Lumbar Spinal StenosisLumbar Spinal Stenosis

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Spinal StenosisSpinal Stenosis

Low back pain is the second most common reason Low back pain is the second most common reason that patients seek medical carethat patients seek medical careMore health care dollars are spent on back pain More health care dollars are spent on back pain than any other conditionthan any other condition33--6 million patients in US with chronic back pain6 million patients in US with chronic back painOf patients who see a specialist for back pain, 13Of patients who see a specialist for back pain, 13--14% have spinal stenosis14% have spinal stenosisOther causes include disc injuries, posterior Other causes include disc injuries, posterior element pain, instability, fracture, etcelement pain, instability, fracture, etc

Lumbar SpineLumbar Spine

Five vertebral bodiesFive vertebral bodiesSacrumSacrumFive intervertebral discsFive intervertebral discsFive lumbar nerve roots exit Five lumbar nerve roots exit through the intervertebral foramenthrough the intervertebral foramenFive sacral nerve roots exit Five sacral nerve roots exit through the sacral foramenthrough the sacral foramen

Spinal CanalSpinal Canal

Bordered Bordered anteriorlyanteriorly by by the vertebral body or the vertebral body or intervertebralintervertebral discdiscBordered laterally by Bordered laterally by the pediclesthe pediclesZZ--joints joints posterolateralposterolateralPosteriorlyPosteriorly bordered bordered by lamina and by lamina and ligamentumligamentum flavumflavum

IntervertebralIntervertebral DiscDisc

Nucleus Nucleus PulposusPulposus -- SemifluidSemifluidmass with consistency similar mass with consistency similar to toothpasteto toothpasteAnulusAnulus fibrosis fibrosis -- 1010--20 sheets 20 sheets (average 17) of collagen fibers (average 17) of collagen fibers called called lamellae lamellae arranged in arranged in concentric rings surrounding concentric rings surrounding the nucleusthe nucleus

VertebaeVertebae

Vertebral bodyVertebral bodyPediclesPediclesArticularArticular processesprocessesLaminaLaminaSpinousSpinous processprocess

InnervationInnervationOuter 1/3 of anulus Outer 1/3 of anulus and PLL innervated and PLL innervated by by sinuvertebralsinuvertebralnervesnervesAnterior disc has Anterior disc has some sensory input some sensory input through sympathetic through sympathetic trunktrunkPosterior spinal Posterior spinal elements carry elements carry nociceptionnociception through through medial branch medial branch nervesnerves

DermatomesDermatomes

May be described as May be described as numbness, an numbness, an ““acheache””, , or less commonly or less commonly paresthesiasparesthesiasDermatomes Dermatomes suggestive but not suggestive but not absoluteabsolute

MyotomesMyotomesT12, L1, L2, L3T12, L1, L2, L3

IliopsoasIliopsoas

L2, L3, L4L2, L3, L4QuadricepsQuadricepsHip adductor groupHip adductor group

L4L4TibialisTibialis anterioranteriorKnee Jerk reflexKnee Jerk reflex

L5L5Extensor Extensor hallucishallucis longuslongusGluteus Gluteus mediusmediusExtensor Extensor digitorumdigitorum longuslongus& & brevisbrevis

S1S1PeroneusPeroneus longuslongus & & brevisbrevisGastrocnemiusGastrocnemius--SoleusSoleusGluteus Gluteus maximusmaximusAnkle Jerk reflexAnkle Jerk reflex

Lumbar StenosisLumbar Stenosis

Congenital (Developmental)Congenital (Developmental)Acquired (Degenerative)Acquired (Degenerative)–– Herniated DiscHerniated Disc–– SpondylolisthesisSpondylolisthesis–– Osseous (Osseous (hypertrophichypertrophic))

Congenital Lumbar StenosisCongenital Lumbar StenosisNormally the spinal canal Normally the spinal canal reaches reaches ““adult sizeadult size”” by age by age 44If it does not reach this If it does not reach this size by that age, it will not size by that age, it will not catch upcatch upRadiographs reveal Radiographs reveal shortened pedicles (10shortened pedicles (10--12mm in length)12mm in length)Stenosis is uniform Stenosis is uniform throughout the spinethroughout the spine

Other Conditions that May Other Conditions that May Contribute to Spinal StenosisContribute to Spinal Stenosis

Bone Bone dysplasiadysplasiaCalcium pyrophosphate Calcium pyrophosphate depositiondepositionAchondroplasticAchondroplastic dwarfismdwarfismDiffuse idiopathic skeletal Diffuse idiopathic skeletal hyperostosishyperostosisSenile Senile ankylosingankylosinghyperostosis of the spinehyperostosis of the spineOssification of the Ossification of the posterior longitudinal posterior longitudinal ligamentligamentPaget'sPaget's disease of bonedisease of bonePrevious lumbar surgeryPrevious lumbar surgery

Metabolic bone diseaseMetabolic bone diseaseHypoparathyroidismHypoparathyroidismRenal Renal osteodystrophyosteodystrophy

InfectionsInfectionsVertebral Vertebral osteomyelitisosteomyelitisDiscitisDiscitis

TumorsTumorsEpidural Epidural lipomalipomaIntraspinalIntraspinal tumors or cyststumors or cysts

Degenerative StenosisDegenerative Stenosis

HypertrophicHypertrophic ZZ--jointsjointsLigamentumLigamentum flavumflavumhypertrophyhypertrophyDiffuse disc bulging Diffuse disc bulging usually presentusually present

MultifactoralMultifactoral Lumbar StenosisLumbar Stenosis

SpondylolisthesisSpondylolisthesis

A common cause of A common cause of spinal stenosisspinal stenosisMay be a result of May be a result of degenerative or degenerative or isthmicisthmic listhesislisthesisSegmental instability Segmental instability more concerning that a more concerning that a ““fixedfixed”” listhesislisthesis

DiagnosisDiagnosis

HistoryHistoryExaminationExaminationImagingImagingElectrodiagnosticElectrodiagnostic StudiesStudies

Complaints (Historic Features)Complaints (Historic Features)Frequently present with diffuse Frequently present with diffuse low back pain, may be chronic low back pain, may be chronic or recently startedor recently startedHave difficulty standing or Have difficulty standing or walking for prolonged period of walking for prolonged period of timetimePain increases with extensionPain increases with extensionClassically, symptoms reduce Classically, symptoms reduce when pushing a shopping cartwhen pushing a shopping cartDegenertiveDegenertive stenosis is most stenosis is most common in patients 55common in patients 55--64 years 64 years in agein age

Lumbar instability is more Lumbar instability is more common in patients under 45 common in patients under 45 years of ageyears of age

Most common presenting Most common presenting complantscomplants11::Back pain (95%)Back pain (95%)ClaudicationClaudication (91%)(91%)Leg pain (71%)Leg pain (71%)Weakness (33%)Weakness (33%)Bladder disturbances (12%)Bladder disturbances (12%)

1Amundsen T, et al. Lumber spinal stenosis. Clinical and radiologicfeatures. Spine. 1995; 20:1178-1186.

ClaudicationClaudication

Almost immediateAlmost immediateProlongedProlongedPain cessation after Pain cessation after stopping ambulationstopping ambulation

Increased pain with Increased pain with increased ambulationincreased ambulationVariableVariableWalking DistanceWalking Distance

Pain unaffected by Pain unaffected by lumbar posturelumbar posture

Pain improved with Pain improved with flexionflexionPositional ChangePositional Change

Mottled or atrophicMottled or atrophicLoss of Loss of pretibialpretibial hair hair growthgrowth

NoneNoneSkin ChangesSkin Changes

Diminished or absentDiminished or absentIntactIntactDistal PulsesDistal Pulses

VascularVascularNeurogenicNeurogenicSign or SymptomSign or Symptom

Physical ExaminationPhysical ExaminationBack pain is the most Back pain is the most common complaint in common complaint in patients with stenosispatients with stenosisPatients typically Patients typically demostratedemostrate a a symiansymianposture (stooped with posture (stooped with flattening of normal flattening of normal lumbar lumbar lordosislordosis))Peripheral vascular Peripheral vascular signs absentsigns absent

Focal weakness is not Focal weakness is not typically present, may typically present, may demonstrate weakness demonstrate weakness in in myotomesmyotomes below the below the level of stenosislevel of stenosisDiminished or absent Diminished or absent reflexes in lower reflexes in lower extremities may be extremities may be presentpresent

ElectrodiagnosticElectrodiagnostic StudiesStudiesSensitivity is very low in Sensitivity is very low in patientpatient’’s with lumbar s with lumbar radicularradicular pain; about 77% pain; about 77% sensitive if sensitive if radiculopathyradiculopathypresentpresent11

Few indications:Few indications:–– Exclusion of more distal Exclusion of more distal

nerve damagenerve damage–– Verification of subjective Verification of subjective

muscle weakness in patients muscle weakness in patients presenting pain inhibition or presenting pain inhibition or lack of cooperationlack of cooperation

–– Possibly if difficult surgery is Possibly if difficult surgery is expectedexpected

No trials looking at the No trials looking at the sensitivity of EMG to sensitivity of EMG to diagnose stenosisdiagnose stenosisElectrophysiological Electrophysiological evaluation does not evaluation does not directly evaluate directly evaluate neurologicneurologic mechanisms mechanisms associated with pain associated with pain generationgenerationCan not accurately Can not accurately determine the precise determine the precise spinal nerve levelspinal nerve level

1Knutsson, et al. Spine 1993; 18:837-42

RadiographsRadiographs

Shows bones onlyShows bones onlyHelpful in older patients where cause of Helpful in older patients where cause of stenosis is likely to be a result of stenosis is likely to be a result of degenerative changes or degenerative changes or listhesislisthesisIf If spondylolisthesisspondylolisthesis is present, need flexion is present, need flexion and extension views to evaluate for and extension views to evaluate for segmental instabilitysegmental instabilityScoliosis evaluation may be beneficial in Scoliosis evaluation may be beneficial in some casessome cases

CT ScanCT Scan

Preferred method for bony evaluation of Preferred method for bony evaluation of spinespineMay diagnose disc pathology though May diagnose disc pathology though sensitivity very low compared with MRIsensitivity very low compared with MRIHelpful in fractures or other bony Helpful in fractures or other bony abnormalities, 3D reconstruction sometimes abnormalities, 3D reconstruction sometimes usefulusefulParticularly helpful in evaluating canal Particularly helpful in evaluating canal patencypatency with post with post myelographymyelography scanningscanning

MRIMRIProvides the best Provides the best anatomic picture anatomic picture and allows focus and allows focus on soft tissueon soft tissueNeeds to correlate Needs to correlate with physical with physical examinationexaminationMany findings on Many findings on MRI can be MRI can be asymptomaticasymptomatic11

HighHigh--field better field better than Open, need than Open, need complete studycomplete study

1Boden, et al. JBJS March 1990, 72A (3):403-8

MRIMRI

Order urgently if Order urgently if CaudaCauda EquinaEquina Syndrome Syndrome redred--flag condition existsflag condition existsIf no redIf no red--flag:flag:–– Refrain from imaging on first visit, especially if Refrain from imaging on first visit, especially if

early in course; wait until symptoms have early in course; wait until symptoms have persisted for persisted for ~6~6--7 wks7 wks

–– Attempt conservative management prior to MRIAttempt conservative management prior to MRINeed MRI if surgery or possibly epidurals Need MRI if surgery or possibly epidurals consideredconsidered

Bogduk. Acute Lumbar Radicular Pain. 1999. pp 43-51.

MRIMRI

MyelogramMyelogramStudy of choice when MRI Study of choice when MRI can not be donecan not be doneCan effectively identify the Can effectively identify the location of narrowinglocation of narrowingFrequently an Frequently an uncomfortable procedureuncomfortable procedurePostPost--myelogrammyelogram CT can CT can give additional information give additional information about canal contentsabout canal contents

Treatment OptionsTreatment Options

NSAIDsNSAIDsCOXCOX--II InhibitorsII InhibitorsOral SteroidsOral SteroidsMuscle RelaxantsMuscle RelaxantsNarcoticsNarcoticsTENsTENsPhysical TherapyPhysical Therapy

Epidural Steroid Epidural Steroid InjectionsInjectionsLaminectomyLaminectomyMultiple Multiple LaminotomyLaminotomyFusionFusion

NSAIDsNSAIDs

Helpful in reducing acute and subHelpful in reducing acute and sub--acute acute painpainMay have therapeutic effect on decreasing May have therapeutic effect on decreasing epidural inflammatory responseepidural inflammatory responseCOXCOX--II inhibitors equally as effective as nonII inhibitors equally as effective as non--selective selective NSAIDsNSAIDs, safety profile better , safety profile better (except (except VioxxVioxx))Should be first line agentShould be first line agent

Oral SteroidsOral Steroids

Can help decrease epidural inflammationCan help decrease epidural inflammationReserve for use in patients with severe painReserve for use in patients with severe painSystemic effects greater than for epidural Systemic effects greater than for epidural steroidssteroidsKnow safety profileKnow safety profile

Muscle RelaxantsMuscle RelaxantsGabaGaba AgonistsAgonists

BaclofenBaclofen ((lioresallioresal))

AlphaAlpha22 AgonistsAgonistsZanaflexZanaflex ((tizanidinetizanidine))

SR Calcium Channel SR Calcium Channel BlockersBlockersDantriumDantrium ((dantrolenedantrolene))

CNS depressantsCNS depressantsSoma (Soma (carisoprodolcarisoprodol))RobaxinRobaxin ((MethocarbamolMethocarbamol))SkelaxinSkelaxin ((MetaxaloneMetaxalone))FlexerilFlexeril ((CyclobenzaprineCyclobenzaprine))

BenzodiazepinesBenzodiazepines

NarcoticsNarcotics

Helpful for severe, acute painHelpful for severe, acute painLay out timeline to get patient offLay out timeline to get patient offAvoid longAvoid long--term useterm usePlan for constipation, stool softeners with Plan for constipation, stool softeners with scriptscript

Physical TherapyPhysical Therapy

No large, or controlled studies on the effectiveness No large, or controlled studies on the effectiveness of physical therapy for spinal stenosisof physical therapy for spinal stenosisSmall observational studies indicate that manual Small observational studies indicate that manual therapy, core strengthening, individualized therapy, core strengthening, individualized exercise programs and a walking program are exercise programs and a walking program are beneficial in reducing pain and help walking beneficial in reducing pain and help walking abilityability1,2,3

Should be used in conjunction with other treatment Should be used in conjunction with other treatment modalities (oral agents, injections, etc)modalities (oral agents, injections, etc)

1Whitman JM, et al. Phys Med Rehabil Clin N Am. 2003 Feb;14(1):77-101, vi-vii.2Fritz JM, et al. Phys Ther. 1997 Sep;77(9):962-73.3Zeifang F, et al. Orthopade. 2003 Oct;32(10):906-10.

Chiropractic CareChiropractic Care

Lumbar stabilization is more effective than Lumbar stabilization is more effective than manipulation in long term pain reliefmanipulation in long term pain relief11

Modality care can be helpful in reducing Modality care can be helpful in reducing inflammation and pain symptoms inflammation and pain symptoms No trials to support chiropractic manipulation No trials to support chiropractic manipulation aids in reducing symptoms or pathology aids in reducing symptoms or pathology from spinal stenosisfrom spinal stenosisCan cause injury if mobilizes spine through Can cause injury if mobilizes spine through an unstable an unstable spondyliticspondylitic segmentsegment

1Rasmussen-Barr E, et al. Man Ther. 2003 Nov;8(4):233-41.

Epidural Steroid InjectionsEpidural Steroid InjectionsESIsESIs in patients with spinal stenosis are not as effective as in patients with spinal stenosis are not as effective as ESIsESIs in patients with herniated discsin patients with herniated discs11

Have been shown to provide some patients with sustained Have been shown to provide some patients with sustained relief and improve function in over relief and improve function in over ½½ of patientsof patients22

TransforaminalTransforaminal approach been shown to improve walking approach been shown to improve walking and standing tolerance in over 60% of patients at 1 yearand standing tolerance in over 60% of patients at 1 year33

The single RCT available used blind epidural injections and The single RCT available used blind epidural injections and showed no difference between a group of patients who showed no difference between a group of patients who received received mepivicainemepivicaine and another group the received and another group the received mepivicaine+methylprednisolonemepivicaine+methylprednisolone44

1Rivest C, et al. Arthritis Care Res. 1998 Aug;11(4):291-7. 2Delport EG, et al. Arch Phys Med Rehabil. 2004 Mar;85(3):479-84.3Botwin KP, et al. Am J Phys Med Rehabil. 2002 Dec;81(12):898-9054Fukusaki M, et al. Clin J Pain. 1998 Jun;14(2):148-51.

Epidural Steroid InjectionsEpidural Steroid Injections

Approaches:Approaches:CaudalCaudalInterlaminarInterlaminarTransforaminalTransforaminal

Blind Blind vsvs FlouroscopicallyFlouroscopically--guidedguided

Caudal Epidural Steroid InjectionsCaudal Epidural Steroid InjectionsEffective for multilevel pathology including spinal stenosisEffective for multilevel pathology including spinal stenosisUses most volume of any approachUses most volume of any approachNonNon--selectiveselectiveMay be performed under May be performed under flouroscopicflouroscopic guidance or blindguidance or blind

EpidurogramEpidurogram

InterlaminarInterlaminar Epidural Steroid Epidural Steroid InjectionsInjections

May be done in office settingMay be done in office settingDoes not require use of Does not require use of flouroscopyflouroscopyCovers a broader area than Covers a broader area than transforaminaltransforaminal injections injections since higher volume is usedsince higher volume is usedSolution placed in posterior Solution placed in posterior epidural spaceepidural spaceIn patients with spinal In patients with spinal stenosis, access at the stenosis, access at the symptomatic level is difficult symptomatic level is difficult and can be dangerousand can be dangerous

TransforaminalTransforaminal Epidural Steroid Epidural Steroid InjectionsInjections

Direct Direct injectateinjectate to the to the anterioranterior epidural spaceepidural spaceDiagnostic and therapeuticDiagnostic and therapeuticLower volume of Lower volume of injectateinjectateMuch lower risk of Much lower risk of duralduralpuncture and associated puncture and associated headacheheadacheDecrease leg pain and Decrease leg pain and increase standing and increase standing and walking tolerance in LSSwalking tolerance in LSS11

1Botwin KP, et al. Am J Phys Med Rehabil. 2002 Dec;81(12):898-905.

FlouroscopicFlouroscopic vsvs Blind InjectionsBlind Injections

FlouroscopicFlouroscopic guidance is the only way to guidance is the only way to ensure that solution travels to the target ensure that solution travels to the target locationlocationFlouroscopyFlouroscopy decreases risk of complicationsdecreases risk of complicationsFlouroscopicFlouroscopic guidance is more effective guidance is more effective than blind injectionsthan blind injectionsFlouroscopyFlouroscopy does have risks associated does have risks associated with radiation exposure, though exposure is with radiation exposure, though exposure is very limitedvery limited

1White AH, et al. Spine. 1980;5:78-86. 2Stewart HD, et al. Br J Rheumatol. 1987;26:424-9.3Renfrew DL, et al. Am J Neuroradiol 1991:12:1003-7.

DecompressiveDecompressive Surgery Surgery ((LaminectomyLaminectomy, , LaminotomyLaminotomy, , FacetectomyFacetectomy, etc.), etc.)

Indicated when a stenosis symptoms exist for more than 8 Indicated when a stenosis symptoms exist for more than 8 weeks despite conservative careweeks despite conservative carePatients with severe symptoms seem to benefit more from Patients with severe symptoms seem to benefit more from surgery than conservative treatmentsurgery than conservative treatment11

More urgent if has progressive loss of motor, bladder, or More urgent if has progressive loss of motor, bladder, or bowel function or there is excruciating pain that can not be bowel function or there is excruciating pain that can not be relieved by nonrelieved by non--operative treatmentoperative treatmentDelay for longer than 6 months in face of persistent and Delay for longer than 6 months in face of persistent and severe symptoms may compromise best resultssevere symptoms may compromise best resultsAdequate decompression is the best way to ensure Adequate decompression is the best way to ensure successful surgerysuccessful surgery

1Amundsen T, et al. Spine. 2000 Jun 1;25(11):1424-35.

FusionFusion

Major indication in stenosis is for patients Major indication in stenosis is for patients with with spondylolisthesisspondylolisthesisUsually done in addition to Usually done in addition to laminectomylaminectomy in in these casesthese casesA solid fusion increases successA solid fusion increases success11, while , while posterior instrumentation may not be posterior instrumentation may not be necessarynecessary22

Risk failure at levels surrounding fusionRisk failure at levels surrounding fusion1Kornblum MB, et al. Spine. 2004 Apr 16;29(7):726-33.2Fischgrund JS, et al. Spine. 1997 Dec 15;22(24):2807-12.

Surgery Surgery vsvs Conservative CareConservative CareConservativeConservative

Mild to moderate Mild to moderate symptomssymptomsCan try briefly in patients Can try briefly in patients with severe symptoms with severe symptoms before surgery consideredbefore surgery consideredA comprehensive A comprehensive approach is bestapproach is bestEpidural steroids can be Epidural steroids can be beneficial (use beneficial (use flouroflouro))Expect 50% of patients to Expect 50% of patients to improveimprove

SurgerySurgerySevere symptoms or red Severe symptoms or red flagsflagsAdequate decompression Adequate decompression is the best indicator of is the best indicator of successsuccessFusion is helpful with Fusion is helpful with spondylolisthesisspondylolisthesisExpect 70Expect 70--80% of patients 80% of patients to improveto improve

1Atlas SJ, et al. Spine. 2000. 25(5):556-62.2Amundsen T, et al. Spine. 2000. 25(11):1424-35.

Red FlagsRed FlagsCancer Related Red Flags Cancer Related Red Flags

History of cancer History of cancer Unexplained weight loss >10 kg within 6 Unexplained weight loss >10 kg within 6 months months Age over 50 years or under 17 years old Age over 50 years or under 17 years old Failure to improve with therapy Failure to improve with therapy Pain persists for more than 4 to 6 weeks Pain persists for more than 4 to 6 weeks Night pain or pain at restNight pain or pain at rest

CaudaCauda EquinaEquina Syndrome Related Red Syndrome Related Red FlagsFlagsUrinary incontinence or retention Urinary incontinence or retention Saddle anesthesia Saddle anesthesia Anal sphincter tone decreased or fecal Anal sphincter tone decreased or fecal incontinence incontinence Bilateral lower extremity weakness or Bilateral lower extremity weakness or numbness numbness Progressive Progressive neurologicneurologic deficitdeficit

Infection Related Red FlagsInfection Related Red FlagsPersistantPersistant fever (temperature over 100.4 fever (temperature over 100.4 F) F) History of intravenous drug abuseHistory of intravenous drug abuseRecent bacterial infection Recent bacterial infection

–– UTI or UTI or pyelonephritispyelonephritis–– CellulitisCellulitis–– Pneumonia Pneumonia

ImmunocompromisedImmunocompromised states states –– Systemic corticosteroids Systemic corticosteroids –– Organ transplantOrgan transplant–– Diabetes mellitusDiabetes mellitus–– HIV HIV –– Rest Pain Rest Pain

Acute Abdominal Aneurysm Red FlagsAcute Abdominal Aneurysm Red FlagsAbdominal pulsating mass Abdominal pulsating mass Atherosclerotic vascular disease Atherosclerotic vascular disease Pain at rest or nocturnal pain Pain at rest or nocturnal pain Age greater than 60 years Age greater than 60 years