M, Okada E, Ninomiya K, Kihara M. Postoperative outcome after modified unilateral-
approach microendoscopic midline decompression for degenerative spinal stenosis. J
Neurosurg Spine. 2009;10(4):293-299.
• Mobbs RJ, Li J, Sivabalan P, Raley D, Rao PJ. Outcomes after decompressive laminectomy
for lumbar spinal stenosis: comparison between minimally invasive unilateral
laminectomy for bilateral decompression and open laminectomy. J Neurosurg Spine.
2014;21(2):179-186
• Wu AM, Zhou Y, Li QL, et al. Interspinous spacer versus traditional decompressive surgery
for lumbar spinal stenosis: a systematic review and meta-analysis. PLoS One.
2014;9(5):e97142.
• Hong P, Liu Y, Li H. Comparison of the eicacy and safety between interspinous process
distraction device and open decompression surgery in treating lumbar spinal stenosis: a
meta-analysis. J Invest Surg. 2015;28(1):40-49.