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Chris Dowding Half Day Feb 16 2012.  About ¾ of all individuals will experience low back pain at some time in their lives; usually, it resolves in a.

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Presentation on theme: "Chris Dowding Half Day Feb 16 2012.  About ¾ of all individuals will experience low back pain at some time in their lives; usually, it resolves in a."— Presentation transcript:

1 Chris Dowding Half Day Feb

2  About ¾ of all individuals will experience low back pain at some time in their lives; usually, it resolves in a matter of weeks.  Low back pain is the leading cause of disability in people younger than 50 years of age.  LBP - M=F  Peak incidence between 35 and 50 years of age  Primary causes of low back pain Muscle strain or ligament sprain Facet joint arthropathy Discogenic pain or Annular tears Spondylolisthesis Spinal stenosis

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4  First described by Verbiest patients with syndrome of the following:  Lumbar canal narrowing  Neurogenic spinal claudication  Radicular pain  Motor weakness in lower limb

5  Spinal Stenosis Narrowing of the spinal canal, resulting in a clinical syndrome of leg dominant pain  Primary subtypes Central canal stenosis Subarticular stenosis (area under facet joints) Neural foramina stenosis  Symptoms are caused by compression of the nerve roots  Results in neurogenic claudication

6  Neurogenic claudication Discomfort or pain that radiates from the spinal area into the buttocks and frequently into thigh and lower leg

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8 Pattern 1Pattern 2Pattern 3Pattern 4 RegionBack Leg Worse with:FlexionExtensionMovementExtension Relief with: Fast:Extension Slow: Nil Usually flexion Fast: Posturing Slow: Nil Flexion Timing: Constant or Intermittent IntermittentConstantIntermittent Neuro:Normal PresentNormal Generator: Degenerative disc; soft tissues Facet arthritis; soft tissues Disc herniation Spinal stenosis

9 Symptoms/FindingsNeurogenic Claudication Vascular Claudication PainDermatomalMuscle grip Sensory LossDermatomalStocking Worse with:Variable exercise, standing Fixed amount of exercise Relief with rest:Slow, positionalImmediate Foot pallor (elevation)NoneMarked PulsesNormalDecreased/absent

10 Claudication

11  Spinal Stenosis Narrowing of spinal canal due to:  Degenerative  (most common)  Developmental  Congenital disorders  Post traumatic  Steroids  Post-surgical  Certain disorders

12  Narrowing is secondary to arthritis Typically following order  Disc degeneration  Facet osteoarthritis  Flavum hypertrophy Symptoms develop around 60 yo

13 Two Components: 1. Outer rim of fibrocartilage called the annulus fibrosus (attaches to cartilaginous end plate) Connects vertebral bodies in a fibrocartilaginous joint (no capsule, little motion) 2. Facet (Zygapophyseal) joints

14  Fibrocartilaginous Collagen, water, Proteoglycans  Annulus Fibrosus Obliquely oriented collagen Type I collagen Outer rim contains free nerve endings  Central Nucleus Pulposus 88+% water, high polysaccharide content No blood vessels or nerves Type II collagen

15  Function spinal motion and stability.  Disk is avascular. Nutrients fluid via diffusion through pores in the hyaline cartilage end plates  As Disks ages Decreased water content, increased collagen.

16 Begins roughly third decade of life. Characterized by a decline in proteoglycan concentration with resultant loss of hydration and a decreased number of viable cells L4-5 and L5-S1 are the disks that typically degenerate first

17 Disk height decreases, resulting in alteration of the segmental spinal biomechanics Increasing wear on facet joints The precise cause(s) of disk degeneration are unclear, and there are several potential contributors – Comorbidities like diabetes, vascular insufficiency, and smoking are potentially associated with disk degeneration – There appears to be a genetic component to disk degeneration

18  Loss of disc height  Infolding of flavum  Increased stress across facets  Facet OA and hypertrophy  Osteophytes and capsule thickening  Cysts

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20  Spondylolithesis (+/- spondylolysis) Can result in stenosis Back pain is primary symptom  Neurogenic claudication is secondary

21  Narrowing of canal due to growth disturbance of posterior elements Congenitally short pedicles Often present in 20’s

22  Constellation of symptoms Leg pain Difficulty ambulating  Comfortable sitting  Pain with prolonged walking Neurologic deficits

23  Age  Pain Location Timing Characteristics  Aggravating or relieving factors?  Previous therapy?  PMHx  Social History/Occupation  Meds/Allergies  Functional Inquiry How far can you walk? Can they bike?

24  Night sweats  Fever  Weight loss  Bowel/Bladder  History of cancer  Immunosuppression  Saddle anaesthesia  Sexual dysfunction  Age > 60  History of IVDU  Chronic infections  Rest/night pain

25  Vitals  Inspect Gait Leg length Trendelenburg test Spinal alignment  Palpate Spinous processes Paraspinal muscles Greater trochanters

26  ROM Spine flexion, extension, rotation, lateral bend Hip flexion, extension, rotation  Pain with etxension, relieved by flexion  Neuro Strength Sensation Reflexes  Half of patients with symptomatic stenosis have motor or sensory deficits  Usually mild

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28  Romberg maneuver Patient stands with eyes closed Look for unsteadiness, wide based stance Indicates damaged proprioception

29  Lumbar x-rays +/- spondylolithesis Extent of disc narrowing Foramina osteophytes  CT/MRI Can illustrate reductions in cross sectional diameter of central canal or foramina Useful for pre-op planning or assessing candidacy for epidural injections Large number of people may have radiologic findings but are asymptomatic

30  Centrally  Lateral recess & neural foramina  Degeneration of Disk Facets (hypertrophy) Synovial cysts Joint capsule Thickening of ligamentum flavum Osteophytes

31  Differential is broad Some non-spinal causes to keep in mind  Vascular claudication  Hip arthritis  Diabetes (peripheral neuropathy)

32  Cramping/tightness in calf  PVD (skin ulcers, trophic changes)  Diminished pulses  Relieved by cessation of activity Versus neurogenic (flexion or sitting down) Capable of activity while flexed  shopping cart  Cycling  walking uphill

33  Groin pain  Referred pain in thigh increased with activity  Internal rotation diminished  XR - OA

34  Glove & stocking distribution  Not affected by activity level

35  Physical therapy  Abdominal strengthening  Biking  Brace/corset  Slight lumbar flexion  Limit hours worn per day  Avoid atrophy  Pain pyramid  Tylenol  NSAIDS  Narcotics

36  Epidural injections  Theory is that compression of nerve roots causes inflammation and thus symptoms  Cortocosteroids to reduce inflammation  Evidence is not convincing one way or another  Although this practice is increasing

37  Natural course of disease Pain / function of patients with lumbar stenosis  remains unchanged in majority patients After one year of non-op management the majority of patients will be neither worse nor better Rapid decline uncommon  Therefore prophylactic treatment non indicated Improvement is also uncommon  If patient is miserable at baseline, non-op management may not be appropriate

38  Progressive neurologic deficit  Intractable pain  Persistent impairment and functional limitation  Confirmation by imaging  LBP is not alleviated with surgery!

39  Goals of surgery Decompress central canal and neural foramina  Options Laminectomy ** Partial facetectomy ** Lumbar arthrodesis  +/- Instrumentation Interspinous distraction MIS

40 Edward N. Hanley Jr., MD, Spinal Stenosis, Charlotte

41  Maine lumbar spine study 119 patients  67 treated surgically  52 treated nonsurgically After 4 years 70% of surgically treated and 52% of nonsurgically treated reported that their predominant pain was better. Satisfaction 63% of surgically treated and 42% of nonsurgically treated.  Atlas et al. Spine

42  Design RCT 4-university hospitals 94 patients Surgical  Laminectomy 10 patients also had transpedicular fusion Outcome  Oswestry Disability Index (0-100)  Intensity of pain (0-10)  Walking ability – self-reported  6,12&24 months

43  Inclusion Criteria Back pain radiation to lower limb/buttock Fatigue loss sensation aggravated by walking Persistent pain without progressive neurologic dysfunction SAC (sagital) < 10 mm Duration of symptoms > 6 months Signs & symptoms correspond to segmental radiographs Severity of disease to justify surgical/non- surgical rx

44  Exclusion Severe LSS intractible pain Progressive neurologic dysfunction Mild LSS with clinical signs feeble enough to exclude surgical treatment Spondylolysis and spondylolytic disease Earlier back operation due to stenosis Herniated disc during last 12 months Another spinal disorder Intermittent claudication due to PVD Severe OA of L/E Neurologic disease with impaired function of L/E Psych Alcoholic

45  Randomization: Central office computer generated blocks variable size for each hospital Physician phoned central office after baseline exam, questionnaire completed

46  Intervention Surgical group  Segmental decompression  Facetectomy  Instability treated at surgeon discretion  Fusion of lumbar spine +/- instrumentation  Degenerative listhesis warranting procedure  Brochure for nature of disease, symptoms and activities Non-operative group  Physiatrist followed throughout  Physiotherapist followed  Exercises  Brochure for nature of disease, symptoms and activities

47  Walking ability Reported & measured No significant difference between 2 groups

48  Conclusion Those undergoing surgery reported greater improvement over non-operative treatment Benefit diminished over time  Issues Longer f/u needed Surgical treatment differed Selected bias from exclusion criteria  Screened for those who may benefit from surgery

49  SPORT Trial  “Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis”  Inclusion 12 weeks of symptoms typical to stenosis  Exclusion Spondylolithesis

50  2 cohorts A) randomization  Op vs non-op B) observational  Elective op vs. elective non-op  Outcomes Bodily pain and physical function  SF-36  Modified Oswestry disability index  6 weeks, 3 months, 6 months, 1 year, 2 years

51  Randomized cohort En bloc at 13 institutions 289 patients  Interventions Op:  “Standard posterior decompressive laminectomy: Non Op:  At least physical therapy, education or counseling  NSAIDs if tolerated

52  Results As-treated  Significant advantage of operative management at 6 weeks, peaked at 6 months and lasted for 2 years  Significant across all outcomes ITT  Significant difference in pain scale favouring operative management  No difference in physical function rating or Oswestry disability scale

53  Issues: Significant cross-over:  “At 2 years, 67% of patients who were randomly assigned to surgery had undergone surgery, whereas 43% of those who were randomly assigned to receive nonsurgical care had also undergone surgery.”  Excludes spondylolithesis  Doesn’t tell us anything about to fuse or not to fuse

54 Claudication and Spinal Stenosis Non-op Educate, Analgesia, Exercise (Core, Aerobic), Physio, Lifestyle, Advise CES Epidural Posterior Decompression (Laminectomy, Foraminotomy) Leg DominantSignif. Back Pain No Instabilit y Instability Degen. Spondylolisthesis, Lat. Listhesis, Scoliosis No Instabilit y Fusion (All Decompressed Levels + ? Additional Levels) Non-instrumented, Instrumented (Pedicle Screws, TLIF, PLIF) Pt. Choice Medical Comorbidity Unsure of Diagnosis Willing to wait Assess Additional Fusion Levels Bone Scan, MRI, Discogram Relative Indication Claudication Spinal Stenosis From Spine rounds Civic Last Updated: Oct 18, 2007 Predictors of Good Surgical Outcome Leg Dominant Pain Not Foraminal ? Degree of Stenosis ? # of Levels ? No scoliosis No WSIB / Disability No Blame No Hysteria No Comorbidity < 6 months pain Baseline fitness ? Surgery for pain as opposed to for neuro deficit (Surgery as P3 to Within Weeks) (Note: Facet Sparing, If No Fusion) Cauda Equina Syndrome (Acute: Surgery as a P2, Chronic: Surgery Within Weeks) Progressive Weakness ? No Surger y

55 1. Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006; 443: Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med 2008; 358: Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine 2007;32: Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008;358:


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