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Lumbar Spinal Canal Stenosis & Lumbar Disc Disease
Dr. Moneer K. FarajConsultant NeurosurgeonCollege of Medicine, Baghdad Uni.
Lumbar spinal canal stenosis :Reduction in the diameter of the spinal canal which results from either congenital stenosis & / or degenerative changes.
Definition
Degenerative changes may result in: Lumbar disc protrusion Facet joint osteoarthritis Ligamentum flavum hypertrophy End plate changes ( modic changes)
Pathogenesis
Neurogenic Claudication◦ Dermatomal: pain/sensory changes/weakness of
buttock, hip, thigh, or leg initiated by standing or walking
◦ slow relief with postural changes (sitting >30 min), NOT simply exertion cessation
◦ elicited with lumbar extension, but may not have any other neurological findings, no signs of vascular compromise (e.g. ulcers, poor capillary refill, etc.)
Clinical Features: History
Facet Joint Syndrome comprises clinical symptoms related to the facet joints such as dysfunction and osteoarthritis.The cardinal symptoms of facet joint pain are: predominant low-back pain osteoarthritis pain type (improvement during
motion) However, in late stages of OA this alleviation will disappear
pain aggravation in extension and rotation (standing, walking downhill)
The pain is often located in the buttocks and groin and infrequently radiates into the posterior thigh. However, it is non-radicular in origin.
Patients often feel stiff in the morning sometimes of such intensity that they have difficulty to get out of bed.
Instability SyndromeThe cardinal symptom of a segmental instability is: mechanical low-back pain Instability pain worsens during motion and improves
during rest Vibration (e.g. driving a car, riding in a train) may
aggravate the pain. Pain is also felt when sudden movements are made.
The resulting muscle spasm can be so severe that the patients experience a lumbar catch (“blockade”). Pain usually does not radiate below the buttocks.
Some patients benefit from wearing a brace.
In patients with facet syndrome, physical findings are: pain provocation on repetitive backward bending pain provocation on repetitive side rotation hyperextension in the prone position
In patients with instability syndrome, physical findings are: abnormal spinal rhythm (when straightening
from a forward bent position). The patient needs the support with hands on thighs when straightening out of the forward bent position by supporting the back.
Clinical Features: Signs
Standard radiographs are rarely diagnostic disc space narrowing with endplate
sclerosis severe facet joint osteoarthritisFlexion/Extension Films Functional views : excessive segmental
motion (>4mm) or subluxation of the facet joint that is rare in asymptomatic individuals
Diagnostic workup
Computed Tomography The current role of CT is for patients with
contraindications for MRI (e.g. pacemaker). In the latter case, CT is often combined with myelography (myelo-CT) to provide conclusions on potential neural compression.
in the evaluation of patients postoperatively to assess lumbar fusion status.
MRI It is superior to computed tomography (CT) because of its tissue contrast and multi planar capabilities.
General objectives of treatment pain relief improvement of health-related quality of
life improvement of work capacity
Treatment
Patient Selection for TreatmentVarious domains must be considered, medical factors psychological factors sociological factors work-related factors
Favorable indications for non-operative treatment minor to moderate structural alterations short duration of persistent symptoms
<6months Pain of variable intensity and location absence of risk factor ( early neurological
deficit) intermittent symptoms
The non-operative management composed of : pain management (medication) functional restoration (physical exercises) cognitive-behavioral therapy (psychological
intervention)
Favorable indications for operative treatment severe structural alterations and instability failure to relief the pain more than 6 months
of medical therapy. Progressive neurological deficit Psychologically stable patient.
Operative Management
Decompression Laminectomy Non instrumented spinal fusion Instrumented spinal fusion Spinal fusion with fixation A combination of previous surgeries
Surgical Procedures
Etiology Tear in the annulus with herniation of the
nucleus outside either laterally compressing nerve root, or centrally causing cauda equina or lumbar stenosis (neurogenic claudication)
Lumbar Disc Syndrome
leg pain > back pain limited back movement (especially forward flexion)
due to pain dermatomal sensory changes, motor weakness,
reflex changes exacerbation with coughing, sneezing or straining.
Patients often report that sitting is the worst position (caused by disc compression).
Relief with flexing the knee or thigh nerve root tension signs
◦ straight leg raise (SLR test) or crossed SLR (pain should occur at less than 60 degrees) suggest LS, Sl root involvement
◦ femoral stretch suggest L2, L3 or L4 root involvement
Clinical Features
Central , sub articular, foramenal, extreme lateral
L5-S1 L4-5 L3-4
Sl L5 L4 Root Involved
45% 45% <10% Incidence
Sciatic pattern
Sciatic pattern Femoral pattern
Pain
Lateralfoot Lateral leg Dorsal foot to hallux
Medial leg Sensory
Gastronemius, Soleus ( plantar flexion)
Extensor hallusis longus ( hallux extension)
Tibialis anterior (dorsiflexion)
Motor
Ankle jerk
Knee jerk Reflexes
x -ray spine (only to rule out other lesions)
CT, CT- Myelography
MRl
consider EMG, nerve conduction studies if diagnosis uncertain
Investigations
conservative◦ bed rest◦ activity modification, patient education (reduce
sitting, lifting)◦ physiotherapy, exercise programs◦ analgesics may help
Treatment
surgical indications◦ intractable pain despite adequate conservative
treatment for >3 months◦ progressive neurological deficit
Types: - open laminectomy with discectomy - micro discectomy
Surgery
Etiology compression or irritation of lumbosacral
nerve roots below conus medullaris due to decreased space in the vertebral canal below L2.
Common causes include herniated disk, spinal stenosis, vertebral fracture and tumors.
Cauda Equina Syndrome
usually acute (develops in less than 24 hours); rarely subacute or chronic
motor (LMN signs)◦ weakness/paraparesis in multiple root distribution◦ reduced deep tendon reflexes (knee or ankle)
autonomic◦ urinary retention (or over flow incontinence) and/or fecal
incontinence due to loss of anal sphincter tone sensory
◦ low back pain radiating to legs (sciatica) aggravated by Valsalva maneuver and by sitting; relieved by lying down
◦ bilateral sensory loss or pain: depends on the level of cauda equina affected
◦ saddle area (S2-S3) anesthesia (most common sensory deficit)◦ sexual dysfunction (late finding)
Clinical Features
Treatment: requires urgent investigation and
decompression (<48 hrs) to preserve bowel and bladder function and/ or to prevent progression to paraplegia
Prognosis: markedly improves with surgical
decompression. Recovery correlates with function at the initial
consult: if patient is ambulatory, likely to continue to be ambulatory; if unable to walk, unlikely to walk after surgery
Thank you