Neurosurgical Updates 2016 Brain & Spine Symposium: Presented by: Mary L. Dombovy, MD, MHSA Paul K. Maurer, MD Anthony L. Petraglia, MD Patrick J. Reid, MD Matthew L. Dashnaw, MD, Pharm D M. Gordon Whitbeck, Jr., MD

Lumbar Spinal Stenosis Presented by Matthew L. Dashnaw, MD, PharmD Neurosurgeon Rochester Regional Health

Goals Define Spinal Stenosis Explain Clinical Features Determine Optimal Imaging Review Treatment Options Review Surgical Options Review Surgical Outcomes

What is Spinal Stenosis? Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the spinal nerves at the level of the lumbar vertebra.

Some “Bad” Causes Huge Disk Herniation Trauma Tumor Infection

What is Spinal Stenosis? Typically 2/2 degeneration Sometimes 2/2 instability Central canal vs. Later Recess

Clinical Features

Clinical Features – Chief Complaint

Clinical Features Cauda Equina Syndrome Flaccid paralysis in distal LE Areflexia Urinary and fecal retention Saddle anesthesia Loss of sensation Neuropathic pain

Clinical Features Neurogenic Claudication Buttock, hip, thigh or leg discomfort Precipitated by walking Relieved by sitting or being “stooped” forward Gradual Exam usually normal Must be differentiated from vascular claudication Relief by standing still Diminished pulses and decreased LE skin temp Trochanteric bursitis – pain on first step, can’t lie on affected side, fail patrick’s test, tender to palp. Also need to r/o degenerative hip disease

Imaging: When and What to Order? Ask the Insurance company Early If warning signs of a serious cause: Deficit, nocturnal pain, fever, weight loss, acute onset, CA Hx After 4-6 weeks of conservative tx What to get MRI is the study of choice Myelogram may also be helpful in some patients

Imaging in Lumbar Stenosis

Treatment Options Do nothing Physical Therapy Medication Natural history over 4 years 70% stable 15% progress, 15% have some improvement Physical Therapy Stretch, strengthen core, and aerobic exercise (water,bike) Reduce lordosis Medication Analgesics Anti-inflammatories Epidural steroid injections Surgery PT – weight loss for overweight folks – aquatic therapy, bicycling

Surgical Options for Spinal Stenosis Lumbar Decompression Surgery Laminectomy +/- foraminotomy 4 year data (SPORT) shows benefit Pain, Function, Disability Intraspinous Spacer Implantation Designed to keep spine in “flexion” Advantages and Disadvantages Lumbar Fusion Surgery Reserved for spondylolisthesis* Several options for instrumentation