Jennifer Belu, PT, MPH Jennifer Belu, PT, MPH -- Physical TherapyPhysical Therapy
Joe Tu, MD Joe Tu, MD -- PM&RPM&R
James Thoman, MD James Thoman, MD –– NeurosurgeryNeurosurgery
Elizabeth Yu, MD Elizabeth Yu, MD -- OrthopedicsOrthopedics
Case Presentation – Lumbar Stenosis
Patient is a 68 year old female with a chief complaint of pain in legs with walking. She has had low back pain for 7 years, but in the
past year the pain has changed and is now down her right leg. It used to occur between sitting and standing, but
now it is painful to stand or walk. The pain is zero sitting and 8 standing. She can walk
25 feet and then has to sit down. She can walk further if she uses a grocery cart. She gets a feeling of weakness in her legs if she
keeps walking
Her pain is in the hips, the lateral thigh on the right and then into the anterior leg. She says that she feels some numbness in the top
of the foot with some tingling if she stands for longer times. She has no bowel or bladder difficulty. Her physical exam showed some mild tenderness in
the greater trochanteric bursae bilaterally. She had minimal weakness in both EHL. SLR is
negative. She had absent AJ bilaterally. Flexion causes no pain in the back, but extension causes pain in the back that then radiates down the right leg into the lateral thigh, but is immediately relieved with flexion.
Case Presentation – Lumbar Stenosis (cont)
1. Stenosis is a product of aging1. Stenosis is a product of agingA. Facets get larger (spurs)A. Facets get larger (spurs)B. Thicker ligamentum flavumB. Thicker ligamentum flavumC. Facets become unstable listhesis C. Facets become unstable listhesis
(especially in females)(especially in females)D. Veeerrrrryyyyy slow processD. Veeerrrrryyyyy slow process
2. Patients may remain stable for years2. Patients may remain stable for years3. Very Very Very rarely become paralyzed3. Very Very Very rarely become paralyzed
Neurogenic Claudication
Pain in legs Occurs with standing Doesn’t go away with just resting after walking,
has to sit down Vascular claudication improves with standing
rest, no problem with standing, and going up hill worse than with neurogenic claudication
Managing symptoms
Activity modification
Therapeutic exercise to improve overall strength and condition
BELU
Low Back Pain: Physical Therapy Perspective – Jennifer Belu, PT, MPH
Lumbar Stenosis: Managing Symptoms
Home modalities In clinic, electrical stimulation/TENS Medication as advised by their primary care
provider or specialist
BELU
Lumbar Stenosis: Activity Modification
Walking with known rest areas Track how long able to walk before caudication
symptoms Kitchen tasks with foot stool to flex lumbar spine
BELU
Lumbar Stenosis: Therapeutic Exercise
Look at musculature: iliopsoas restricted (often more sitting results in pattern of restriction which exacerbates symptoms) Weak hip abductors, extensors, and rotators Trunk weakness
Posture: compensation (i.e. excessive cervical extension to compensate for forward flexed trunk) Treadmill with incline to increase endurance and
increase time to symptoms Aquatics!
BELU
Introduction Discuss spinal stenosis Discuss symptoms and characteristics Discuss management strategies Discuss possible use of injection therapy Indications/contraindications Risks/side effects/benefits Data
Spinal Stenosis Management StrategiesJoseph Tu, MD
TU
Symptoms
Degenerative lumbar spinal stenosis (LSS) is a common source of pain and disability in the elderly population
Neurogenic claudication is the hallmark symptom of LSS Classic Symptoms: Buttock and bilateral leg pain Worse with walking, prolonged standing, relative lumbar
extension) Typically relieved by sitting, bending forward, or pushing a
grocery cart
TU
Symptoms
Vascular Claudication: Relieved solely by rest (not having to sit or bend
forward) Walking uphill is worse
TU
Symptoms
LSS is a result of the degenerative spine cascade thus can affect Central spinal canal Lateral recesses Intervertebral foramina
Result in: Unilateral or bilateral, and monoradicular or polyradicular symptoms
TU
Symptoms
Axial back pain is also present Quality of this axial symptom is consistent with
osteoarthritis of the lumbar spine (stiffness with a dull, aching pain) default to a stooped-forward posture to alleviate
pain by widening the spinal canal and decreasing the forces on the zygaphophyseal joints
TU
Etiology
Not simply due to mechanical compression Multi-factorial There are vascular, biochemical, and
biomechanical factors that contribute to the symptoms of LSS
TU
Etiology
Venous engorgement theory Spinal veins dilate during ambulation in stenotic
patients Blood flow stagnates and intrathecal pressures
rise Microcirculatory neuroischemic insult
Claudication symptoms
TU
Etiology
Arterial insufficiency: Normally, lower limb exercise, including
ambulation, the lumbar radicular arterioles dilate to provide nourishment to the spinal nerve roots Arterial dilation may be defective in LSS
TU
Etiology
The inflammatory cascade: Stenosis acts as mechanical
compression of a nerve root may be a ‘‘primer’’ for a subsequent inflammatory response
Causes the radicular symptoms Chronic LSS to have periodic acute flares
of symptoms Chronically inflamed nerve root, with
increased mechanical sensitivity, can become perturbed by a new inflammatory precipitator, vascular changes, or degenerative instability (listhesis causing radicular symptoms)
TU
Management
Conservative Activity modification (limit extension-based activity) Assistive device for ambulation (walker) Medications (Tylenol, NSAIDs, neuromodulating agents,
and low dose opiates) Physical therapy and exercise
Interventional Epidural corticosteroid injections Surgery
TU
Prognosis
Natural history of LSS is not entirely known It is known that rapid neurological progression is
rare Chronic degenerative process Worsen with age
TU
Surgery vs Non-surgical
Studies of nonoperative therapy for lumbar stenosis report 15–45% improvement, 15–30% worsen, and the rest remain symptomatically about the same Outcomes at 1 and 4 years favored surgical management After 8–10 years, low back pain outcome, predominant
symptom (either back or leg pain) improvement, and satisfaction with their current status were similar
Leg pain relief, though, still favored those treated surgically
TU
Epidural Steroid Injection (ESI)
Epidural steroid injections are frequently used in nonoperative management regime Used as an adjunct to a comprehensive
rehabilitation program and not used in isolation Pain relief obtained with injections can facilitate
the patient’s tolerance of a rehabilitation program
TU
ESI
No clear evidence on when to initiate a trial, the frequency, nor duration of epidural steroid injection Literature does support their use for
predominantly radicular symptoms, especially acutely, and less for axial symptoms.
TU
ESI
‘‘Series of three’’: No literature support for this If one well-placed injection is not effective, then it
is unlikely that a second or third administered in the same location will be
However, potentially a different route of administration could be utilized for a second injection
TU
ESI
Mechanisms of pain relief of corticosteroids: Inhibition of nerve root edema Improved microcirculation Reduced ischemia Inhibition of prostaglandin synthesis Non-inflammatory action of direct inhibition of C-
fiber neuronal membrane excitation
TU
Different Approaches
Interlaminar Transforaminal Caudal Interlaminar with catheter Particulate vs non-particulate steroids Conflicting study results
TU
Different Approaches
Interlaminar Transforaminal Caudal Interlaminar with catheter Particulate vs non-particulate steroids Conflicting study results
TU
Different Approaches
Most studies noted: Short-term benefit ranging from 1 week to 2
months of relief One demonstrated a longer term benefit with up
to 10 months of relief Studies Varied in different approaches
TU
Different Approaches
Unilateral single dermatome symptoms, or post-laminectomy: Transforaminal
Particulate: risk of arterial thrombosis Non-particulate: no risk of thrombosis May be superior for
radiculitis/radiculopathy
Bilateral, non-specific symptoms: Interlaminar
Paramedian approach Catheter
Particulate Severe LSS, Post-laminectomy: Caudal
TU
Interlaminar
TU
Transforaminal
TU
Caudal
TU
Conclusion
Limited research evaluating the appropriate use of lumbar ESIs specifically to treat LSS Specific conclusions cannot be drawn There is no information to conclude which
injection technique is most efficacious
TU
Take Home
Trial Conservative management Surgical candidate? Failed conservative management? May trial ESI Various approaches to place the medication Trial and error for patient
TU
Surgical Options Direct decompression Open Vs. Minimally invasive
Indirect decompression X-stop Fusion TLIF XLIF ALIF *Interspinous fusion*
OH(IO)!! My Aching Back! - Lumbar Stenosis, Surgical DecompressionWilliam James Thoman, MD
THOMAN
Patient Selection
Claudication Stable Vs. unstable spine Flexion and extension x-rays
General health of patient Bone quality Back pain
THOMAN
Open decompression(laminectomy)
Standard approach Leg symptoms worse than back pain May use diagnostic injection
Stable spine on dynamic films Normal lordotic spine Advance age Poor bone quality
THOMAN
Open decompression(laminectomy)
Advantages Direct visualization Proven test of time Cannot tolerate fusion
Disadvantages Increase risk of infection Retraction injury?
Longer recovery due to pain from incision Iatrogenic instability
THOMAN
Minimally Invasive Decompression
Similar indication as open May be safe option for patient with stable
listhesis or mild instability Loss of some of the lordosis Maintain posterior tension band
Advance age Poor bone quality
THOMAN
Minimally Invasive Decompression
THOMAN
Minimally Invasive Decompression
Advantages (Anecdoctal) Decreased blood loss Decreased infection rate Decreased post-operative pain Decreased medication use Decreased hospital stay Decreased cost Decreased operative time
Depends on surgery and patient
Disadvantages Steep learning curve Understanding the anatomy
THOMAN
Indirect Decompression
X-stop Lumbar stenosis, foraminal stenosis
Fusion (TLIF, ALIF, XLIF, *Interspinous fusion*) Collapse disc space Spondylolisthesis Stable Unstable
Foraminal stenosis Back Pain?
THOMAN
X-stop
Interspinous distraction spacer Patient get relief when they lean forward
Distract bulging ligament Advantages
MIS procedure which is quick Elderly and sickly patient
Disadvantages Temporary
*Interspinous fusion devices* Similar to x-stop Opening for biologic products May be good for patient with slight listhesis or slight instability May be in addition to MIS decompression
THOMAN
X-stop
THOMAN
Lumbar Spinal Stenosis:To fuse or not to fuse?
Elizabeth Yu, MD
Indications Symptomatic spinal stenosis WITH: Spondylolisthesis Scoliosis Destabilization Greater than 50% of the facet joint is compromised Recurrent lumbar spinal stenosis with additional
resection
http://www.dartmouth.edu/sport-trial/whatissport.htm
YU
Spondylolisthesis
SPORT trial Multicenter study (13) LSS with spondylolisthesis Failed 12 weeks nonoperative treatment Outcomes: 6 weeks, 3 and 6 months, 1 and 2 years Short form-36: body pain and physical function Oswestry disability index
304 randomized, 303 observational cohorts Intention-to-treat analysis: no difference As-treated analysis: both cohorts showed significant
improvement in the surgical group up to 2 years (SF-36, ODI)
As-treated cohort: operative treatment had greater improvement in pain and function over 2 years than those treatment nonoperatively
YU
4 year follow up Maintenance of greater pain relief and
improvement in function of patient treated operatively VS. nonoperatively
YU
Fuse or not?
Herkowitz et. al. Prospective comparative study 50
patients Lumbar spinal stenosis with
spondylolisthesis 3 year follow up
Decompression VS. decompression with noninstrumented fusion Clinical improvement in pain and
neurogenic symptoms significantly better in fusion group
http://www.medscape.com/viewarticle/446146_3
YU
Instrument or not?
Fischgrund et. al. Prospective RCT 76 patients Lumbar spinal stenosis with
spondylolisthesis 3 year follow up
Decompression with noninstrumented fusion VS. decompression with instrumented fusion 83% fusion rate with
instrumentation VS. 45% without instrumentation HOWEVER no significant
difference in clinical outcome of pain and neurogenic symptoms
YU
Scoliosis
Progression of curve Concern for continued
progression with decompression alone
Stiffness of curve Overall sagittal and coronal
balance Concavity of curve Distraction may be necessary
YU
Case 54 year old male who neurogenic claudication. 50% back pain with start up pain 50% bilateral thigh pain with ambulation and
standing Temporary relief from ESI injections
YU
3 months postoperatively
YU
Discussion and Questions