Baghdad College of Medicine / 5
th
grade
Student’s Name :
Dr. Muneer K. Faraj
Lec. 2
Lumbar Spinal Canal
Stenosis
Wed. 26 / 10 / 2016
DONE BY : Ali Kareem
مكتب اشور لالستنساخ
2016 – 2017
Lumbar Spinal Canal Stenosis Dr. Muneer
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Lumbar Spinal Canal Stenosis & Lumbar Disc Disease
Lumbar spinal canal stenosis : Reduction in the diameter of the spinal canal
which results from either congenital stenosis & / or degenerative changes.
Pathogenesis
Degenerative changes may result in:
o Lumbar disc protrusion
o Facet joint osteoarthritis
o Ligamentum flavum hypertrophy
o End plate changes ( modic changes)
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Clinical Features : History
Neurogenic Claudication
o Dermatomal: pain/sensory changes/weakness of buttock, hip, thigh, or leg
initiated by standing or walking
o Slow relief with postural changes (sitting >30 min), NOT simply exertion
cessation
o Elicited with lumbar extension, but may not have any other neurological
findings, no signs of vascular compromise (e.g. ulcers, poor capillary refill,
etc.)
Facet Joint Syndrome
comprises clinical symptoms related to the facet joints such as dysfunction and
osteoarthritis.
The cardinal symptoms of facet joint pain are:
o Predominant low-back pain
o Osteoarthritis pain type (improvement during motion) However, in late
stages of OA this alleviation will disappear
o Pain aggravation in extension and rotation (standing, walking downhill)
o The pain is often located in the buttocks and groin and infrequently radiates
into the posterior thigh. However, it is non-radicular in origin.
o Patients often feel stiff in the morning sometimes of such intensity that they
have difficulty to get out of bed.
Instability Syndrome
The cardinal symptom of a segmental instability is:
o Mechanical low-back pain
o Instability pain worsens during motion and improves during rest
o Vibration (e.g. driving a car, riding in a train) may aggravate the pain.
o Pain is also felt when sudden movements are made. The resulting muscle
spasm can be so severe that the patients experience a lumbar catch
(“blockade”). Pain usually does not radiate below the buttocks.
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o Some patients benefit from wearing a brace.
Clinical Features : Signs
In patients with facet syndrome, physical findings are:
o Pain provocation on repetitive backward bending
o Pain provocation on repetitive side rotation
o Hyperextension in the prone position
In patients with instability syndrome, physical findings are:
o Abnormal spinal rhythm (when straightening from a forward bent position).
The patient needs the support with hands on thighs when straightening out of
the forward bent position by supporting the back.
Diagnostic workup
Standard radiographs are rarely diagnostic
o Disc space narrowing with endplate sclerosis
o Severe facet joint osteoarthritis
Flexion/Extension Films
o Functional views : excessive segmental motion (>4mm) or subluxation of
the facet joint that is rare in asymptomatic individuals
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Computed Tomography
o The current role of CT is for patients with contraindications for MRI (e.g.
pacemaker). In the latter case, CT is often combined with myelography
(myelo-CT) to provide conclusions on potential neural compression.
o In the evaluation of patients postoperatively to assess lumbar fusion status.
MRI
o It is superior to computed tomography (CT) because of its tissue contrast
and multi planar capabilities.
Treatment
General objectives of treatment
o Pain relief
o Improvement of health-related quality of life
o Improvement of work capacity
Patient Selection for Treatment
Various domains must be considered,
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o Medical factors
o Psychological factors
o Sociological factors
o Work-related factors
Favorable indications for non-operative treatment
o Minor to moderate structural alterations
o Short duration of persistent symptoms <6months
o Pain of variable intensity and location
o Absence of risk factor ( early neurological deficit)
o Intermittent symptoms
The non-operative management composed of :
o Pain management (medication)
o Functional restoration (physical exercises)
o Cognitive-behavioral therapy (psychological intervention)
Operative Management
Favorable indications for operative treatment
o Severe structural alterations and instability
o Failure to relief the pain more than 6 months of medical therapy.
o Progressive neurological deficit
o Psychologically stable patient.
Surgical Procedures
o Decompression Laminectomy
o Non instrumented spinal fusion
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o Instrumented spinal fusion
o Spinal fusion with fixation
o A combination of previous surgeries
Lumbar Disc Syndrome
Etiology
o Tear in the annulus with herniation of the nucleus outside either laterally
compressing nerve root, or centrally causing cauda equina or lumbar stenosis
(neurogenic claudication)
Clinical Features
o Leg pain > back pain
o Limited back movement (especially forward flexion) due to pain
o Dermatomal sensory changes, motor weakness, reflex changes
o Exacerbation with coughing, sneezing or straining. Patients often report that
sitting is the worst position (caused by disc compression).
o Relief with flexing the knee or thigh
o Nerve root tension signs
Straight leg raise (SLR test) or crossed SLR (pain should occur at less
than 60 degrees) suggest LS, Sl root involvement
Femoral stretch suggest L2, L3 or L4 root involvement
Central , sub articular, foramenal, extreme lateral
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L3-4
L4-5
L5-S1
Root Involved
L4
L5
Sl
Incidence
<10%
45%
45%
Pain
Femoral pattern
Sciatic pattern
Sciatic pattern
Sensory
Medial leg
Lateral leg
Dorsal foot to hallux
Lateralfoot
Motor
Tibialis anterior
(dorsiflexion)
Extensor hallusis
longus ( hallux
extension)
Gastronemius,
Soleus ( plantar
flexion)
Reflexes
Knee jerk
Ankle jerk
Investigations
o X-Ray spine (only to rule out other lesions)
o CT, CT- Myelography
o MRl
o Consider EMG, nerve conduction studies if diagnosis uncertain
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Treatment
o Conservative
Bed rest
Activity modification, patient education (reduce sitting, lifting)
Physiotherapy, exercise programs
Analgesics may help
Surgery
o Surgical indications
Intractable pain despite adequate conservative treatment for >3
months
Progressive neurological deficit
o Types :
Open laminectomy with discectomy
Micro discectomy
Cauda Equina Syndrome
Etiology
o Compression or irritation of lumbosacral nerve roots below conus medullaris
due to decreased space in the vertebral canal below L2.
o Common causes include herniated disk, spinal stenosis, vertebral fracture
and tumors.
Clinical Features
o Usually acute (develops in less than 24 hours); rarely subacute or chronic
o Motor (LMN signs)
Weakness/paraparesis in multiple root distribution
Reduced deep tendon reflexes (knee or ankle)
o Autonomic
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Urinary retention (or over flow incontinence) and/or fecal
incontinence due to loss of anal sphincter tone
o Sensory
Low back pain radiating to legs (sciatica) aggravated by Valsalva
maneuver and by sitting; relieved by lying down
Bilateral sensory loss or pain: depends on the level of cauda equina
affected
Saddle area (S2-S3) anesthesia (most common sensory deficit)
Sexual dysfunction (late finding)
Treatment :
o Requires urgent investigation and decompression (<48 hrs) to preserve
bowel and bladder function and/ or to prevent progression to paraplegia
Prognosis :
o Markedly improves with surgical decompression.
o Recovery correlates with function at the initial consult: if patient is
ambulatory, likely to continue to be ambulatory; if unable to walk, unlikely
to walk after surgery
#END of this Lecture …