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lumbar spinal stenosis

A narrowing of the lumbar spinal canal. Etiology: 1) spondylosis, or degenerative arthritis affecting the spine (most common) [5] 2) progressive disc degeneration due to aging, trauma, or other factors 3) facet osteophytes, ligamentum flavum hypertrophy, & disc bulging can encroach on the central canal & neural foramina 4) spondylolithesis can exacerbate spinal stenosis 5) space-occupying lesions - lipoma, synovial cysts, neural cysts, other neoplasms 6) metastatic calcification 7) traumic & post-surgical, fibrosis 8) skeletal disease - Paget's disease of bone - ankylosis spondylitis, - rheumatoid arthritis - diffuse idiopathic skeletal hyperostosis (DISH) 9) developmental causes - dwarfism: achondroplasia, Morquio's syndrome - spinal dysraphism: spina bifida, spondylolithesis, myelomeningocele Epidemiology: - common in the elderly (> 60 years of age) Pathology: 1) mechanical compression & ischemia of nerve roots 2) pathology is largely bony & unlikely to improve spontaneously 3) role of inflammation is uncertain 4) may coexist with spinal pathology in thoracic spine 5) most commonly L3-L4, L4-L5 Clinical manifestations: 1) pain that radiates to the buttocks & proximal legs, or pain may begin distally (calf) & ascend [3] 2) pain is induced by walking & relieved by rest 3) pain takes several minutes to resolve when induced by walking* 4) thigh pain induced after 30 seconds of lumbar extension 5) pain is relieved by spinal flexion a) increases the spinal canal space b) stooping, bending forward, sitting, lying in a flexed position, climbing a hill c) no pain when sitting (LR=1.9-30) [14] d) relief of pain at night by flexion of hip & knee [11] 6) pain is aggravated by extension of the spine a) further narrows the spinal canal space b) standing, walking, & descending hills or walking up or down stairs [18] 7) burning sensation around the buttocks (LR=1.6-32) [14] 8) intermittent priapism associated with walking (LR=1.6-32) [14] 9) wide-based gait (LR=1.9-95) [14] 10) abnormal Romberg test (LR=1.4-13) [14] 11) neuromuscular deficits of the lower extremity - weakness of L4, L5, S1 innervated muscles - hallux extensors, hip abductors, hip extensors, ankle dosiflexion - weakness of extension at the knee (L2, L3, L4, quadriceps) - tightness of hamstrings (L4, L5, S1, S2) 12) deep tendon reflexes may be absent at the ankles, but normal at the knees [18] 13) neurologic exam may be normal if the patient is rested * in contrast, pain due to peripheral vascular diseases resolves promptly Special laboratory: - electromyography & nerve conduction testing generally not required - absent H-reflex is a subtle manifestation of S1 nerve involvement - exercise tolerance testing (ETT) does not have a specific role, but can be useful - ankle-brachial index (ABI) if vascular disease suspected Radiology: - magnetic resonance imaging (MRI) of the lumbar spine (without gadolinium) [25,26] - lumbar spinal stenosis may coexist with spinal pathology in the thoracic spine - include thoracic spine in MRI if clinical manifestations do not fit lumbar spinal stenosis [11] - lumbar spinal stenosis may be incidentally detected in patients who have imaging for another reason [18] - the degree of stenosis does not predict severity of symptoms - X-rays of the knees & hips if osteoarthritis suspect Complications: - cauda equina syndrome Differential diagnosis: 1) peripheral vascular disease (intermittent claudication) 2) osteoarthritis of the spine, hips, knees 3) distal polyneuropathy generally without postural or activity effects 4) inflammatory conditions involving lumbosacral nerve roots or cauda equina are generally without neurogenic claudication 5) vertebral compression fracture of the lumbar spine [18] Management: 1) conservative management a) physical therapy* - evidence-based support is lacking - as effective as surgery [15] - no randomized controlled trials demonstrate effectiveness (GRS11) [11] b) stretching, strengthening, aerobic fitness c) weight loss in overweight patients d) abdominal corsets controversial 2) pharmaceutical pain management: a) NSAIDs b) opiates 3) epidural glucocorticoids &/or anesthetics of limited benefit - glucocorticoid-lidocaine no better than lidocaine alone [12,17] - prednisone of no benefit (see low back pain) 4) surgery (laminectomy) [11]* a) urgent surgery indicated for - rapidly progressive neurological symptoms - onset of bladder dysfunction b) outcomes better than conservative management because pathology is largely bony & unlikely to change spontaneously [7,11] c) outcome predictors for surgery - positive: male, younger, better ability to walk, less comorbidity, more pronounced canal stenosis - negative: depression, cardiovascular disease, scolisis - outcomes for octogenarians similiar to outcomes for younger patients (mean age 64 years) [13] d) consider spinal cord stimulation if persistent pain after surgery [8] e) microdecompression is as effective as the more invasive open laminectomy [14] f) adding fusion surgery to decompression surgery of little to no benefit & is associated with longer hospitalization & increased costs [19] * laminectomy correct choice vs physical therapy per GRS8, GRS11 [11]

Interactions

disease interactions

Related

1st sacral spinal nerve (S1) 4th lumbar spinal nerve (L4) 5th lumbar spinal nerve (L5) neurogenic claudication; pseudoclaudication

General

spinal stenosis

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  3. Alvarez JA & Hardy RH Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician 57:1825, 1998 PMID: 9575322
  4. North American Spine Society Diagnosis and treatment of degenerative lumbar spinal stenosis http://www.spine.org/forms/NASSCG_Stenosis.pdf corresponding NGC guideline withdrawn Jan 2017
  5. Binder DK et al, Lumbar spinal stenosis Semin Neurol 2002, 22:157 PMID: 12524561
  6. Mazanec DJ et al, Lumbar Canal Stenosis: start with nonsurgical therapy. Cleve Clin J Med 2002, 69:909 PMID: 12430977
  7. Weinstein JN et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008 Feb 21; 358:794. PMID: 18287602 - Weinstein JN, Tosteson TD, Lurie JD et al Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976). 2010 Jun 15;35(14):1329-38. PMID: 20453723
  8. Chou R et al, Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009 May 1;34(10):1066-77. PMID: 19363457
  9. Suri P, Rainville J, Kalichman L, Katz JN. Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? JAMA 2010; 304(23):2628-2636 PMID: 21156951
  10. Burnett MG, Stein SC, Bartels RH Cost-effectiveness of current treatment strategies for lumbar spinal stenosis: nonsurgical care, laminectomy, and X-STOP. J Neurosurg Spine. 2010 Jul;13(1):39-46. PMID: 20594016
  11. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  12. Friedly JL et al A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. N Engl J Med 2014; 371:11-21. July 3, 2014 PMID: 24988555 http://www.nejm.org/doi/full/10.1056/NEJMoa1313265 - Andersson GB Epidural Glucocorticoid Injections in Patients with Lumbar Spinal Stenosis. N Engl J Med 2014; 371:75-76July 3, 2014 PMID: 24988561 http://www.nejm.org/doi/full/10.1056/NEJMe1405475
  13. Rihn JA et al. Effectiveness of surgery for lumbar stenosis and degenerative spondylolisthesis in the octogenarian population: Analysis of the Spine Patient Outcomes Research Trial (SPORT) data. J Bone Joint Surg Am 2015 Feb 4; 97:177 PMID: 25653317 http://jbjs.org/content/97/3/177
  14. Nerland US et al Minimally invasive decompression versus open laminectomy for central stenosis of the lumbar spine: pragmatic comparative effectiveness study. BMJ 2015;350:h1603 PMID: 25833966 http://www.bmj.com/content/350/bmj.h1603?etoc=
  15. Delitto A, Piva SR, Moore CG et al Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis: A Randomized Trial. Ann Intern Med. 2015;162(7):465-473 PMID: 25844995 http://annals.org/article.aspx?articleid=2214174 - Katz JN Surgery for Lumbar Spinal Stenosis: Informed Patient Preferences Should Weigh Heavily. Ann Intern Med. 2015;162(7):518-519. PMID: 25844999 http://annals.org/article.aspx?articleid=2214181
  16. The NNT: Spinal Stenosis in the Elderly Diagnostics and Likelihood Ratios, Explained http://www.thennt.com/lr/spinal-stenosis-in-the-elderly/
  17. Chou R, Hashimoto R, Friedly J et al Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. Published online 25 August 2015 PMID: 26302454 http://annals.org/article.aspx?articleid=2430207
  18. Medical Knowledge Self Assessment Program (MKSAP) 17, 19 American College of Physicians, Philadelphia 2015, 2023
  19. Forsth P, Olafsson G, Carlsson T et al A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med 2016; 374:1413-1423. April 14, 2016 PMID: 27074066 http://www.nejm.org/doi/full/10.1056/NEJMoa1513721 - Peul WC, Moojen WA. Fusion for Lumbar Spinal Stenosis - Safeguard or Superfluous Surgical Implant? N Engl J Med 2016; 374:1478-1479. April 14, 2016 PMID: 27074071 http://www.nejm.org/doi/full/10.1056/NEJMe1600955
  20. Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):253-65. Review. PMID: 20227646 Free PMC Article
  21. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008 Feb 21;358(8):818-25. PMID: 18287604
  22. NEJM Knowledge+ Question of the Week August 7, 2018 https://knowledgeplus.nejm.org/question-of-week/695/ - Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016;352:h6234 PMID: 26727925 PMCID: PMC6887476 Free PMC article https://www.bmj.com/content/352/bmj.h6234
  23. Zaina F, Tomkins-Lane C, Carragee E et al. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016 Jan 29;2016(1):CD010264 PMID: 26824399 PMCID: PMC6669253 Free PMC article https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010264.pub2/full
  24. NEJM Knowledge+ Neurology
  25. Lafian AM, Torralba KD. Lumbar spinal stenosis in older adults. Rheum Dis Clin North Am. 2018;44:501-512. PMID: 30001789
  26. Rao D, Scuderi G, Scuderi C, Grewal R, Sandhu SJ. The Use of Imaging in Management of Patients with Low Back Pain. J Clin Imaging Sci. 2018 Aug 24;8:30. PMID: 30197821 PMCID: PMC6118107 Free PMC article. Review.
  27. National Institute of Arthritis and Muscluloskeletal and Skin Diseases (NIAMS) Spinal Stenosis https://www.niams.nih.gov/health-topics/spinal-stenosis