Ben Okafor FRCS FRCS.orth Consultant Orthopaedic & Spine Surgeon Whipps Cross University Hospital

Transcription

1 Ben Okafor FRCS FRCS.orth Consultant Orthopaedic & Spine Surgeon Whipps Cross University Hospital

2 Classification Pathology Clinical features Imaging Treatment Options Outcomes

3 Definition: 1. Narrowing of the spinal canal or neuroforamina 2. Leading to symptomatic compression of the neural element. Increasing degeneration (Age > 60) Hallmark: Neurogenic claudication Symptoms > Signs Main pathology: Facet arthropathy / hypertrophy

4 Developmental / Congenital Stenosis: - Short Pedicles / Wide Pedicles - Reduced AP Diameter - Onset: yrs. Degenerative Stenosis: - Facet Hypertrophy - Ligament + Capsular Hypertrophy - Reduced AP + ML Diameter (concentric) - Disc bulge - Onset: yrs.

5 Relative reduction of intra-spinal space 1. Reduced bony dimensions Facet Hypertrophy Congenitally narrow canal 2. Increased contents Thickened ligamentum flavum Disc prolapse Epidural Lipomatosis (BMI>35; N=20-25)

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7 Pain / Paraesthesia Neurogenic claudication Standing leg intolerance Back Pain NORMAL neurology

8 Age of Onset: yrs. L5 Root / L4-5 Level >1 root involvement: 60-70%

9 KEY to diagnosis Onset of Pain: ie on walking Distribution of pain: Dermatomal vs. Non-dermatomal Aggravating Factors Relieving Factors Uphill / Trolley

10 my legs turn to jelly my legs don t want to obey me easier to walk uphill I used to walk miles, now I can t I always think of a place to sit, before setting out from home Shopping Trolley Test

11 Venous Congestion Micro-vascular ischaemia Impaired clearance of inflammatory mediators Root Inflammation (+/- Oedema, Fibrosis) Dorsal Root Ganglion excitability Botwin (2003); Truumees (2005); Ma (2005)

12 Local Signs: Midline / Paramedian Tenderness, Spinal RoM Neurological Signs: Often None But exclude Upper motor neurone lesion Tension Signs: Usually None

13 Abdomen: AAA; renal Vascular Claudication- pulses Hip / Knee / SIJ examination Gait/posture

14 Physical Finding Literature Review Limited lumbar extension % Muscle weakness 18-52% Sensory deficit 32-58% Katz JN, et al: Diagnosis of lumbar spinal stenosis. Rheum. Dis. Clin. North Am. 20: , 1994

15 Vascular Claudication Hip / Knee OA Trochanteric Bursitis Peripheral Neuropathy (? DM) Rare causes: Renal / retroperitoneal mass Sacral tumour Spinal Infection Exaggerated Pain response (Depression / Litigation)

16 Medical: Anti-coagulation CVS / Chest / Renal Diabetes Surgical: Any previous surgery Segmentation defects Coronal/Rotational Deformity: Scoliosis Sagittal Deformity: Spondylolisthesis

17 X-Rays Standing Spine?pelvis/hips MRI CT (+/- myelogram)

18 Screening exam Stenosis cannot be diagnosed Assessment spinal alignment

19 Non-invasive Soft tissue visualization Gold standard

20 Sagittal images Visualization of foramen

21 Superceded by MRI Useful if MRI contraindicated

22 Claustrophobia Open MRI Weight bearing MRI Temazepam 20mg (anxiety)

23 Differentiation between neuropathy and radiculopathy Acute active denervation vs. chronic denervation

24 Non-operative Operative

25 Oral Meds: NSAID s naproxen etc Steroids: eg prednisolone?? Suppository: eg diclofenac 100mg -Short course Muscle relaxants:diazepam/baclofen Opiates/pain killers- be wary!

26 Tricyclic antidepressants: -blocks serotonin reuptake Sedative: amitriptyline 10-75mg Less sedative: Nortriptyline 10-75mg Second line treatment Gabapentin; pregablin;duloxetine

27 PhysioRx: Flexion-Stabilisation Program Back School Bracing Chiropractic Rx Osteopathic Rx Self help Strengthening Flexibility Open up spinal canal Loosen soft tissues Reduce symptoms Maintenance exercises

28 TRACTION THERAPY?

29 Indication: Therapeutic Diagnostic Anatomical Location Root Facet Epidural Foraminal

30 Johnsson et al (1992) The natural course of lumbar spinal stenosis. Acta Orthop Scand Suppl 1993;251: patients; non-surgically treated Mean age: 60 yrs. Mean F/u: 49 months 75%: Unchanged 15%: Better 15%:Deteriorated

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32 Low co-morbidity Symptom duration Leg pain predominant Leg pain and weakness Cauda equina symptoms? painless motor weakness?? Chronic neuropathic pain??sensory symptoms predominant??multiple co-morbidities?

33 To Decompress & restore intra-spinal capacity Front: Disc Back: Lig. Flavum + Facets To Stabilise? Fuse? Soft Stabilisation? Motion preserving To maintain the intra-spinal capacity gained

34 To recreate the natural Intra-Spinal Volume To ensure that this volume is maintained (even in the erect posture) To avoid de-stabilising the spine

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38 Sagittal plane Instability Coronal plane Instability Symptomatic

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40 WALLIS Device/DIAM etc

41 WALLIS Device

42 Interspinous distraction/spacer devices (stand alone)

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44 LEG PAIN: Improvement expected Pre-op neural damage may preclude improvement in leg pain BACK PAIN: May NOT Improve Any improvement is an added bonus

45 Surgery Metanalysis of 74 studies 70% with good to excellent outcomes Katz, et al. Spine pts followed for 7 yrs 3-5 yrs 60% free of severe pain, 20% in pain, and 15% re-operated Non-surgical 52% 4 yrs

46 General: Infection DVT / PE Anaesthetic / Positioning related Specific / Technical: Neural / Dural Damage CSF Leak / Long term complications Cauda Equina Syndrome Recurrence (of PIVD &/or Stenosis) Complications of instrumentation Long Term: Persisting Leg / Back Pain Post-op Scarring RSD? Need for Re-surgery

47 Relative reduction of intra-spinal volume Spinal stenosis is a clinical diagnosis Hallmark: Neurogenic claudication Main pathology: Facet arthropathy / hypertrophy Mode of treatment depends on severity

48 Pain beyond 6 weeks without improvement Failure of conservative treatment Deteriorating symptoms Previous back surgery? Neurologic symptoms/signs of concern or deficit Constant back and leg pain Pain causing sleep disturbance (red flags?) Cauda equina syndrome

49 Ben Okafor FRCS FRCS.orth Consultant Orthopaedic & Spine Surgeon Whipps Cross University Hospital Private secretary:

50 Thank you