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SPINAL STENOSIS
Jung U. Yoo, M.D.Professor and Chairman
Department of Orthopedics and Rehabiliatation
Oregon Health and Science University
STABILITY
• ORDINARY ACTIVITIES MAY GENERATE OVER 1000LB OF FORCE
MOTION
NEUROPROTECTION
• SPINAL CORD• NERVE ROOTS
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
STENOSIS
STENOSIS
• Compresses the exiting nerve root
FORAMINAL STENOSIS
CANAL SHAPE
• Round
• Triangular
• Trefoiled (15%)
• Trefoiled & asymmetric
DEGENERATION & STENOSIS
PREVALENCE
• Most common indication for spinal surgery in patients over 60 y.o.
• 400,000 Americans are estimated to have spinal stenosis
STENOSIS
• Narrowing of the spinal canal or neuroforamina
• causing a symptomatic compression of the neural element.
SYMPTOMS
• Neurogenic claudication
• Radicular pain
• Weakness
• Sensory abnormalities
• Back pain
PHYSICAL FINDINGSPhysical 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. 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
POSTURE
AMBULATION
DIFFERENTIAL DIAGNOSIS
• Vascular claudication
• Osteoarthritis of hip or knee
• Lumbar disc protrusion
• Intraspinal tumor
• Unrecognized neurologic disease
• Peripheral neuropathy
• Root symptoms• Unilateral• No claudication• Acute or chronic
FORAMINAL STENOSIS
• Claudication• Radicular pain• Weakness is rare• Acute or chronic
LATERAL RECESS STENOSISLATERAL RECESS STENOSIS
CENTRAL STENOSIS
• Varied presentation• Classically with
neurogenic claudication
• Some may only have back pain
• Rarely painless progressive weakness
DIAGNOSTIC TESTS
X-RAY
• Screening exam• Stenosis cannot be
diagnosed
X-RAY
• Instability such as scoliosis or listhesis
CT SCAN
• Difficult to diagnose stenosis
• Replaced by MRI• May be useful for those
who cannot have an MRI
CT SCAN
• Excellent bony detail
MRI
• Non-invasive• Soft tissue
visualization• Gold standard
MRI
• Sagittal images• Visualization of
foramen
• Excellent for intra-canal pathology
• Poor for foraminal pathology
• Replaced by MRI
MYELOGRAPHYMYELOGRAPHY
• Invasive• 1% spinal headache• Recurrent stenosis• Inability to obtain MRI
MYELOGRAPHYMYELOGRAPHY
MYELOGRAPHY
• Excellent visualization of spinal canal
CT-MYELOGRAPHY
• Excellent for recurrent stenosis
• Invaluable in surgical planning
CT-MYELOGRAPHY
MRI
• Expensive• Patient cooperation• Claustrophobia• Open MRI
EMG-NCS
• Differentiation between neuropathy and radiculopathy
• Acute active denervation vs. chronic denervation
TREATMENT
NONOPERATIVE RX
• Rest
• Analgesic
• Oral steroid
• Physical therapy
• Bracing
• Spinal injection
REST
• Short term activity modification for acute pain
• Long term activity modification is not recommended
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
• Transforaminal root block
• Facet joint injection
EPIDURAL STEROID
• Commonly prescribed• 50% short-term efficacy• Not as selective• May not require
fluroscope
TRANSFORAMINAL ROOT BLOCK
• Highly selective• Diagnostic as well as
therapeutic• Delivers medicine to
the floor of spinal canal
FACET INJECTION
• Facet for back pain• Not for radicular pain• May act as epidural in
40% of cases
SPINAL INJECTION
• Most effective for acute pain
• May not be indicated in cases of acute denervation or progressive motor loss
OPERATIVE TREATMENT
• Decompression of neural element
• Stabilization of unstable segment
“LAMINECTOMY”
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
FUSION
• Sagittal instability• Scoliosis• Iatrogenic pars defect• Greater than 50% facet
joint resection
INSTRUMENTATION
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