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Subject: Spinal Stenosis
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Spondylosis or degenerative arthritis is the most common cause of spinal stenosis, resulting from compression of the spinal cord by disc degeneration, facet arthropathy, osteophyte formation, and ligamentum flavum hypertrophy.
The L4-L5 level is most commonly involved.
The prevalence of spinal stenosis is high if assessed solely by imaging in elderly patients. Not all patients with radiographic spinal stenosis are symptomatic. The degree of radiographic stenosis does not always correlate with patient symptoms. Lumbar MRI shows significant abnormalities in 57% of patients >60 years.
Predominant age: Symptoms develop in 5th to 6th decades (congenital stenosis is symptomatic earlier).
Spinal stenosis can result from congenital or acquired causes. Degenerative spondylosis is most common.
Disc dehydration leads to loss of height with bulging of the disc annulus and ligamentum flavum into the spinal canal, increasing facet joint loading.
Facet loading leads to reactive sclerosis and osteophytic bone growth, further compressing spinal canal and foraminal elements.
Other causes of acquired spinal stenosis include:
Leaning forward while walking
Pushing a shopping cart
Lying in flexed position
Avoiding provocative maneuvers (back extension, ambulating long distances without resting)
Helps distinguish spinal stenosis from other causes of back pain and peripheral vascular disease.
Neurogenic claudication (i.e., pain, tightness, numbness, and subjective weakness of lower extremities) may mimic vascular claudication.
Examine gait (rule out cervical myelopathy or intracranial pathology).
Loss of lumbar lordosis
Evaluate range of motion of lumbar spine.
Pain with extension of the lumbar spine is typical.
Straight-leg raise test may be positive if nerve root entrapment is present.
Muscle weakness is usually mild and involves the L4, L5, and (rarely) S1 nerve roots.
About half of patients with symptomatic stenosis have a reduced or absent Achilles reflex. Some have reduced or absent patellar reflex.
Vascular claudication. Symptoms of vascular claudication do not improve with leaning forward and usually abate with standing or rest.
CBC, ESR, C-reactive protein (if considering infection or malignancy)
New back pain lasting >2 weeks or back pain accompanied by neurologic findings in patients >50 years generally warrants neuroimaging.
MRI is the modality of choice.
CT myelography is an alternative to MRI but is invasive and has higher risk of complications.
Plain radiography helps exclude other causes of new back pain (e.g., malignant lytic lesions) but does not reveal the underlying pathology.
Radiologic abnormalities in general do not correlate with the clinical severity.
Spinal stenosis generally does not lead to neurologic damage.
Surgery may be required for pain relief to increase mobility and improve quality of life.
In general, nonoperative interventions are preferred in the absence of progressive or debilitating neurologic symptoms:
Spinal decompression and physical therapy yield similar effects 2[A].
There is controversy about fusion being performed with decompression because of a future spondylolisthesis risk 3[C].
Acetaminophen: caution in those with preexisting liver disease; increased warnings for hepatotoxicity; limit daily dosing in the elderly.
NSAIDs: Consider potential for GI side effects, fluid retention, and renal failure.
Tramadol—currently a schedule IV controlled substance; has the potential to cause confusion, dizziness, lower seizure threshold, and increase fall risk in the elderly; should be used with caution
The available evidence does not support the routine use of epidural steroid injections. Judicious injections may be reasonable in certain cases.
Use opioids sparingly and only when other treatments have failed to control severe pain.
Anti-inflammatory medications should be used with caution in the elderly due to the risks of GI bleeding, fluid retention, renal failure, and cardiovascular risks.
Side effects of opioids include constipation, confusion, urinary retention, drowsiness, nausea, vomiting, and the potential for dependence and abuse.
>10% of elderly lack Achilles reflexes.
Patients with spinal stenosis are typically able to ride a bicycle (leaning forward tends to relieve symptoms).
Aquatic therapy (helpful for muscle training and general conditioning)
Strengthening of abdominal and back muscles
While a brace or corset may help in the short term, use is not recommended for prolonged periods due to development of paraspinal muscle weakness.
Encourage physical activity to prevent deconditioning.
Surgery is indicated when symptoms persist despite conservative measures.
Age alone should not be an exclusion factor for surgical intervention. Cognitive impairment, multiple comorbidities, and osteoporosis may increase the risk of perioperative complications in the elderly.
Lumbar decompressive laminectomy is the mainstay of treatment. The traditional approach is laminectomy and partial facetectomy.
Controversy exists about whether the decompression should be supplemented by a fusion procedure:
A less invasive alternative, known as interspinous distraction (X STOP implant), is an option 4[B].
The evidence for use of the Aperius interspinous implant device is inconclusive 5[C].
A unilateral partial hemilaminectomy combined with transmedial decompression may adequately treat stenosis with less morbidity in the elderly 6[C].
Admission criteria/initial stabilization: acute or progressive neurologic deficit
Discharge criteria: improved pain or after neurologic deficit has been addressed
Follow up based on progression of symptoms.
No limitations to activity; patients may be as active as tolerated. Exercise should be encouraged.
Activity as tolerated, if no other pathology is present (e.g., fractures)
Patients should present for care if they develop progressive motor weakness and/or bladder/bowel dysfunction.
Patients should know the natural history of the condition and how best to relieve symptoms.
Spinal stenosis is generally benign, but the pain can lead to limitation in ADLs and progressive disability.
Surgery usually improves pain and symptoms in patients who fail nonoperative treatment.
Surgical outcomes are similar in terms of pain relief and functional improvement for patients of all ages.
Severe spinal stenosis can lead to bowel and/or bladder dysfunction.
Surgical complications include infection, neurologic injury, chronic pain, and disability.
M48.00 Spinal stenosis, site unspecified
M48.06 Spinal stenosis, lumbar region
M48.04 Spinal stenosis, thoracic region
M48.05 Spinal stenosis, thoracolumbar region
M48.08 Spinal stenosis, sacral and sacrococcygeal region
M48.07 Spinal stenosis, lumbosacral region
M48.02 Spinal stenosis, cervical region
M48.01 Spinal stenosis, occipito-atlanto-axial region
M47.9 Spondylosis, unspecified
M48.03 Spinal stenosis, cervicothoracic region
724.00 Spinal stenosis, unspecified region
724.02 Spinal stenosis, lumbar region, without neurogenic claudication
724.01 Spinal stenosis, thoracic region
724.09 Spinal stenosis, other region
723.0 Spinal stenosis in cervical region
721.90 Spondylosis of unspecified site, without mention of myelopathy
724.03 Spinal stenosis, lumbar region, with neurogenic claudication
76107001 Spinal stenosis (disorder)
18347007 Spinal stenosis of lumbar region
41341006 Spinal stenosis of thoracic region
370471003 Lumbosacral stenosis (disorder)
8847002 Spondylosis (disorder)
83561009 Spinal stenosis in cervical region
202783003 Degenerative thoracic spinal stenosis (disorder)
202761002 Degenerative cervical spinal stenosis (disorder)
202788007 Degenerative lumbar spinal stenosis (disorder)
Spinal stenosis typically presents as neurogenic claudication (pain, tightness, numbness, and subjective weakness of lower extremities), which can mimic vascular claudication.
Flexion of the spine generally relieves symptoms associated with spinal stenosis.
Spinal extension (prolonged standing, walking downhill, and walking downstairs) can worsen symptoms of spinal stenosis.
Consider urgent surgery for patients with cauda equina/conus medullaris syndrome or progressive bladder dysfunction. Other patients with lumbar spinal stenosis typically do well with initial conservative management.