Presentation on theme: "Spinal Stenosis/Neurogenic Claudication"— Presentation transcript:
1 Spinal Stenosis/Neurogenic Claudication Chris DowdingHalf Day Feb
2 Low Back PainAbout 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=FPeak incidence between 35 and 50 years of agePrimary causes of low back painMuscle strain or ligament sprainFacet joint arthropathyDiscogenic pain or Annular tearsSpondylolisthesisSpinal stenosis
4 What is Spinal Stenosis? First described by Verbiest 19547 patients with syndrome of the following:Lumbar canal narrowingNeurogenic spinal claudicationRadicular painMotor weakness in lower limb
5 Definition Spinal Stenosis Primary subtypes Narrowing of the spinal canal, resulting in a clinical syndrome of leg dominant painPrimary subtypesCentral canal stenosisSubarticular stenosis (area under facet joints)Neural foramina stenosisSymptoms are caused by compression of the nerve rootsResults in neurogenic claudication
6 Definition Neurogenic claudication Discomfort or pain that radiates from the spinal area into the buttocks and frequently into thigh and lower leg
7 Pattern 4 Leg dominant pain Pain is brought on by activity and relieved by rest in flexion.Pain is always intermittent. Neurological symptoms usually absent at rest.Vascular – worse with walking, relief with rest, poor or absent pulsesNeurogenic – worse with walking or standing, relief with sitting or flexion, physical exam normal, pulses present
8 Claudication Pattern 1 Pattern 2 Pattern 3 Pattern 4 Region Back Leg Worse with:FlexionExtensionMovementRelief with:Fast:ExtensionSlow: NilUsually flexionFast: PosturingTiming:Constant or IntermittentIntermittentConstantNeuro:NormalPresentGenerator:Degenerative disc; soft tissuesFacet arthritis; soft tissuesDisc herniationSpinal stenosisRegion – location where pain is at its worst. Doesn’t mean that pain is not present elsewhere as well.Again, reminder that this classification system is based on pattern recognition and not necessarily anatomic site or pathologic process. The overwhelming majority of patients with Pattern 1 and Pattern 2 back pain are not surgical candidates. If physical rehab can improve or get rid of pain, the specific anatomic pain generator does not matter.With pattern 3 and pattern 4, surgical management becomes more likely and identification of an anatomic pain generator becomes very important.
9 Claudication Symptoms/Findings Neurogenic Claudication Vascular ClaudicationPainDermatomalMuscle gripSensory LossStockingWorse with:Variable exercise, standingFixed amount of exerciseRelief with rest:Slow, positionalImmediateFoot pallor (elevation)NoneMarkedPulsesNormalDecreased/absent
11 Etiology Spinal Stenosis Narrowing of spinal canal due to: Degenerative(most common)DevelopmentalCongenital disordersPost traumaticSteroidsPost-surgicalCertain disorders
12 Degenerative Stenosis Narrowing is secondary to arthritisTypically following orderDisc degenerationFacet osteoarthritisFlavum hypertrophySymptoms develop around 60 yo
13 Intervertebral Joints 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 Intervertebral Disks Collagen, water, Proteoglycans Fibrocartilaginous Annulus FibrosusObliquely oriented collagenType I collagenOuter rim contains free nerve endingsCentral Nucleus Pulposus88+% water, high polysaccharide contentNo blood vessels or nervesType II collagenStructure deforms when pressure is put on vertebral column as in weight bearingActs as a shock absorberAnnulus totally encloses the nucleus and keeps it under constant pressureAs you get older, the H2O content decreases and the nucleus becomes more fibrocartilaginous, therefore less easily deformable and more easily damagedNucleus, when under extreme pressure, can herniate or extrude from the disc in a posterior or posterior-lateral directionUsually occurs in cervical or lumbar regionNucleus can put pressure on spinal nerve causing refereed symptoms (motor and sensory)Can cause pressure on cord itself if true posterior
15 Intervertebral Disks Function Disk is avascular. As Disks ages spinal motion and stability.Disk is avascular.Nutrients fluid via diffusion through pores in the hyaline cartilage end platesAs Disks agesDecreased water content, increased collagen.
16 Disk Degeneration Begins roughly third decade of life. Characterized by a decline in proteoglycan concentration with resultant loss of hydration and a decreased number of viable cellsL4-5 and L5-S1 are the disks that typically degenerate first
17 Degenerative DisksDisk height decreases, resulting in alteration of the segmental spinal biomechanicsIncreasing wear on facet jointsThe precise cause(s) of disk degeneration are unclear, and there are several potential contributorsComorbidities like diabetes, vascular insufficiency, and smoking are potentially associated with disk degenerationThere appears to be a genetic component to disk degeneration
18 Degenerative Stenosis Loss of disc height Infolding of flavum Increased stress across facets Facet OA and hypertrophy Osteophytes and capsule thickening Cysts
20 Degenerative Stenosis Spondylolithesis (+/- spondylolysis)Can result in stenosisBack pain is primary symptomNeurogenic claudication is secondary
21 Developmental Stenosis Narrowing of canal due to growth disturbance of posterior elementsCongenitally short pediclesOften present in 20’s
22 Presentation Constellation of symptoms Leg pain Difficulty ambulating Comfortable sittingPain with prolonged walkingNeurologic deficits
23 History Age Pain Aggravating or relieving factors? Previous therapy? LocationTimingCharacteristicsAggravating or relieving factors?Previous therapy?PMHxSocial History/OccupationMeds/AllergiesFunctional InquiryHow far can you walk?Can they bike?The two most important questions on history are: Back dominant vs Leg dominant; Constant vs intermittentCharacteristics of pain – dull, sharp, electric, shooting. Numbness, tingling.Relief with certain posturing
24 Red Flags Night sweats Saddle anaesthesia Fever Sexual dysfunction Weight lossAge > 60Bowel/BladderHistory of IVDUHistory of cancerChronic infectionsImmunosuppressionRest/night painPain not relieved when patient lies down.
26 Physical Exam ROM Neuro Spine flexion, extension, rotation, lateral bendHip flexion, extension, rotationPain with etxension, relieved by flexionNeuroStrengthSensationReflexesHalf of patients with symptomatic stenosis have motor or sensory deficitsUsually mild
28 Special Tests Romberg maneuver Patient stands with eyes closed Look for unsteadiness, wide based stanceIndicates damaged proprioception
29 Imaging Lumbar x-rays CT/MRI +/- spondylolithesis Extent of disc narrowingForamina osteophytesCT/MRICan illustrate reductions in cross sectional diameter of central canal or foraminaUseful for pre-op planning or assessing candidacy for epidural injectionsLarge number of people may have radiologic findings but are asymptomaticSLR defined as the reproduction of sciatica symptoms when the hip is flexed passively with a straight leg between 30 and 70 degrees.The diagnostic odds ratio remains low because surgical patients WITHOUT a disc herniation are likely to have a positive SLR.Straight leg raising, by itself, can produce pain from a variety of sources, including myogenic pain, ischialburisitis, annular tear, and hamstring tightness, as well as herniated disc.
30 Location of stenosis Centrally Lateral recess & neural foramina Degeneration ofDiskFacets (hypertrophy)Synovial cystsJoint capsuleThickening of ligamentum flavumOsteophytes
31 Identifying the cause Differential is broad Some non-spinal causes to keep in mindVascular claudicationHip arthritisDiabetes (peripheral neuropathy)
32 Vascular Claudication Cramping/tightness in calfPVD (skin ulcers, trophic changes)Diminished pulsesRelieved by cessation of activityVersus neurogenic (flexion or sitting down)Capable of activity while flexedshopping cartCyclingwalking uphill
33 Hip Arthritis Groin pain Referred pain in thigh increased with activityInternal rotation diminishedXR - OA
34 DiabetesGlove & stocking distributionNot affected by activity level
36 Conservative Management Epidural injectionsTheory is that compression of nerve roots causes inflammation and thus symptomsCortocosteroids to reduce inflammationEvidence is not convincing one way or anotherAlthough this practice is increasing
37 Natural History? Natural course of disease Pain / function of patients with lumbar stenosisremains unchanged in majority patientsAfter one year of non-op management the majority of patients will be neither worse nor betterRapid decline uncommonTherefore prophylactic treatment non indicatedImprovement is also uncommonIf patient is miserable at baseline, non-op management may not be appropriate
38 Surgical indications Progressive neurologic deficit Intractable pain Persistent impairment and functional limitationConfirmation by imagingLBP is not alleviated with surgery!
39 Lumbar Stenosis: So when should we operate? Goals of surgeryDecompress central canal and neural foraminaOptionsLaminectomy **Partial facetectomy **Lumbar arthrodesis+/- InstrumentationInterspinous distractionMIS
40 Algorithm?Edward N. Hanley Jr., MD, Spinal Stenosis, Charlotte
41 Treatment – Spinal Stenosis Maine lumbar spine study119 patients67 treated surgically52 treated nonsurgicallyAfter 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. SpineOver time, relative benefits of surgery declined but still remained superior to nonsurgical managementBetter, same or worse rating scale.
42 Malmivaara 2007 Design RCT 4-university hospitals 94 patients Surgical Laminectomy 10 patients also had transpedicular fusionOutcomeOswestry Disability Index (0-100)Intensity of pain (0-10)Walking ability – self-reported6,12&24 months
43 Malmivaara 2007 Inclusion Criteria Back pain radiation to lower limb/buttockFatigue loss sensation aggravated by walkingPersistent pain without progressive neurologic dysfunctionSAC (sagital) < 10 mmDuration of symptoms > 6 monthsSigns & symptoms correspond to segmental radiographsSeverity of disease to justify surgical/non- surgical rx
44 Malmivaara 2007 Exclusion Severe LSS intractible pain Progressive neurologic dysfunctionMild LSS with clinical signs feeble enough to exclude surgical treatmentSpondylolysis and spondylolytic diseaseEarlier back operation due to stenosisHerniated disc during last 12 monthsAnother spinal disorderIntermittent claudication due to PVDSevere OA of L/ENeurologic disease with impaired function of L/EPsychAlcoholic
45 Malmivaara 2007 Randomization: Central office computer generated blocks variable size for each hospitalPhysician phoned central office after baseline exam, questionnaire completed
46 Malmivaara 2007 Intervention Surgical group Segmental decompression FacetectomyInstability treated at surgeon discretionFusion of lumbar spine +/- instrumentationDegenerative listhesis warranting procedureBrochure for nature of disease, symptoms and activitiesNon-operative groupPhysiatrist followed throughoutPhysiotherapist followedExercises
47 Malmivaara 2007 Walking ability Reported & measured No significant difference between 2 groups
48 Malmivaara 2007 Conclusion Issues Those undergoing surgery reported greater improvement over non-operative treatmentBenefit diminished over timeIssuesLonger f/u neededSurgical treatment differedSelected bias from exclusion criteriaScreened for those who may benefit from surgery
49 Weinstein 2008SPORT Trial“Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis”Inclusion12 weeks of symptoms typical to stenosisExclusionSpondylolithesis
50 Weinstein 2008 2 cohorts Outcomes A) randomization B) observational Op vs non-opB) observationalElective op vs. elective non-opOutcomesBodily pain and physical functionSF-36Modified Oswestry disability index6 weeks, 3 months, 6 months, 1 year, 2 years
51 Weinstein 2008 Randomized cohort Interventions En bloc at 13 institutions289 patientsInterventionsOp:“Standard posterior decompressive laminectomy:Non Op:At least physical therapy, education or counselingNSAIDs if tolerated
52 Weinstein 2008 Results As-treated ITT Significant advantage of operative management at 6 weeks, peaked at 6 months and lasted for 2 yearsSignificant across all outcomesITTSignificant difference in pain scale favouring operative managementNo difference in physical function rating or Oswestry disability scale
53 Weinstein 2008 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 spondylolithesisDoesn’t tell us anything about to fuse or not to fuse
54 Claudication Spinal Stenosis Claudication and Spinal Stenosis Non-op Educate, Analgesia, Exercise (Core, Aerobic), Physio, Lifestyle, Advise CESCauda Equina Syndrome(Acute: Surgery as a P2, Chronic: Surgery Within Weeks)Leg DominantSignif. Back Pain? No SurgeryPt. ChoiceMedical ComorbidityUnsure of DiagnosisWilling to waitProgressive WeaknessNo InstabilityInstabilityNo Instability(Surgery as P3 to Within Weeks)Degen. Spondylolisthesis, Lat. Listhesis, ScoliosisPosterior Decompression (Laminectomy, Foraminotomy)Epidural(Note: Facet Sparing, If No Fusion)Predictors of Good Surgical OutcomeRelative IndicationAssess Additional Fusion LevelsLeg Dominant PainNot Foraminal? Degree of Stenosis? # of Levels? No scoliosisNo WSIB / DisabilityNo BlameNo HysteriaNo Comorbidity< 6 months painBaseline fitness? Surgery for pain as opposed to for neuro deficitBone Scan, MRI, DiscogramFusion (All Decompressed Levels + ? Additional Levels)Non-instrumented, Instrumented (Pedicle Screws, TLIF, PLIF)From Spine rounds CivicLast Updated: Oct 18, 2007
55 RefsAtlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006; 443:198.Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med 2008; 358:818.Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine 2007;32:1-8.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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