Jennifer Belu, PT, MPH Jennifer Belu, PT, MPH -- Physical TherapyPhysical Therapy

Joe Tu, MD Joe Tu, MD -- PM&RPM&R

James Thoman, MD James Thoman, MD –– NeurosurgeryNeurosurgery

Elizabeth Yu, MD Elizabeth Yu, MD -- OrthopedicsOrthopedics

Case Presentation – Lumbar Stenosis

Patient is a 68 year old female with a chief complaint of pain in legs with walking. She has had low back pain for 7 years, but in the

past year the pain has changed and is now down her right leg. It used to occur between sitting and standing, but

now it is painful to stand or walk. The pain is zero sitting and 8 standing. She can walk

25 feet and then has to sit down. She can walk further if she uses a grocery cart. She gets a feeling of weakness in her legs if she

keeps walking

Her pain is in the hips, the lateral thigh on the right and then into the anterior leg. She says that she feels some numbness in the top

of the foot with some tingling if she stands for longer times. She has no bowel or bladder difficulty. Her physical exam showed some mild tenderness in

the greater trochanteric bursae bilaterally. She had minimal weakness in both EHL. SLR is

negative. She had absent AJ bilaterally. Flexion causes no pain in the back, but extension causes pain in the back that then radiates down the right leg into the lateral thigh, but is immediately relieved with flexion.

Case Presentation – Lumbar Stenosis (cont)

1. Stenosis is a product of aging1. Stenosis is a product of agingA. Facets get larger (spurs)A. Facets get larger (spurs)B. Thicker ligamentum flavumB. Thicker ligamentum flavumC. Facets become unstable listhesis C. Facets become unstable listhesis

(especially in females)(especially in females)D. Veeerrrrryyyyy slow processD. Veeerrrrryyyyy slow process

2. Patients may remain stable for years2. Patients may remain stable for years3. Very Very Very rarely become paralyzed3. Very Very Very rarely become paralyzed

Neurogenic Claudication

Pain in legs Occurs with standing Doesn’t go away with just resting after walking,

has to sit down Vascular claudication improves with standing

rest, no problem with standing, and going up hill worse than with neurogenic claudication

Managing symptoms

Activity modification

Therapeutic exercise to improve overall strength and condition

BELU

Low Back Pain: Physical Therapy Perspective – Jennifer Belu, PT, MPH

Lumbar Stenosis: Managing Symptoms

Home modalities In clinic, electrical stimulation/TENS Medication as advised by their primary care

provider or specialist

BELU

Lumbar Stenosis: Activity Modification

Walking with known rest areas Track how long able to walk before caudication

symptoms Kitchen tasks with foot stool to flex lumbar spine

BELU

Lumbar Stenosis: Therapeutic Exercise

Look at musculature: iliopsoas restricted (often more sitting results in pattern of restriction which exacerbates symptoms) Weak hip abductors, extensors, and rotators Trunk weakness

Posture: compensation (i.e. excessive cervical extension to compensate for forward flexed trunk) Treadmill with incline to increase endurance and

increase time to symptoms Aquatics!

BELU

Introduction Discuss spinal stenosis Discuss symptoms and characteristics Discuss management strategies Discuss possible use of injection therapy Indications/contraindications Risks/side effects/benefits Data

Spinal Stenosis Management StrategiesJoseph Tu, MD

TU

Symptoms

Degenerative lumbar spinal stenosis (LSS) is a common source of pain and disability in the elderly population

Neurogenic claudication is the hallmark symptom of LSS Classic Symptoms: Buttock and bilateral leg pain Worse with walking, prolonged standing, relative lumbar

extension) Typically relieved by sitting, bending forward, or pushing a

grocery cart

TU

Symptoms

Vascular Claudication: Relieved solely by rest (not having to sit or bend

forward) Walking uphill is worse

TU

Symptoms

LSS is a result of the degenerative spine cascade thus can affect Central spinal canal Lateral recesses Intervertebral foramina

Result in: Unilateral or bilateral, and monoradicular or polyradicular symptoms

TU

Symptoms

Axial back pain is also present Quality of this axial symptom is consistent with

osteoarthritis of the lumbar spine (stiffness with a dull, aching pain) default to a stooped-forward posture to alleviate

pain by widening the spinal canal and decreasing the forces on the zygaphophyseal joints

TU

Etiology

Not simply due to mechanical compression Multi-factorial There are vascular, biochemical, and

biomechanical factors that contribute to the symptoms of LSS

TU

Etiology

Venous engorgement theory Spinal veins dilate during ambulation in stenotic

patients Blood flow stagnates and intrathecal pressures

rise Microcirculatory neuroischemic insult

Claudication symptoms

TU

Etiology

Arterial insufficiency: Normally, lower limb exercise, including

ambulation, the lumbar radicular arterioles dilate to provide nourishment to the spinal nerve roots Arterial dilation may be defective in LSS

TU

Etiology

The inflammatory cascade: Stenosis acts as mechanical

compression of a nerve root may be a ‘‘primer’’ for a subsequent inflammatory response

Causes the radicular symptoms Chronic LSS to have periodic acute flares

of symptoms Chronically inflamed nerve root, with

increased mechanical sensitivity, can become perturbed by a new inflammatory precipitator, vascular changes, or degenerative instability (listhesis causing radicular symptoms)

TU

Management

Conservative Activity modification (limit extension-based activity) Assistive device for ambulation (walker) Medications (Tylenol, NSAIDs, neuromodulating agents,

and low dose opiates) Physical therapy and exercise

Interventional Epidural corticosteroid injections Surgery

TU

Prognosis

Natural history of LSS is not entirely known It is known that rapid neurological progression is

rare Chronic degenerative process Worsen with age

TU

Surgery vs Non-surgical

Studies of nonoperative therapy for lumbar stenosis report 15–45% improvement, 15–30% worsen, and the rest remain symptomatically about the same Outcomes at 1 and 4 years favored surgical management After 8–10 years, low back pain outcome, predominant

symptom (either back or leg pain) improvement, and satisfaction with their current status were similar

Leg pain relief, though, still favored those treated surgically

TU

Epidural Steroid Injection (ESI)

Epidural steroid injections are frequently used in nonoperative management regime Used as an adjunct to a comprehensive

rehabilitation program and not used in isolation Pain relief obtained with injections can facilitate

the patient’s tolerance of a rehabilitation program

TU

ESI

No clear evidence on when to initiate a trial, the frequency, nor duration of epidural steroid injection Literature does support their use for

predominantly radicular symptoms, especially acutely, and less for axial symptoms.

TU

ESI

‘‘Series of three’’: No literature support for this If one well-placed injection is not effective, then it

is unlikely that a second or third administered in the same location will be

However, potentially a different route of administration could be utilized for a second injection

TU

ESI

Mechanisms of pain relief of corticosteroids: Inhibition of nerve root edema Improved microcirculation Reduced ischemia Inhibition of prostaglandin synthesis Non-inflammatory action of direct inhibition of C-

fiber neuronal membrane excitation

TU

Different Approaches

Interlaminar Transforaminal Caudal Interlaminar with catheter Particulate vs non-particulate steroids Conflicting study results

TU

Different Approaches

Interlaminar Transforaminal Caudal Interlaminar with catheter Particulate vs non-particulate steroids Conflicting study results

TU

Different Approaches

Most studies noted: Short-term benefit ranging from 1 week to 2

months of relief One demonstrated a longer term benefit with up

to 10 months of relief Studies Varied in different approaches

TU

Different Approaches

Unilateral single dermatome symptoms, or post-laminectomy: Transforaminal

Particulate: risk of arterial thrombosis Non-particulate: no risk of thrombosis May be superior for

radiculitis/radiculopathy

Bilateral, non-specific symptoms: Interlaminar

Paramedian approach Catheter

Particulate Severe LSS, Post-laminectomy: Caudal

TU

Interlaminar

TU

Transforaminal

TU

Caudal

TU

Conclusion

Limited research evaluating the appropriate use of lumbar ESIs specifically to treat LSS Specific conclusions cannot be drawn There is no information to conclude which

injection technique is most efficacious

TU

Take Home

Trial Conservative management Surgical candidate? Failed conservative management? May trial ESI Various approaches to place the medication Trial and error for patient

TU

Surgical Options Direct decompression Open Vs. Minimally invasive

Indirect decompression X-stop Fusion TLIF XLIF ALIF *Interspinous fusion*

OH(IO)!! My Aching Back! - Lumbar Stenosis, Surgical DecompressionWilliam James Thoman, MD

THOMAN

Patient Selection

Claudication Stable Vs. unstable spine Flexion and extension x-rays

General health of patient Bone quality Back pain

THOMAN

Open decompression(laminectomy)

Standard approach Leg symptoms worse than back pain May use diagnostic injection

Stable spine on dynamic films Normal lordotic spine Advance age Poor bone quality

THOMAN

Open decompression(laminectomy)

Advantages Direct visualization Proven test of time Cannot tolerate fusion

Disadvantages Increase risk of infection Retraction injury?

Longer recovery due to pain from incision Iatrogenic instability

THOMAN

Minimally Invasive Decompression

Similar indication as open May be safe option for patient with stable

listhesis or mild instability Loss of some of the lordosis Maintain posterior tension band

Advance age Poor bone quality

THOMAN

Minimally Invasive Decompression

THOMAN

Minimally Invasive Decompression

Advantages (Anecdoctal) Decreased blood loss Decreased infection rate Decreased post-operative pain Decreased medication use Decreased hospital stay Decreased cost Decreased operative time

Depends on surgery and patient

Disadvantages Steep learning curve Understanding the anatomy

THOMAN

Indirect Decompression

X-stop Lumbar stenosis, foraminal stenosis

Fusion (TLIF, ALIF, XLIF, *Interspinous fusion*) Collapse disc space Spondylolisthesis Stable Unstable

Foraminal stenosis Back Pain?

THOMAN

X-stop

Interspinous distraction spacer Patient get relief when they lean forward

Distract bulging ligament Advantages

MIS procedure which is quick Elderly and sickly patient

Disadvantages Temporary

*Interspinous fusion devices* Similar to x-stop Opening for biologic products May be good for patient with slight listhesis or slight instability May be in addition to MIS decompression

THOMAN

X-stop

THOMAN

Lumbar Spinal Stenosis:To fuse or not to fuse?

Elizabeth Yu, MD

Indications Symptomatic spinal stenosis WITH: Spondylolisthesis Scoliosis Destabilization Greater than 50% of the facet joint is compromised Recurrent lumbar spinal stenosis with additional

resection

http://www.dartmouth.edu/sport-trial/whatissport.htm

YU

Spondylolisthesis

SPORT trial Multicenter study (13) LSS with spondylolisthesis Failed 12 weeks nonoperative treatment Outcomes: 6 weeks, 3 and 6 months, 1 and 2 years Short form-36: body pain and physical function Oswestry disability index

304 randomized, 303 observational cohorts Intention-to-treat analysis: no difference As-treated analysis: both cohorts showed significant

improvement in the surgical group up to 2 years (SF-36, ODI)

As-treated cohort: operative treatment had greater improvement in pain and function over 2 years than those treatment nonoperatively

YU

4 year follow up Maintenance of greater pain relief and

improvement in function of patient treated operatively VS. nonoperatively

YU

Fuse or not?

Herkowitz et. al. Prospective comparative study 50

patients Lumbar spinal stenosis with

spondylolisthesis 3 year follow up

Decompression VS. decompression with noninstrumented fusion Clinical improvement in pain and

neurogenic symptoms significantly better in fusion group

http://www.medscape.com/viewarticle/446146_3

YU

Instrument or not?

Fischgrund et. al. Prospective RCT 76 patients Lumbar spinal stenosis with

spondylolisthesis 3 year follow up

Decompression with noninstrumented fusion VS. decompression with instrumented fusion 83% fusion rate with

instrumentation VS. 45% without instrumentation HOWEVER no significant

difference in clinical outcome of pain and neurogenic symptoms

YU

Scoliosis

Progression of curve Concern for continued

progression with decompression alone

Stiffness of curve Overall sagittal and coronal

balance Concavity of curve Distraction may be necessary

YU

Case 54 year old male who neurogenic claudication. 50% back pain with start up pain 50% bilateral thigh pain with ambulation and

standing Temporary relief from ESI injections

YU

3 months postoperatively

YU

Discussion and Questions