Jennifer Belu, PT, MPH - - Physical Therapy Physical Therapy - - PowerPoint PPT Presentation

Jennifer Belu, PT, MPH Jennifer Belu, PT, MPH -

• Physical Therapy

Physical Therapy Joe Tu, MD Joe Tu, MD -

• PM&R

PM&R James Thoman, MD James Thoman, MD – – Neurosurgery Neurosurgery Elizabeth Yu, MD Elizabeth Yu, MD -

• Orthopedics

Orthopedics

Case Presentation – Lumbar Stenosis

• Patient is a 68 year old female with a chief complaint
• f 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
• f 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 aging
• 1. Stenosis is a product of aging
• A. Facets get larger (spurs)
• A. Facets get larger (spurs)
• B. Thicker ligamentum flavum
• B. Thicker ligamentum flavum
• C. Facets become unstable listhesis
• C. Facets become unstable listhesis

(especially in females) (especially in females)

• D. Veeerrrrryyyyy slow process
• D. Veeerrrrryyyyy slow process
• 2. Patients may remain stable for years
• 2. Patients may remain stable for years
• 3. Very Very Very rarely become paralyzed
• 3. 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 Strategies Joseph 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
• steoarthritis 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
• f 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,
• r 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
• f 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 Decompression William 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

• peratively 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