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CANAL SHAPE
Round Triangular Trefoiled (15%) Trefoiled & asymmetric
STENOSIS
Narrowing of the spinal canal or neuroforamina causing a symptomatic compression of the neural element.
PATHOPHYSIOLOGY
Three-joint Complex
a large tripod with the disc as the front support and two facet joints as the back supports Any alteration in one of these joints can lead to damage to the others
Vertebra
Healthy
Nerve Root Intervertebral Disc
Stenotic
Trapped Nerve Root
Spinal Canal
Ligament Flavum
Vertebrae provide support for your head and body Discs act as shock absorbers Vertebra protects spinal cord Nerves have space and are not pinched
As we age, ligaments and bone can thicken Narrowing is called stenosis Narrowing impinges on nerves in spinal canal and nerve roots exiting to the legs Result - pain & numbness in back and legs
STENOSIS
PREVALENCE
Most common indication for spinal surgery in patients over 60 y.o. 400,000 Americans are estimated to have spinal stenosis
SYMPTOMS
Neurogenic claudication Radicular pain Weakness Sensory abnormalities Back pain
PHYSICAL FINDINGS
Physical Finding Limited lumbar extension Muscle weakness Sensory deficit
Katz JN, et al: Diagnosis of lumbar spinal stenosis. Rheum. Dis. Clin. North Am. 20:471-483, 1994
NEUROGENIC CLAUDICATION
Cardinal symptom of lumbar stenosis Progressive pain and/or paresthesia in the back, buttock, thigh and calves brought on by walking or standing, and relieved by sitting or lying down with hip flexion
DIFFERENTIAL DIAGNOSIS
Vascular claudication Osteoarthritis of hip or knee Lumbar disc protrusion Intraspinal tumor Unrecognized neurologic disease Peripheral neuropathy
NONOPERATIVE TREATMENT
Rest Analgesic Oral steroid Physical therapy Bracing Spinal injection
REST
Short term activity modification for acute pain Long term activity modification is not recommended
Treatment of Degenerative Lumbar Spinal Stenosis, Agency for Health and Quality 2004
ANALGESIC
NSAIDS Tylenol Narcotics Neurontin
Oral Steroid
Effective for acute pain Short duration therapy ? Chronic or repeat tapering dose
PHYSICAL THERAPY
Avoid extension exercises acutely William Flexion Exercises Water aerobics Strengthening of weak muscle groups
SPINAL INJECTIONS
EPIDURAL STEROID
Commonly prescribed 50% short-term efficacy Not as selective May not require fluroscope
SPINAL INJECTION
Most effective for acute pain May not be indicated in cases of acute denervation or progressive motor loss
OPERATIVE TREATMENT
LAMINECTOMY
FUSION
Sagittal instability Scoliosis Iatrogenic pars defect Greater than 50% facet joint resection
INSTRUMENTATION
References
Jung U. Yoo, M.D. Spinal Stenosis. Department of Orthopedics and Rehabiliatation: Oregon Health and Science University. Hazem Eltahawy. Lumbar Spinal Stenosis: Symptoms and Treatment. University Neuologic Surgeons