SPINAL STENOSIS

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SPINAL STENOSIS

• Jung U. Yoo, M.D.
• Professor and Chairman
• Department of Orthopedics and Rehabiliatation
• Oregon Health and Science University

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STABILITY

• ORDINARY ACTIVITIES MAY GENERATE OVER 1000LB OF
  FORCE

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MOTION
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NEUROPROTECTION

• SPINAL CORD
• NERVE ROOTS

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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

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STENOSIS
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STENOSIS
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FORAMINAL STENOSIS

• Compresses the exiting nerve root

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CANAL SHAPE

• Round
• Triangular
• Trefoiled (15)
• Trefoiled asymmetric

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DEGENERATION STENOSIS
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PREVALENCE

• Most common indication for spinal surgery in
  patients over 60 y.o.
• 400,000 Americans are estimated to have spinal
  stenosis

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STENOSIS

• Narrowing of the spinal canal or neuroforamina
• causing a symptomatic compression of the neural
  element.

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SYMPTOMS

• Neurogenic claudication
• Radicular pain
• Weakness
• Sensory abnormalities
• Back pain

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PHYSICAL FINDINGS

• Physical Finding Literature Review
• Limited lumbar extension 66-100
• Muscle weakness 18-52
• Sensory deficit 32-58
• Katz JN, et al Diagnosis of lumbar spinal
  stenosis. Rheum. Dis. Clin. North Am. 20471-483,
  1994

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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

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POSTURE
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AMBULATION
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DIFFERENTIAL DIAGNOSIS

• Vascular claudication
• Osteoarthritis of hip or knee
• Lumbar disc protrusion
• Intraspinal tumor
• Unrecognized neurologic disease
• Peripheral neuropathy

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FORAMINAL STENOSIS

• Root symptoms
• Unilateral
• No claudication
• Acute or chronic

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LATERAL RECESS STENOSIS

• Claudication
• Radicular pain
• Weakness is rare
• Acute or chronic

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CENTRAL STENOSIS

• Varied presentation
• Classically with neurogenic claudication
• Some may only have back pain
• Rarely painless progressive weakness

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DIAGNOSTIC TESTS
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X-RAY

• Screening exam
• Stenosis cannot be diagnosed

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X-RAY

• Instability such as scoliosis or listhesis

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CT SCAN

• Difficult to diagnose stenosis
• Replaced by MRI
• May be useful for those who cannot have an MRI

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CT SCAN

• Excellent bony detail

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MRI

• Non-invasive
• Soft tissue visualization
• Gold standard

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MRI

• Sagittal images
• Visualization of foramen

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MYELOGRAPHY

• Excellent for intra-canal pathology
• Poor for foraminal pathology
• Replaced by MRI

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MYELOGRAPHY

• Invasive
• 1 spinal headache
• Recurrent stenosis
• Inability to obtain MRI

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MYELOGRAPHY
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CT-MYELOGRAPHY

• Excellent visualization of spinal canal

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CT-MYELOGRAPHY

• Excellent for recurrent stenosis
• Invaluable in surgical planning

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MRI

• Expensive
• Patient cooperation
• Claustrophobia
• Open MRI

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EMG-NCS

• Differentiation between neuropathy and
  radiculopathy
• Acute active denervation vs. chronic denervation

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TREATMENT
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NONOPERATIVE RX

• Rest
• Analgesic
• Oral steroid
• Physical therapy
• Bracing
• Spinal injection

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REST

• Short term activity modification for acute pain
• Long term activity modification is not recommended

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ANALGESIC

• NSAIDS
• Tylenol
• Narcotics
• Neurontin

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Oral Steroid

• Effective for acute pain
• Short duration therapy
• ? Chronic or repeat tapering dose

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PHYSICAL THERAPY

• Avoid extension exercises acutely
• William Flexion Exercises
• Water aerobics
• Strengthening of weak muscle groups

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SPINAL INJECTIONS

• Epidural steroid
• Transforaminal root block
• Facet joint injection

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EPIDURAL STEROID

• Commonly prescribed
• 50 short-term efficacy
• Not as selective
• May not require fluroscope

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TRANSFORAMINAL ROOT BLOCK

• Highly selective
• Diagnostic as well as therapeutic
• Delivers medicine to the floor of spinal canal

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FACET INJECTION

• Facet for back pain
• Not for radicular pain
• May act as epidural in 40 of cases

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SPINAL INJECTION

• Most effective for acute pain
• May not be indicated in cases of acute
  denervation or progressive motor loss

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OPERATIVE TREATMENT

• Decompression of neural element
• Stabilization of unstable segment

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LAMINECTOMY
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DECOMPRESSION OF LATERAL RECESS

• Undercutting the ventral aspect of the facet
  joints and the associated ligamentum flavum.
• Medial facetectomy if necessary
• The traversing nerve root underneath the facet
  joint must be visualized

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FUSION

• Sagittal instability
• Scoliosis
• Iatrogenic pars defect
• Greater than 50 facet joint resection

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INSTRUMENTATION
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