Thomas M. Howard, MD Sports Medicine Spinal Stenosis Thomas M. Howard, MD Sports Medicine

These Patients Consume: Many appointments Many narcotic medications Many specialty appointments Ortho, Pain, Neurology, Neurosurgery, Physical Therapy TIME!!

Lumbar Spine

Epidemiology 12 mil visits/yr for LBP 3-4% will have spinal stenosis Usually age >50 Prevalence 1.7-8% annually

Anatomy Three-joint complex Disc complex Ligamentum flavum Nerve roots Facet joints and disc Disc complex Nucleus pulposis and annulus fibrosis Ligamentum flavum Nerve roots

Pathophysiology Facet arthropathy and osteophytic growths Hypertrophy of ligamentum flavum HNP and disc spurring Degenerative spondylolithesis Underlying effect is not mechanical but more decreased CSF flow and local ischemia

Symptoms Post h/o HNP, chronic LBP, surgery, old injury C/o burning, cramping, numbness, tingling or fatigue Back Pain 95% Leg pain 71% 15% thighs only Often bilateral Leg weakness 33 % Pseudoclaudication 94% Pain relieved by sitting or lying

Examination ROM DTR’s Strength Sensory Full forward flexion without sx Limited extension with pain DTR’s Usually nl Strength EHL (L5), TA (L4), Peroneals (S1), Gastroc (S1), Quad (L3-4), Hip flexors (L2-3) Sensory

Examination Vascular exam Consider ABI Pulses Temp Trophic changes Pop, DP, PT Temp Trophic changes Consider ABI

Differential Diagnosis Piriformis Syndrome Trochanteric Bursitis Hip OA Vascular Claudication SI Dysfunction

Radiographs

MRI

CT Myelogram

EMG

Non-operative Medications Injections Physical Therapy Weight Management Lumbar stabilization and core strengthening Aerobic fitness Activity Modification Avoid repetitive bending, lifting, extension activities

Medications Tylenol NSAID’s Narcotics Glucosamine Chondroitan Short acting Vicodin, Percocet, T3, Demerol, Dilaudid Sustained release MS Contin, Oxycontin, Methadone, Fentanyl Glucosamine Chondroitan

Injections Epidural Steroid Injection Serial injections 1-3 on monthly basis 24-60% relief

Surgery Laminectomy Discectomy Remove bone between base of spinous process and facet-pedicle junction May require fusion and or posterior plates/screws Discectomy

Prognosis Surgery Non-surgical Metanalysis of 74 studies 64% with good to excellent outcomes Katz, et al. Spine 1996- 88 pts followed for 7 yrs 3-5 yrs 52% free of severe pain, 30% in severe pain, and 17% re-operated 7-10 yrs 30% in severe pain and 24% re-operated Non-surgical 52% improved @ 4 yrs

Poor Prognostic Factors Prolonged duration of sx Severe sx Psychosomatic disorders Sphincter disturbances Insurance or medical-legal issues Poor self-assessment of health

Cervical Spine

Epidemiology CSM is most common spinal disorder in >55 UK 23.6% of 585 pts with tetraparesis or paresis

Anatomy Similar 3-joint complex Center of motion Flex C 5-6 Ext C 6-7

Pathophysiology Static compression Dynamic compression Ischemia Nerve root compression or cord problems (cervcial cord myelopathy)

Static Compression Disc herniation Osteophytic spurring Vertebral body Zagoapophyseal joints

Dynamic Compression Cervical Instability Ligamentum flavum buckling with extension Stretching over anterior oseophytes with flexion

Symptoms Neck Pain Crepitus UE motor (atrophy) or sensory sx LE spasticity Gait disturbance Bowel/bladder sx

Exam- UE C5-Deltoid, biceps C6- Biceps, wrist ext C7-elbow ext, wrist flex, finger ext C8- finger flexors T1-hand intrinsics

Exam-LE Babinski Clonus Hyper-reflexia Spastic gait Abnormal Rhomberg Lhermitte’s sign

Radiographs Cervical spondylosis Flex/ext views

MRI Eval functional reserve and impingement of nerve and cord R/o myelopathy

Differential Diagnosis Brachial Plexopathy Burner Syndrome ALS MS Polyneuropathy Cervical Spondylosis

Non-surgical Management Medications Injections ESI, facet, trigger pts Activity modification Posture Strengthening Cervical Traction

Surgical Management Anterior approach Discectomy and fusion Posterior approach for more advanced disease for laminectomy and posterior fusion

Outcomes Non-op 1/3 improved 26% deteriorate Surgical 50% at best

Prognostic Indicators Severe preop neuro def Abn cord signal or myelomalacia Severity of cord compression on plain film

Summary & Pearls Abn gait consider cord problems When evaluating cervical discs look at the LE for UMN signs Surgery is best to be avoided Step-wise approach to pain management Use your Pain Specialist Serial exams Know your myotomes and dermatomes