Lumbar Stenosis

Posted bythespinebookadminPosted inDegenerative, Topics

Background 

  • Narrowing of lumbar spinal canal due to bony or soft tissue structures 
  • Most common cause of lumbar spine sugery in patinets >65 
  • L45 
  • RF 
    • White 
    • Increase BMI 
    • Congenital spine anomalies 
      • Failure of posterior elements to develop – leading to short pedicles and laminae 

Pathophys 

  • Due to 
    • Disc bulge/ herniation 
    • Flavum hypetrophy/ buckling 
    • Facet cysts/ hypertrophy/ osteophytes 
    • Uncinate spurs (posterior vertebral body osteophyte) 
  • Stenosis Zones 
    • Central (<10cm) 
      • Flavum 
      • Non specific compression or traversing root symptomes 
    • Lateral Recess (subarticular) 
      • Facet joints 
      • Traversing root symptoms 
    • Foraminal 
      • Loss of disk height 
      • Disc protrusion 
      • Facet encroachment (SAP) 
      • Exiting nerve root symptoms 

Symptoms 

  • Back pain 
    • Referred buttock pain 
  • Radiculopathy 
  • Neurogenic claudication 
    • Wose with extension, better with flexion 
    • Weakness 
  • Bowel bladder 
    • Recurrent UTI due autonomic sphincter dysfunction 

Physical Exam 

  • Kemp sign 
    • Unilateral radicular pain from foraminal stenosis worse via back extension 
  • SLR 
  • Valsalva negative 
  • Normal neuo exam common as pain only with extension o ambulation 
  • Exevise tolerance test Iss most senssitive 
    • PE is not 

Hip Spine Syndrome 

  • Primary pain? 
  • Dx injection to confirm 

Differentiate from Vascular Claudication 

  • History – with activity and rest vs flex ex 
    • Up stairs easier – Neuro 
    • Down stairs easier – Vascualar 
  • Bike 
    • Easy – neuro 
    • Hard – vascular 
  • ABI/ pulses 
  • Vascular studies 

Management 

  • Non OP First Line 
    • Non opioid meds 
    • Flexion based PT 
    • Steroid injections (epidural and transforaminal) 
      • Have been effective and may obviate need for surgery 
  • Persistent pain 6 months trial of non op or progressive neuro (weakness/ bowel bladder) 
    • Decompression 
    • Decompression with fusion 
      • Indications 
        • Spondylolisthesis 
          • Sagittal facets 
          • Dynamical instability: Flex-ex view >4mm 
          • Intact disc height 
          • Facet gapping >1 
          • Fluid in facet capsule 
        • Iatrogenic removal of >50% of facets 
        • Scoliosis >30 
      • ASD >30% at 10 years 

Complications 

  • Infection 
  • Penumoa 
  • Renal failure 
  • Neuro deficit 
  • UTI 
  • Anemia 
  • Confusopn 
  • Dural tear 
  • Failure 
  • Revision 
  • ASD 

Facets morre coronal as distal