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Spinal Stenosis

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Other Names

  • Lumbar Spine Stenosis (LSS)
  • Thoracic Spine Stenosis (TSS)

Background

  • 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"[1]
  • No gold standard for diagnosis, thus a combination of history, physical exam and imaging studies

History

  • First described by Verbiest in 1954[2]

Epidemiology

  • Prevalence
    • Increases with age[3]
    • 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%[4], however these estimates include asymptomatic individuals
    • In symptomatic patients, the prevalence is estimated to be closer to 9.3%[5] and up to 47% in individuals over 60[6]
  • Healthcare Burden
    • 2007: More than 37,500 operations for spinal stenosis in medicare patients costing $1.65 billion[7]
    • In 2014, estimated to be closer to $2 billion[8]
    • Most common reason for spine surgery over 65[9]

Pathophysiology

  • Can be congenital or acquired
    • Degenerative, acquired is most common cause
  • Degenerative
    • 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[10]
    • 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[11]
    • 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

Associated Conditions


Risk Factors


Differential Diagnosis


Clinical Features

  • History
    • 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[12]
    • 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
    • Straight Leg Test: Supine, knee extended, leg passively flexed at hip until reproduction of symptoms
    • Kemp Test: Radicular symptoms made worse with back extension

Evaluation

Radiographs

MRI

  • Imaging modality of choice in patients with suspected spinal stenosis
  • Findings
    • Central canal stenosis with thecal sac
    • Loss of perineural fat, compression of lateral recess/foramen
    • Facet, ligamentum flavum hypertrophy

CT

  • CT with myelography is an alternative if MRI is contraindicated

Diagnostic Criteria

  • 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[13]
  • 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>

EMG/NCS

  • Not routinely recommended or required
  • In individuals with uncertain etiology, may be useful

Classification

Etiologic Classification

  • Acquired
    • Degenerative (most common)
    • Post-operative
    • Traumatic
    • Inflammatory/ rhematologic
    • Other systemic disease (Paget's disease, etc)
  • Congenital
    • Shortened pedicles, medially placed facets

Anatomic Classification

  • 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

Management

Prognosis

  • North American Spine Society[14]
    • 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[15]
    • 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

Nonoperative

  • Indications
    • Mild-to-moderate symptoms
    • Pain is controllable
    • Uncomplicated with no myelopathy or objective neurological deficits
  • General
    • Evidence guiding conservative management is limited
  • 2013 systematic review: current evidence insufficient to provide official guidelines for clinical practice[19]
  • Medications
  • 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[20]
  • Exercise Therapy
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • Corticosteroid Injection
    • Placed in the epidural space under ultrasound or fluoroscopic guidance
    • Recommended by 2013 North American Spine Society
    • 2014 study: blinded study found no benefit in using glucocorticoids plus lidocaine over lidocaine alone[21]
    • 2015 systematic review: minimal-no effect in walking ability[22]

Operative

  • Indications
    • Initial presentation with myelopathy
    • Moderate-severe symptoms
    • Chronically worsening symptoms
    • Failure of conservative therapy
  • Technique
    • Bilateral laminectomy
    • Pedicle-to-pedicle decompression

Rehab and Return to Play

Rehabilitation

  • 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[23]

Return to Play

  • Post-operative
    • Highly variable, depend on procedure and surgeon
    • Athletes tend to do well after lumbar discectomy[24]
    • Lumbar fusion, not recommended to return to contact or collision sports[25]
    • Recovery period is usually 4-6 months
    • Remove from sports: persistent neurological deficits, spinal instability, post-fusion procedures

Complications

  • Cauda Equina Syndrome
  • Chronic pain
  • Physical deconditioning
  • Surgical complications
    • Wound infection (up to 10%)
    • Dural tear
    • Failure of symptoms to improve

See Also


References


  1. Deyo, R. A. Treatment of lumbar spinal stenosis: a balancing act. Spine J. 10, 625–627 (2010)
  2. Verbiest, H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J. Bone Joint Surg. Br. 36-B, 230–237
  3. Kalichman L, Cole R, Kim DH, et al. : Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. 2009;9(7):545–50. 10.1016/j.spinee.2009.03.005
  4. Ishimoto Y, Yoshimura N, Muraki S, et al. : Associations between radiographic lumbar spinal stenosis and clinical symptoms in the general population: the Wakayama Spine Study. Osteoarthritis Cartilage. 2013;21(6):783–8. 10.1016/j.joca.2013.02.656
  5. Ishimoto Y, Yoshimura N, Muraki S, et al. : Prevalence of symptomatic lumbar spinal stenosis and its association with physical performance in a population-based cohort in Japan: the Wakayama Spine Study. Osteoarthritis Cartilage. 2012;20(10):1103–8. 10.1016/j.joca.2012.06.018
  6. Kalichman, L. et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. 9, 545–550 (2009).
  7. Deyo RA, Mirza SK, Martin BI, et al. : Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):1259–65.
  8. Parker, S. L. et al. Two-year comprehensive medical management of degenerative lumbar spine disease (lumbar spondylolisthesis, stenosis, or disc herniation): a value analysis of cost, pain, disability, and quality of life: clinical article. J. Neurosurg. Spine 21, 143–149 (2014).
  9. Deyo, R. A., Gray, D. T., Kreuter, W., Mirza, S. & Martin, B. I. United States trends in lumbar fusion surgery for degenerative conditions. Spine 30, 1441–1445; discussion 1446–1447 (2005).
  10. Fortin M, Lazary A, Varga PP, et al. : Association between paraspinal muscle morphology, clinical symptoms and functional status in patients with lumbar spinal stenosis. Eur Spine J. 2017;26(10):2543–51.
  11. Tomkins-Lane CC, Battié MC, Hu R, et al. : Pathoanatomical characteristics of clinical lumbar spinal stenosis. J Back Musculoskelet Rehabil. 2014;27(2):223–9.
  12. de Schepper EI, Overdevest GM, Suri P, et al. : Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests. Spine (Phila Pa 1976). 2013;38(8):E469–81.
  13. Epstein BS, Epstein JA, Jones MD: Lumbar spinal stenosis. Radiol Clin North Am. 1977;15(2):227–39.
  14. Kreiner DS, Shaffer WO, Baisden JL, et al. : An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013;13(7):734–43.
  15. Minamide A, Yoshida M, Maio K: The natural clinical course of lumbar spinal stenosis: a longitudinal cohort study over a minimum of 10 years. J Orthop Sci. 2013;18(5):693–8
  16. Sinikallio S, Aalto T, Airaksinen O, et al. : Depression is associated with a poorer outcome of lumbar spinal stenosis surgery: a two-year prospective follow-up study. Spine (Phila Pa 1976). 2011;36(8):677–82.
  17. Sandén B, Försth P, Michaëlsson K: Smokers show less improvement than nonsmokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish spine register. Spine (Phila Pa 1976). 2011;36(13):1059–64.
  18. Giannadakis C, Nerland US, Solheim O, et al. : Does Obesity Affect Outcomes After Decompressive Surgery for Lumbar Spinal Stenosis? A Multicenter, Observational, Registry-Based Study. World Neurosurg. 2015;84(5):1227–34.
  19. Ammendolia C, Stuber K, de Bruin LK, et al. : Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review. Spine (Phila Pa 1976). 2012;37(10):E609–16.
  20. Delitto A, Piva SR, Moore CG, et al. : Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med. 2015;162(7):465–73.
  21. Friedly JL, Comstock BA, Turner JA, et al. : A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11–21.
  22. Liu K, Liu P, Liu R, et al. : Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis. Drug Des Devel Ther. 2015;9:707–16.
  23. McGregor AH, Probyn K, Cro S, et al. : Rehabilitation following surgery for lumbar spinal stenosis. A Cochrane review. Spine (Phila Pa 1976). 2014;39(13):1044–54.
  24. Hsu WK, McCarthy KJ, Savage JW, et al. The professional athlete spine initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. Spine J. 2011;11:180-186.
  25. Li Y, Hresko MT. Lumbar spine surgery in athletes: outcomes and return-to-play criteria. Clin J Sports Med. 2012;31:487-498.
Created by:
John Kiel on 17 June 2019 16:44:04
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Last edited:
23 November 2020 15:49:09
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