2. Causes of Stenosis Degenerative spondylo-listhesis Facet subluxation and hypertrophy Pagets disease Tumour Facet joint cyst Congenital- achondroplasia Scoliosis with lateral shift

3. Differential Diagnosis Vascular Claudication Hip OA Lumbar disc protrusion MS Tumour AV malformation Peripheral Neuropathy

4. Zones of nerve compression in Spinal Stenosis

5. Types of Stenosis Central: No pain, but legs ‘slow’ on walking Lateral recess: Unilateral leg pain, increased on walking.

6. Diagnosis Congenital Stenosis Infectious Stenosis Traumatic Stenosis

7. Diagnosis Degenerative Stenosis

8. JT. Right L45 Facet Joint Cyst. Severe Right sided leg pain and Low back pain Treated with decompression surgery

9. 65/M. Pagets Disease causing stenosis. Long standing LBP. Neurogenic claudication distance 50 yards

10. Symptoms 70% also have back pain Leg pain worse on walking and standing and eased on sitting or bending forwards Can cycle or walk leaning forwards on a trolley Gradually Progressive Increased on walking on hard surfaces, down an incline and in high heels

11. Tandem Stenosis In 15-20% of patients both cervical and lumbar stenosis are present Hoffman Sign positive. Heel-Toe gait – poor balance. Usually operate on the neck first

12. Signs Minimal!! One of the hallmarks of these patients is that they have no spinal tenderness, a full range of movement, SLR is normal and there is no neuro-deficit. Diagnosis is purely in the history

13. Spinal Stenosis- what’s new? Diagnosis often missed as no positive examination findings Diagnosis on history: difficulty walking with cramps in legs, eased on sitting Epidural injections- short term relief Surgery- Now never do a laminectomy alone- alters the biomechanics Always add dynamic stabilization- excellent outcomes

14. When to refer? Pain uncontrolled in primary care Walking getting progressively worse Surgery is straight forward No increase in surgical risk due to age.

15. Treatment Conservative -Rest, analgesics, anti- inflammatories, oral steroids, antispasmodics, physiotherapy, weight loss, steroid injections

16. T reatment- Laminectomy and Dynamic Stabilization( my preferred option)

17. Complications and Outcomes of Surgery 2-4% risk of infection, CSF leak, and Neural Injury No death, or paralysis in 17 years of practise in over 4000 cases Surgery has become safer, outcomes better and recovery quicker 80% better on average Increased age alone does not result in increased risk of surgery

18. Dynamic Stabilization 29 elderly patients with degenerative scoliosis. Decompressive laminectomy and dynamic stabilization without fusion. (Dynesis) 54 month mean follow up. Oswestry score improvement of 51.6%. 51.7% improvement in VAS leg pain, and 57.8% for VAS back pain. Sivestre M, Lolli F, Bakaloudis G. Dynamic stabilization for degenerative lumbar scoliosis in elderly patients. Spine 2010 Jan

19. Dynamic Stabilization 100 patients. Decompression and pedicle screw based dynamic stabilization (Cosmic) Improved disability scores. ODI pre-op of 51, and post-op of 21. Improvement in pain. VAS pre-op 6.5 and post-op 2.1. SF-36 outcomes were also improved. Stoffel M, Behr M, Reinke A, Meyer B. Pedicle screw-based dynamic stabilization of the thoracolumbar spine with the Cosmic-system: a prospective observation. Achta Neurochirurg 2010 May