1. Lumbar Spinal Stenosis and Morphometry of Lumbar Vertebral Canal Ruchira Sethi, Dept of Anatomy SMC, Ghaziabad Vishram Singh, Dept of Anatomy SMC, Ghaziabad BKS Chauhan, Dept of Radiology SMC, Ghaziabad BB Thukral, Dept of Radiodiagnosis VMMC & SJH, New Delhi

2. 16001107-01 IF THIS IS YOU,YOU ARE NOT ALONE

3. 16001107-01 LOW BACK PAIN(LBP)  2 nd most common cause of visit to doctor’s clinic  60-80% of population will have lower back pain at some time in their lives  Each year, 15-20% will have back pain  Incidence of 5 cases per 100,000  Most common cause of disability for persons < 45 years  An ever increasing prevalence, especially in younger age group

4. 16001107-01 LBP DEGEN- ERATIO N OCCUP- ATIONAL TRAUM A BODY MECHANI CS CAUSES OF LOW BACK PAIN ALTERED AND/OR DERANGED STABILITY OF SPINE

5. 16001107-01 Overweight/obesity

6. 16001107-01 No known cause defined

7. 16001107-01  One of the leading manifestation of degeneration / LBP is Lumbar Spinal Stenosis (LSS).  It is defined as narrowing of lumbar vertebral canal which causes compression of cauda equina and emerging nerve roots.  Central stenosis – most commonest form occurs at disc level secondary to osseous &/or ligamentous thickening following degenerative changes Contd-

8. 16001107-01 Healthy Stenot ic Vertebral canal Ligamentum flavum IVD Vertebrae provide body support Discs act as “shock absorbers” Vertebra protects spinal cord and nerves Nerves have space and are not pinched With degeneration, ligaments and bone thicken Narrowing is called “stenosis” Narrowing squeezes nerves in spinal canal and nerve roots exiting spine to legs- pinched nerves Result - pain & numbness in back &legs

9. 16001107-01 Objective of the study was 1) To test whether decrease in vertebral canal diameters is a significant risk factor for LBP 2) Are the diameters comparable between asymptomatic and symptomatic subjects 3) Defining prevalence of LSS in symptomatic subjects 4) Evaluating LSS prevalence with respect to age, sex and vertebral level Verteb- ral level sex age

10. 16001107-01 MATERIALS & METHOD LBP By pre-defined questionnaire Oswestry low back pain GROU PS Group A –asymptomatic, M=26,F=24 Group B- symptomatic, M=23, F=27 MORP HO- METRY Measuring antero posterior and transverse diameters Defining stenotic spines  One hundred subjects were enrolled for the study; age-group 20-70 years; (mean age=43.88 +14.07yrs ) Philips Brilliance 40 CT scanner Axial,and sagittal images, 2.5mm slice gap

11. 16001107-01 Sitting or bending forward relieves symptoms Standing provokes symptoms Pain/weakness in the legs Patients lean forward while walking to relieve symptoms Symptoms of Lumbar Spinal Stenosis (Elevator Syndrome)

12. 16001107-01 Classic Presentation: Chronic dull or aching back pain spreading to legs Numbness and “pins and needles” in legs, calves or buttocks Weakness, or a loss of balance A decreased endurance for physical activities Symptoms of Lumbar Spinal Stenosis

13. 16001107-01 Sagital diameter Transverse diameter Methodology for measuring diameters:  Distance between posterior border of vertebral body to the lamina in midline  Distance between inner borders of both the pedicles of the vertebral body VB SP PLJ VB=vertebral body, SP= spinous process,PLJ= pediculo-laminar junction VB SP

14. 16001107-01 LOW BACK PAIN QUESTIONNAIRE ASYMPTOMAT IC SYMPTOMATI C ARE THE DIAMETERS COMPARABLE??? PREVALENCE OF LSS AGESEX VERTEBR AL LEVEL GROUPS SPS S SD/ SEM/ RANGE Version 19 STUDE NT T TEST P value =/<0.05sig PPREVAL ENCE CI 95% STATISTICS

15. 16001107-01 A B ASYMPTOMATIC GROUP SYMPTOMATIC GROUP RESULTS & DISCUSSION P value < 0.0001 at all vertebral levels Except L1

16. 16001107-01  ANTERO POSTERIOR DIAMETER DISTRIBUTED GENDER WISE  Less in females in health, smallest at L3 vertebral level  Less in males in disease

17. 16001107-01 A B ASYMPTOMATIC GROUP SYMPTOMATIC GROUP P value < 0.0001 at all vertebral levels

18. 16001107-01  TRANSVERSE DIAMETER DISTRIBUTED GENDER WISE  Greatest diameter at caudal vertebral level in health  Females have larger diameter than males in health

19. 16001107-01  AP diameter considered more diagnostic for LSS  Vertebral column with 2or >2 vertebral levels with AP diameter less than 10mm – considered stenotic spines  Out of 50---42 (84%) vertebral columns were stenosed  more common in females  commonest at L5 vertebral level Prevalence of LSS

20. 16001107-01  Commonest at middle age groups

21. 16001107-01  CT scan plays a major role in defining and determining LSS  A normal vertebral canal diameter is always more than 12mm,as concurred with literature  Both the diameters are greatest caudally in health  Larger size caudally ensures protection and accommodate movements at lumbo-sacral transition zone  Low back pain is an important indicator of LSS  Reduction is more at caudal vertebral levels  With the changing life style patterns LBP is increasingly becoming a disease of younger age group

22. 16001107-01 Stenosis manifests as LBP Stenosis more in females Stenosis more at caudal vertebral levels IT’S NO MORE A DOMAIN OF OLD AGE GROUP CONCLUSION

23. 16001107-01 AP/ TD Group A Group B COMPR ESSION SIGNS / SYMPT OMS KINEM ATICS DEGEN ERATI ON LSS

24. 16001107-01 DIAGNOSETREATPREVENT WHAT CAN BE DONE