Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Spinal Stenosis
Spinal Stenosis
Dhruv B. Pateder MD
BasicsDescription
-
Compression of neural elements secondary
to osteoarthritic changes (bone spurs, hypertrophied ligamentum flavum,
disc space narrowing) at intervertebral levels and facet joints -
Characterized by back and/or lower extremity pain, numbness, weakness, and possible bladder/bowel dysfunction.
General Prevention
No known preventive measures
Epidemiology
-
Symptoms develop during the 5th and 6th decades.
-
No gender predominance
-
Degenerative spondylolisthesis with spinal stenosis is 4 times more common in females (1–3).
Incidence
1.7–8% (1–3)
Risk Factors
Increasing age and spinal arthritis
Genetics
No definitive genetic links
Pathophysiology
-
Disc dehydration leads to loss of height
with bulging of the annulus and ligamentum flavum into the spinal
canal, thus increasing joint loading of the facets. -
Increased joint loading leads to reactive
sclerosis and osteophytic bone growth, which in turn leads to
additional compression of the neural elements.
Etiology
-
Congenital:
-
Chondrodystrophy
-
Idiopathic
-
-
Acquired:
-
Degenerative
-
Spondylolytic
-
Iatrogenic
-
Posttraumatic
-
Paget disease
-
Diagnosis-
Long-standing back pain that progresses to buttock and lower extremity pain
-
Neurogenic claudication (pain, tightness, numbness, and subjective weakness of lower extremities)
-
Symptoms worsen with standing, walking, and back extension.
-
Symptoms improve with sitting or leaning forward.
Signs and Symptoms
History
-
Insidious onset
-
Progresses slowly
-
Symptoms worse when walking “uphill” and improve with leaning forward (e.g., while pushing a cart in a grocery store)
Physical Exam
-
Few physical findings may be present even in affected patients.
-
Gait alteration (Rule out cervical myelopathy or intracranial pathology.)
-
Loss of lumbar lordosis
-
Decreased ROM of the lumbar spine
-
Straight-leg-raise test may be positive if nerve root entrapment is present.
-
Muscle weakness, most commonly in the L5 distribution.
-
Consider rectal examination to rule out cauda equina syndrome in selected patients.
-
Tests
Spinal stenosis usually is diagnosed with a combination of history, physical examination, and imaging studies.
Lab
Complete blood cell count, C-reactive protein, and ESR usually are used if infection or cancer is in the differential diagnosis.
Imaging
-
AP and lateral spine radiographs:
-
Show degenerative changes or spondylolisthesis
-
Rule out fractures, infection, or tumor
-
Flexion/extension views help evaluate instability.
-
-
MRI shows compression of neural elements.
-
CT-myelography:
-
Comparable to MRI in showing neural
compression, but an invasive procedure (contrast injection associated
with subsequent headache) -
Often obtained in patients who have had
previous spinal instrumentation or cannot tolerate an MRI examination
(e.g., those with claustrophobia, pacemaker)
-
Diagnostic Procedures/Surgery
Selective injections can be used to localize the source
of pain in patients with multiple sites of neural compression and
unclear findings.
of pain in patients with multiple sites of neural compression and
unclear findings.
Pathological Findings
-
Decreased disc height
-
Facet hypertrophy
-
Spinal canal and/or foraminal narrowing
-
Disc herniation of bulging
-
Possible intervertebral instability
Differential Diagnosis
-
Vascular claudication (symptoms do not improve with leaning forward)
-
Cervical myelopathy
-
Spinal stenosis in the thoracic spine
P.413
TreatmentGeneral Measures
-
Brace or corset may help for a short
time, but it is not recommended for long term because it leads to
paraspinal muscle weakness. -
Weight loss
Activity
As tolerated, as long as no other pathology (e.g., fractures, gross instability, etc.) is present
Special Therapy
Physical Therapy
-
General conditioning (Patients can ride
an exercise bicycle without many problems because they can lean forward
and relieve symptoms.) -
Aquatic therapy
-
Back extensor muscle strengthening
-
Abdominal muscle strengthening
-
Gait training
Medication
No role for maintenance opiates
First Line
-
Anti-inflammatory medications (in absence of gastrointestinal side effects)
-
Enteric-coated aspirin (fewer gastrointestinal side effects)
-
Acetaminophen
Second Line
-
COX-2 inhibitors (Be aware of a changing side-effect profile.)
-
Lumbar epidural steroids
Surgery
-
Indicated when nonoperative treatment fails, and the patient cannot attain a tolerable quality of life.
-
Preoperative clearance by an internist, cardiologist, and/or anesthesiologist is necessary.
-
-
Decompression of neural elements is a mainstay of treatment.
-
Generally includes a laminectomy, but
foraminotomies and discectomy also should be performed if they are
involved in neural compression
-
-
Fusion is necessary in the presence of
instability or if extensive decompression results in instability (with
disruption of the pars interarticularis and/or >50% of articular
facets) -
Instrumentation with pedicle screws commonly is used to achieve fusion.
Follow-upRoutine follow-up is at 6 weeks, 3 months, 6 months, 1 year, 2 years, and then every 2 years.
Prognosis
-
Spinal stenosis generally worsens with time.
-
Surgery is successful in improving pain and symptoms in patients for whom nonoperative treatment fails.
Complications
-
Severe spinal stenosis can lead to bowel and/or bladder dysfunction.
-
Surgical complications include infection, neurologic injury, pseudarthrosis, chronic pain, and disability.
Patient Monitoring
Patients are monitored for resolution of symptoms, fusion (if arthrodesis was performed), and development of any complications.
References
1. Amundsen T, Weber H, Lilleas F, et al. Lumbar spinal stenosis. Clinical and radiologic features. Spine 1995;20:1178–1186.
2. Hilibrand AS, Rand N. Degenerative lumbar stenosis: Diagnosis and management. J Am Acad Orthop Surg 1999;7:239–249.
3. Zucherman
JF, Hsu KY, Hartjen CA, et al. A multicenter, prospective, randomized
trial evaluating the X STOP interspinous process decompression system
for the treatment of neurogenic intermittent claudication: Two-year
follow-up results. Spine 2005;30:1351–1358.
JF, Hsu KY, Hartjen CA, et al. A multicenter, prospective, randomized
trial evaluating the X STOP interspinous process decompression system
for the treatment of neurogenic intermittent claudication: Two-year
follow-up results. Spine 2005;30:1351–1358.
Additional Reading
Yuan
HA, Garfin SR, Dickman CA, et al. A historical cohort study of pedicle
screw fixation in thoracic, lumbar, and sacral spinal fusions. Spine 1994;19:2279S–2296S.
HA, Garfin SR, Dickman CA, et al. A historical cohort study of pedicle
screw fixation in thoracic, lumbar, and sacral spinal fusions. Spine 1994;19:2279S–2296S.
MiscellaneousCodes
ICD9-CM
-
723.0 Cervical spinal stenosis
-
724.00 Spinal stenosis
-
724.02 Lumbar spinal stenosis
Patient Teaching
Patients should be educated about the natural history of
the condition and about awareness of progressive motor weakness and
bladder/bowel dysfunction.
the condition and about awareness of progressive motor weakness and
bladder/bowel dysfunction.
FAQ
Q: What is the most common symptom of spinal stenosis?
A: Positional pain (worse with lumbar spine in extension and better with lumbar spine in flexion).
Q: What is the best imaging modality to diagnose spinal stenosis?
A: MRI.