Canal Stenosis

Anatomy of the Spine

Understanding your spine: Helpful Terms

Extension occurs when standing

Flexion Occurs when sitting or bending forward

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

Bone (Facet Joint)

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

Literature Review 66-100% 18-52% 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

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

Disease Burden of LSS

Lack of activity may lead to: Obesity General physical deterioration Depression/other psychological problems Worsening of co-morbidities

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 Transforaminal root block Facet joint injection

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

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

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