- Lumbar Spine Stenosis (LSS)
- Thoracic Spine Stenosis (TSS)
- This page refers to spinal stenosis of the thorac-lumbar spine
- Defined as a degenerative condition characterized by narrowing of the spinal canal
- North American Spine Society: "a clinical syndrome of buttock or lower extremity pain, which may occur with or without back pain, associated with diminished space available for the neural and vascular elements in the lumbar spine"
- No gold standard for diagnosis, thus a combination of history, physical exam and imaging studies
- First described by Verbiest in 1954
- Increases with age
- In adults over 40, prevalence of moderate stenosis ranges from 23.6% to 77.9% while the prevalence of severe stenosis ranges from 8.4% to 30.4%, however these estimates include asymptomatic individuals
- In symptomatic patients, the prevalence is estimated to be closer to 9.3% and up to 47% in individuals over 60
- Healthcare Burden
- Can be congenital or acquired
- Degenerative, acquired is most common cause
- Bony, ligamentous and synovial elements of axial spine degenerative and overgrowth
- This leads to progressive compression of neural and vascular elements of the spinal canal
- May be exacerbated by weak axial musculature, excessive body weight
- Bony structures: facet osteophytes, uncinate spurs, spondylolisthesis
- Soft tissue pathology: herniated discs, ligamentum flavum hypertrophy, synovial facet cysts
- Central canal stenosis
- Mainly axial back pain, neurogenic claudication
- Typically bilaterally, most commonly L4-5, followed by L3-4, L5-S1
- Ischemic theory: compression decreases arterial flow to nerve roots, leading to ischemic pain and weakness
- Venous stasis theory: venous blood stasis leads to inadequate oxygenation and subsequent pain and claudication
- Lateral and foraminal stenosis
- More commonly unilateral symptoms, impinging either traversing root or exiting root
- Lateral: compressed by facet joint, subarticular ligament hyptrophy
- Foraminal: scoliosis, degenerative disc, synovial cyst
- Neurogenic vs vascluar claudication
- Important to exclude vascular etiology as a cause of radicular back pain
- Neurogenic: worse with postural changes, normal pulses
- Vascular: Fewer changes with postural movement, abnormal pulses
- Degenerative Disc Disease
- Cauda Equina Syndrome (rare)
- Hip-Spine Syndrome
- Co-occurring hip symptoms can complicate clinical picture
- Older age
- Congenital spinal stenosis
- Tobacco Use Disorder
- Occupations with repetitive spinal stress
- Patients may endorse static back pain, radicular pain or even neurogenic claudication
- Symptoms are often exacerbated by ambulation, extension
- Symptoms are often relieved by sitting, forward flexion
- Schepper et al: most sensitive clinical finding is radiating leg pain worse with standing
- Up to 10% of patients may have recurrent UTI due to autonomic sphincter dysfunction (need citation)
- Physical Exam: Physical Exam Back
- Patients may have a wide based gait
- Special Tests
- Standard Radiographs Lumbar Spine and Standard Radiographs Thoracic Spine
- Useful to evaluate patients anatomy with axial loading
- Reflection of biomechanical balance in standing or sitting position
- Findings do not always correlate with symptoms
- Findings include nonspecific degenerative changes, scoliosis, spondylolisthesis
- Flexion Extension Radiographs
- Can be helpful to evaluate for dynamic instability
- Imaging modality of choice in patients with suspected spinal stenosis
- Central canal stenosis with thecal sac
- Loss of perineural fat, compression of lateral recess/foramen
- Facet, ligamentum flavum hypertrophy
- CT with myelography is an alternative if MRI is contraindicated
- Challenging due to lack of standardized radiologic criteria
- Plain Radiographs
- Lower limit of normal of lumbar spinal canal is 15 mm, congenital stenosis defined as less than 10 mm
- Cross sectional area (CSA) of thecal sac
- Measured on MRI or CT
- CSA < 100 mm suggests relative LSS, CSA < 75 mm suggests absolute LSS</ref>Schönström N, Willén J: Imaging lumbar spinal stenosis. Radiol Clin North Am. 2001;39(1):31–53, v.</ref>
- Not routinely recommended or required
- In individuals with uncertain etiology, may be useful
- Degenerative (most common)
- Inflammatory/ rhematologic
- Other systemic disease (Paget's disease, etc)
- Shortened pedicles, medially placed facets
- Central stenosis
- Due to hypertrophy of ligamentum flavum (posterior), bulging disc (anterior)
- Lateral recess stenosis
- Sometimes referred to as subarticular recess
- Due to facet joint arthropathy, osteophyte formation
- Foraminal stenosis
- Due to loss of disc height, scoliosis
- Extraforaminal stenosis
- Due to lateral disc herniations
- North American Spine Society
- Up to 50% of Patients with mild-to-moderate symptomatic lumbar stenosis do well
- Rapid or catastrophic neurologic decline is rare
- Minamide et al performed a 4 year study in patients with LSS
- Patients: unchanged (70%), improved (15%), worsened (15%)
- In another 10 year study of 34 patients treated conservatively
- 30% of patients improved, 30% unchanged, 30% worsened
- Predictors of poor surgical outcome
- Predictors of good surgical outcome
- Patients with predominantly leg pain symptoms more so than primarily back pain
- Mild-to-moderate symptoms
- Pain is controllable
- Uncomplicated with no myelopathy or objective neurological deficits
- Evidence guiding conservative management is limited
- 2013 systematic review: current evidence insufficient to provide official guidelines for clinical practice
- Lumbosacral bracing
- Semi-rigid lumbosacral brace may improve walking ability, decrease pain in some patients
- Physical Therapy
- Involves combination of core strengthening, flexibility training, and stability exercises
- Small studies suggest any form of PT results in improvement in pain, function
- One study suggested PT to potentially be as effective as surgery, although interpret with caution as many patients crossed over to the surgical arm
- Exercise Therapy
- Transcutaneous Electrical Nerve Stimulation (TENS)
- Corticosteroid Injection
- Initial presentation with myelopathy
- Moderate-severe symptoms
- Chronically worsening symptoms
- Failure of conservative therapy
- Bilateral laminectomy
- Pedicle-to-pedicle decompression
Rehab and Return to Play
- Post-operative therapy is important
- 2014 RCT: active rehabilitation initiated six weeks to three months after surgery is more effective than standard care for long-term improvement in functional status, low back pain, and leg pain
Return to Play
- Highly variable, depend on procedure and surgeon
- Athletes tend to do well after lumbar discectomy
- Lumbar fusion, not recommended to return to contact or collision sports
- Recovery period is usually 4-6 months
- Remove from sports: persistent neurological deficits, spinal instability, post-fusion procedures
- Cauda Equina Syndrome
- Chronic pain
- Physical deconditioning
- Surgical complications
- Wound infection (up to 10%)
- Dural tear
- Failure of symptoms to improve
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
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