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

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

3. Lumbar Spine

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

5. 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

6. 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

7. 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

8. 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

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

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

11. Radiographs

12. MRI

13. CT Myelogram

14. EMG

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

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

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

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

19. Prognosis Surgery Non-surgical Metanalysis of 74 studies
64% with good to excellent outcomes
Katz, et al. Spine 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% 4 yrs

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

21. Cervical Spine

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

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

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

25. Static Compression Disc herniation Osteophytic spurring Vertebral body
Zagoapophyseal joints

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

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

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

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

30. Radiographs
Cervical spondylosis
Flex/ext views

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

32. Differential Diagnosis
Brachial Plexopathy
Burner Syndrome
ALS MS
Polyneuropathy
Cervical Spondylosis

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

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

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

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

37. 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