Transcript Spinal Stenosis

September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
LUMBAR SPINAL STENOSIS
Evidence Based Masterclass
Eleanor Dunstan
Spinal Physiotherapy ESP
LUMBAR SPINAL STENOSIS (LSS)
‘A clinical syndrome of buttock or lower
extremity pain, which may occur with or
without back pain, associated with diminished
space available for the neural and vascular
elements in the lumbar spine’
Watters 2008
AGE CHANGES IN THE SPINE
ETIOLOGY
DEGENERATIVE
FRACTURES
INFECTION
TUMORS
ACQUIRED
PAGETS
SPONDYLOLISTHESIS
POST SURGICAL
PATIENT PRESENTATION
• Back pain, usually prolonged Hx
• Leg pain, (approx 90% of cases, Fritz 1998) unilateral or bilateral but of
more recent onset.
• Neurogenic claudication (NC) - progressive weakness, tiredness or
heaviness of the legs when walking. Evident in 62% of LSS, (Turner et al)
• Stooped posture
• Wide based gait
• Symptoms exacerbated with extension and relieved with flexion.
Extension usually limited.
• Motor or sensory disturbance, 50% (Fritz et al) show objective signs.
PATHOPHYSIOLOGY
• Lumbar extension reduces cross sectional area of central canal, and
foramina reported as 20-67% in stenotic spine.
• Pressure is exerted on venules surrounding nerve fibers, leading to
engorgement and ischemic nerve impairment, (Katz, 2008)
• Neurogenic claudication is thought to result from intermittent hypoxia
resulting in ischemic nerve conduction failure and transient chemical
and electrophysiological changes, (Adamova, 2003)
• The proposal of transient ischemia may account for symptom
reversibility in spinal flexion when sitting or leaning forwards.
IMAGING
• MRI is the study of choice in
diagnosis of LSS - can visualise
disc, soft tissue,bony change and
intrathecal content.
• No image can diagnose stenosis
without a corresponding clinical
history.
• Imaging can appear worse than
the symptoms suggest and
doesn’t necessarily correlate with
clinical findings.
• Boden et al, reported 21%
prevelance of stenosis on MRI in
asymptomatic individuals over
65.
CASE HISTORY
Subjective Examination
Objective Examination
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•
•
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• Stooped posture, flat Lsp.
• Full Lsp flexion, painful restricted
extension.
• Alt LT sens right outer shin.
• Normal power
• +ve SLR right 60 degrees
• AJ/KJ, P&E
•
•
•
•
•
64 year old male.
R TKR, HTN
20yr Hx LBP
12mth Hx bilat L/L numbness,
knees-feet.
6/12 Hx right leg pain.
Worse with walking/lifting
Min Sx when pushing trolley
Denies leg weakness / falls
Co-codamol 30/500, helps.
MRI RESULTS
a) L4/5 stenosis
b) Narrowed L4/5
neuroforamen, L4 NR
comp.
c) Hypertrophic Facets,
with intra-articular
effusions and hypertrophy
of lig flavum.
DIAGNOSTIC UTILITY
• De Graaf et al, 2006, systematic review of
diagnostic accuracy for LSS, (24 articles).
• Revealed considerable variation in clinical tests.
Some showed high sensitivity others high
specificity, but not both.
• Poor quality and incomparability of studies mean
conclusions regarding diagnostic accuracy and
utility could not be drawn.
ANYONE NEED A REMINDER?
Sensitivity : True +ve rate
• Proportion of patients with LSS who test positive.
Specificity : True –ve rate
• Proportion of patients without LSS who test
negative.
Likelihood Ratios:
Expression of diagnostic usefulness
+VE LR >5 Rules in diagnosis
-VE LR <.30 Rules out diagnosis
DIAGNOSTIC VALUES
Ax
Sens
Spec
+ve LR
-VE LR
MRI
77-87%
94-100%
8
.03
Ease sit
52%
83%
3.1
.58
Agg walk
71%
30%
1.0
.96
Trolley +ve
63%
67%
1.9
.55
Pain free
flexion
79%
44%
1.4
.48
Leg pain
extension
51%
69%
1.6
.71
Treadmill
incline (Sx)
68%
83%
4.1
.93
Treadmill
incline
(recovery)
82%
68%
2.6
.26
IN SUMMARY
• Acquired degenerative stenosis is the most
common reason for spinal surgery in >65.
(Deyo,2010)
• Pathophysiology surrounding phenomenon of NC
is still unclear.
• Index of suspicion for LSS raised from multiple
sources. No one gold standard test.
• MRI will rule in the diagnosis of LSS, but needs
careful clinical correlation to action appropriate
management.
DIFFERENTIAL DIAGNOSIS
PVD
B12
LSS
OA
DPN
CASE STUDIES
CASE STUDY 1
Subjective Examination
• 67 year old lady.
• Coeliac, T2 DM
(Metformin), HTN.
• 18mth Hx painful
parasthesias both legs.
• Limited walking distance
1/2mile
- Pain in calf and feet
- Fatigue
Objective Examination
• Limited, painful Lsp ROM.
• Normal power and sens.
• Reflexes P&E, AJ/KJ
• -VE SLR bilat
• Wide BOS, slight ataxic gait
pattern.
• UMN exam - NAD
CASE STUDY 2
Subjective Examination
• 75 year old lady.
• T2 DM, HTN,AF,
Hypothyroid (Rx),CKD.
• Bilateral Foot Pain 5yrs
- Shooting / tingling
- Worsening numbness
- Pain / cramps at night
- Neck pain, no LBP
- Diclofenac /Co-codamol,
unable to tolerate
pregabalin.
Objective Examination
• Normal Csp ROM, no pain.
• Alt sens LT/PP, buttocks,
thighs, calf and feet bilat.
• No weakness
• Absent AJ’s bilaterally
• Normal Csp XR
• Normal routine bloods.
CASE STUDY 3
Subjective Examination
• 70 year old male.
• IHD, HTN, Prostate CA,
Smoker, Obesity.
• 6/12 Hx bilat thigh and calf
pain.
- Cramping pain with walking.
- Intermittent calf numbness.
- Tired, heavy legs.
- Cold feet.
• No help with analgesia.
Objective Examination
•
•
•
•
•
Limited and painful Lsp mvt.
Normal Sens and power.
-VE SLR
P&E, AJ/KJ
Discolouration right foot,
slow capillary refill.
• Normal / equal dorsalis
pedis pulses.
PERIPHERAL ARTERY DISEASE (PAD)
• Atherosclerosis leads to arterial insufficiencies
and intermittent ischemia, vascular claudication.
• Symptoms: cramping/ache in posterior leg
muscles. Occurs with exercise, subsides with rest.
• Blockages may be in the abdomen, pelvis, groin,
thigh and/or calf.
• Associated CVS risk factors.
EXAMINATION
Capillary Return
AORTIC PALPATION
PERIPHERAL PULSE CHECK
DIAGNOSIS
•
•
•
•
•
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Pulses
Ankle–brachial index (ABI)
Doppler Ultra Sound
CT angiography
MR angiography
Angiogram
VASCULAR V NEUROGENIC CLAUDICATION
• Leg pain with walking – NOT alleviated with sitting /
stooping.
• Leg pain with cycling – NOT with LSS
• Stairs elicit pain – Only coming downstairs with LSS
• Symptoms in posterior leg muscles.
• CV History
CASE STUDY 3
Subjective Examination
• 70 year old male.
• IHD, HTN, Prostate CA,
Smoker, Obesity.
• 6/12 Hx bilat thigh and calf
pain.
- Cramping pain with walking.
- Intermittent calf numbness.
- Tired, heavy legs.
- Cold feet.
• No help with analgesia.
Objective Examination
• Limited and painful Lsp mvt.
• Normal Sens and power.
• -VE SLR
• P&E, AJ/KJ
• Discolouration right foot,
slow capillary refill.
• Normal / equal dorsalis
pedis pulses.
DIABETIC POLYNEUROPATHY (DPN)
• Prevalence: 66% Type I, 59% Type II
• Pathogenisis: metabolic and vascular
- Poor glucose control +/or duration
- Associated with modifiable CVS risk factors
• Clinical manifestations mostly sensory. Length related
distribution, toes and feet most affected.
• Significant distal weakness is uncommon.
• AJ reflexes absent.
Diabetes damages the nervous system in 2
main ways:
1. High glucose levels
causes biological
change, resulting in
nerve break down
2. High glucose levels
damage the blood
vessels that supply
nerves with oxygen and
nutrition, accelerating
the neural break down.
LSS V DPN
• Clinical history and note of other sensory sx
• Presence of retinopathy / nephropathy.
• Use of vibration/monofilament sensory
examination.
• Nerve conduction studies: Electophysiological
examination contributes to the differential
diagnostics between LSS and DPN
(Adamova, 2003)
CASE STUDY 2
Subjective Examination
• 75 year old lady.
• T2 DM, HTN,AF,
Hypothyroid (Rx),CKD.
• Bilateral Foot Pain 5yrs
- Shooting / tingling
- Worsening numbness
- Pain / cramps at night
- Neck pain, no LBP
- Diclofenac /Co-codamol,
unable to tolerate
pregabalin.
Objective Examination
• Normal Csp ROM, no pain.
• Alt sens LT/PP, buttocks,
thighs, calf and feet bilat.
• No weakness
• Absent AJ’s bilaterally
• Normal Csp XR
• Normal routine bloods.
VITAMIN B12 DEFICIENCY
• B12 works with folate in the synthesis of DNA and RBC
• Involved in production of myelin sheath and
conduction of nerve impulses.
• Dietry source is from animal products.
• Pernicious Anaemia – autoimmune condition affecting
1:10,000.
• Can mimic symptoms of stenosis and occur as a dual
pathology.
Vegetarians /
Vegans
Symptoms Include:
•Tiredness
•Lethargy
•Paraesthesia's of extremities
•Ataxia
•Neurological Disturbance
PPI’S / Acid
supressing
drugs
Elderly >60
At
Risk
Substance
Abuse:
Alcoholism,
Nitrous Oxide
Diabetics on
Metformin
Malabsorption:
Chron’s, UC,
Coeliac,IBS
CASE STUDY 1
Subjective Examination
• 67 year old lady.
• Coeliac, T2 DM
(Metformin), HTN.
• 18mth Hx painful
parasthesias both legs.
• Limited walking distance
1/2mile
- Pain in calf and feet
- Fatigue
Objective Examination
• Limited, painful Lsp ROM.
• Normal power and sens.
• Reflexes P&E, AJ/KJ
• -VE SLR bilat
• Wide BOS, slight ataxic gait
pattern.
• UMN exam - NAD
CONSIDER
• Retrospective study of 457 spinal out-patients,
8.5% were B12 deficient.(Patel, Rasul & Sell, 2011)
• Literature suggest as common as 1:10 >75yrs
• Detection of deficiency with consequent
treatment results in better outcomes.
• Conclude that in older, stenotic population, with
sensory symptoms B12 deficiency should be
considered.
IN SUMMARY
• Even if LSS has been confirmed via MRI, other
conditions may co-exist.
• Careful questioning and examination should aim rule
out other possible pathologies.
• Further diagnostics may be required to confirm
suspicions.
• Successful treatment outcome depends on correct
differential diagnosis.
REFERENCES
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Adamova B, Vohanka S, Dusek L. Differential diagnostics in patients with mild lumbar spinal stenosis: the contributions and
limits of various tests. Eur Spine J, 2003 12:190-196.
Anekstein Y, Smorgick Y, Lotan R et al. Diabetes Mellitus as a risk factor for the development of lumbar spinal stenosis. IMAJ
2010;12:16-20.
Agency for Healthcare Research and Quality. Treatment of Degenerative Lumbar Spinal Stenosis. Summary, Evidence
report/technology assesment:number 32. AHRQ Publication No. 01-E047, March 2001.
Barz T, Melloh M, Staub L et al. The diagnostic value of a treadmill test in predicting lumbar spinal stenosis. Eur Spine J
2008;17:686-690.
Boden S, Davies DO, Dina TS et al. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. A
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Deyo RA, Mirza SK, Martin BL et al. Trends, major medical complications, and charges associated with surgery for lumbar
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Fritz JM, Delitto A, Welch WC et al. Lumbar spinal stenosis: a review of current concepts in evaluation, management and
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Goldman SM. Diabetis peripheral neuropathy and spinal stenosis: prevalence of overlap and misdiagnosis. An introductory
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REFERENCES
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Patel MS, Rasul Z, Sell P. Dual pathology as a result of spinal stenosis and vitamin B12 deficiency. Eur Spine J 2011;20:22472251.
Richmond BJ, Ghodadra T. Imaging of spinal stenosis. Phys Med Rehabil Clin N Am 2003;14:41-56.
Sugioka T, Hayashino Y, Konno S et al. Predictive value of self-reported patient information for the identification of lumbar
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Szpalski M, Gunzburg R. Lumbar spinal stenosis in the elderly:an overview. Eur Spine J 2003;12:88-93.
Turner JA, Ersek M, Herron L et al. Surgery for lumbar spinal stenosis: An attempted meta-analysis of the literature. Spine
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Watters WC, Baisden J, Gilbert TJ et al. Degenerative lumbar spinal stenosis:an evidence-based clinical guideline for the
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