SPINAL STENOSIS
Jung U. Yoo, M.D.
Professor and Chairman
Department of Orthopedics and
Rehabiliatation
Oregon Health and Science University
STABILITY
• ORDINARY
ACTIVITIES MAY
GENERATE OVER
1000LB OF FORCE
MOTION
NEUROPROTECTION
• SPINAL CORD
• NERVE ROOTS
PATHOPHYSIOLOGY
• “Three-joint
Complex”
– a large tripod with the
disc as the front
support and two facet
joints as the back
supports
– Any alteration in one
of these joints can lead
to damage to the others
STENOSIS
STENOSIS
FORAMINAL STENOSIS
• Compresses the
exiting nerve root
CANAL SHAPE
• Round
• Triangular
• Trefoiled
(15%)
• Trefoiled &
asymmetric
DEGENERATION & STENOSIS
PREVALENCE
• Most common indication for spinal surgery
in patients over 60 y.o.
• 400,000 Americans are estimated to have
spinal stenosis
STENOSIS
• Narrowing of the spinal canal or
neuroforamina
• causing a symptomatic compression of
the neural element.
SYMPTOMS
•
•
•
•
•
Neurogenic claudication
Radicular pain
Weakness
Sensory abnormalities
Back pain
PHYSICAL FINDINGS
Physical Finding
• Limited lumbar extension
• Muscle weakness
• Sensory deficit
•
Literature Review
66-100%
18-52%
32-58%
Katz JN, et al: Diagnosis of lumbar spinal stenosis. Rheum. Dis. Clin. North
Am. 20:471-483, 1994
NEUROGENIC
CLAUDICATION
• Cardinal symptom of lumbar stenosis
• Progressive pain and/or paresthesia in the
back, buttock, thigh and calves brought on
by walking or standing, and relieved by
sitting or lying down with hip flexion
POSTURE
AMBULATION
DIFFERENTIAL DIAGNOSIS
•
•
•
•
•
•
Vascular claudication
Osteoarthritis of hip or knee
Lumbar disc protrusion
Intraspinal tumor
Unrecognized neurologic disease
Peripheral neuropathy
FORAMINAL STENOSIS
•
•
•
•
Root symptoms
Unilateral
No claudication
Acute or chronic
LATERAL RECESS STENOSIS
•
•
•
•
Claudication
Radicular pain
Weakness is rare
Acute or chronic
CENTRAL STENOSIS
• Varied presentation
• Classically with
neurogenic
claudication
• Some may only have
back pain
• Rarely painless
progressive weakness
DIAGNOSTIC TESTS
X-RAY
• Screening exam
• Stenosis cannot be
diagnosed
X-RAY
• Instability such as
scoliosis or listhesis
CT SCAN
• Difficult to diagnose
stenosis
• Replaced by MRI
• May be useful for those
who cannot have an MRI
CT SCAN
• Excellent bony detail
MRI
• Non-invasive
• Soft tissue
visualization
• Gold standard
MRI
• Sagittal images
• Visualization of
foramen
MYELOGRAPHY
• Excellent for intra-canal
pathology
• Poor for foraminal
pathology
• Replaced by MRI
MYELOGRAPHY
•
•
•
•
Invasive
1% spinal headache
Recurrent stenosis
Inability to obtain MRI
MYELOGRAPHY
CT-MYELOGRAPHY
• Excellent visualization
of spinal canal
CT-MYELOGRAPHY
• Excellent for recurrent
stenosis
• Invaluable in surgical
planning
MRI
•
•
•
•
Expensive
Patient cooperation
Claustrophobia
Open MRI
EMG-NCS
• Differentiation between neuropathy and
radiculopathy
• Acute active denervation vs. chronic
denervation
TREATMENT
NONOPERATIVE RX
•
•
•
•
•
•
Rest
Analgesic
Oral steroid
Physical therapy
Bracing
Spinal injection
REST
• Short term activity
modification for acute
pain
• Long term activity
modification is not
recommended
ANALGESIC
•
•
•
•
NSAIDS
Tylenol
Narcotics
Neurontin
Oral Steroid
• Effective for acute pain
• Short duration therapy
• ? Chronic or repeat tapering dose
PHYSICAL THERAPY
• Avoid extension
exercises acutely
• William Flexion
Exercises
• Water aerobics
• Strengthening of weak
muscle groups
SPINAL INJECTIONS
• Epidural steroid
• Transforaminal root block
• Facet joint injection
EPIDURAL STEROID
•
•
•
•
Commonly prescribed
50% short-term efficacy
Not as selective
May not require
fluroscope
TRANSFORAMINAL ROOT
BLOCK
• Highly selective
• Diagnostic as well as
therapeutic
• Delivers medicine to
the floor of spinal
canal
FACET INJECTION
• Facet for back pain
• Not for radicular pain
• May act as epidural in
40% of cases
SPINAL INJECTION
• Most effective for acute pain
• May not be indicated in cases of acute
denervation or progressive motor loss
OPERATIVE TREATMENT
• Decompression of neural
element
• Stabilization of unstable
segment
“LAMINECTOMY”
DECOMPRESSION OF
LATERAL RECESS
• Undercutting the ventral
aspect of the facet joints
and the associated
ligamentum flavum.
• Medial facetectomy if
necessary
• The traversing nerve
root underneath the
facet joint must be
visualized
FUSION
•
•
•
•
Sagittal instability
Scoliosis
Iatrogenic pars defect
Greater than 50%
facet joint resection
INSTRUMENTATION
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