Lumbar Spinal Stenosis
Lumbar Canal Stenosis
Lumbar spinal stenosis is a narrowing of the spinal canal that may lead to nerve entrapment and subsequent clinical manifestations. The constellation of symptoms includes leg and back pain, neurogenic claudication, difficulty with walking, and other possible complications.
Presentation
Lumbar spinal stenosis (LSS) is a narrowing of the spinal canal in the lumbar region, in which the surrounding osseous and soft tissue structures lead to nerve compression [1] [2]. This condition is either congenital [3] or secondary to a degenerative process, trauma, infection, or surgery [4]. LSS commonly affects the aging population and has a slight predilection for males [1].
The clinical presentation, which is insidious, initially consists of backache but eventually progresses to include worsening pain, fatigue, weakness, and numbness of the leg(s) [1]. Specifically, patients describe symptoms such as tingling, burning, cramping, fatigue, and stiffness of the lower extremities. Moreover, the leg pain is most often bilateral and radiates distally, particularly with exercise [1].
As evident in the majority of cases, neurogenic intermittent claudication is the most predominant sign attributed to LSS [4] [5]. This manifestation is produced and worsened by walking or standing but alleviated with sitting or lying down on the side [1] [4]. Squatting and bicycle riding may also provide relief since flexion of the trunk leads to widening of the lumbar canal [1]. As the disease advances, the patient is likely to adopt a stooped posture [1].
LSS in the younger population [6] may cause radicular symptoms consisting of unilateral neurogenic claudication due to stenosis of the foraminal or lateral recess canal [4]. These patients experience severe leg pain that is worsened with lumbar extension [7].
Complications
Excruciating leg pain, paresthesia, and difficulty with ambulation are all likely sequelae in patients with LSS. Additionally, other possible complications include neurogenic bladder and/or abnormal bowel function [1] [8] and nocturnal leg cramps [9].
Physical exam
On visual inspection, the patient may have a stooped posture. Furthermore, examination of the lower back reveals limited extension [6]. Additionally, a neurological assessment may show absent or reduced ankle reflexes as well as sensory deficits [4].
Entire Body System
Nocturnal Leg Cramp
- Additionally, other possible complications include neurogenic bladder and/or abnormal bowel function and nocturnal leg cramps. Physical exam On visual inspection, the patient may have a stooped posture.[symptoma.com]
Skin
Ulcer
- Too many NSAIDs can cause ulcers and other stomach problems and, especially among older people, may increase the chance of heart attacks and strokes. They might also interact with other medicines.[webmd.com]
- They can lead to gastritis or stomach ulcers. If you develop acid reflux or stomach pains while taking an anti-inflammatory, be sure to talk with your doctor. Steroid injections. Cortisone is a powerful anti-inflammatory drug.[orthoinfo.aaos.org]
Neurologic
Abnormal Gait
- Early symptoms are mostly abnormal sensations in the hands, abnormal gait – particularly in the dark –, and deficiencies in the fine motor skills of the hands. Disturbances in writing mostly occur at advanced stages.[doi.org]
Insomnia
- MAIN OUTCOME MEASURES: We assessed back/leg pain intensity, the frequency and severity of NCCs, insomnia severity, and functional disability at baseline and after 2 weeks, 1 month, and 3 months.[ncbi.nlm.nih.gov]
Workup
Patients presenting with the above symptoms should be evaluated by their personal history, clinical picture, physical exam findings, and confirmatory studies. It is important to note that the severity of the clinical presentation does not usually correspond to the degree of stenosis [1].
Imaging
The American College of Physicians (ACP) recommends against routine imaging for low back pain unless there are risk factors for infection, malignancy, or other diseases [10] [11]. However, the traditional workup has included spinal radiography as the initial test. In patients with LSS, this modality is likely to reveal abnormalities such as degenerative changes in the disc or vertebrae, or other disease processes [1].
A spinal computed tomographic (CT) scan provides visualization of the canal and allows for accurate measurements of its diameter [1]. It may demonstrate narrowed canal with impingement by surrounding structures resulting in a "cloverleaf" or the pathognomonic "trefoil" appearance. To improve sensitivity, intrathecal contrast can be used but this is associated with risks.
Magnetic resonance imaging (MRI), the preferred study for diagnosis of LSS, is useful in the assessment of the spinal cord and associated soft tissue structures such as the cauda equina, epidural fat, intervertebral discs, etc. [1]. Additionally, this test helps rule out differential diagnoses. Specifically, LSS has characteristic appearances on T1 and T2-weighted images.
Other
Electromyelography is not required but is beneficial in diagnosing neuropathies secondary to demyelination and inflammation [1].
X-Ray
Schmorl's Nodes
- Schmorl's nodes (SNs) are described as vertical herniation of the disc into the vertebral body through a weakened part of the end plate that can lead to disc degeneration.[ncbi.nlm.nih.gov]
Treatment
- No patient underwent surgical treatment during the study period. The symptom severity scores of the ZCQ improved significantly after treatment in the medication (p 0.048), exercise (p 0.003), and acupuncture (p 0.04) groups.[ncbi.nlm.nih.gov]
- Moreover, subgroup analysis showed there were no safety differences between laminectomy and conservative treatment, X-STOP and conservative treatment at early stage of duration.[ncbi.nlm.nih.gov]
- Finally, the benefits of surgical treatment versus nonsurgical treatment is ultimately inconclusive because of the nature of data collection, inconsistencies with the clinical definition of LSS, and a lack of standardized treatment guidelines.[ncbi.nlm.nih.gov]
- We also screened reference lists and conference proceedings related to treatment of the spine.[ncbi.nlm.nih.gov]
- Based on treatment traditions, open laminectomy has been the gold standard surgical treatment, but various other surgical and non-surgical treatments for LSS are widely used in clinical practice.[ncbi.nlm.nih.gov]
Prognosis
- Radiological findings were mainly referred to for diagnosis, and clinical symptoms, age, radiological findings, and medical history were regarded to be important for prognosis.[ncbi.nlm.nih.gov]
- While further observations are required, an awareness of this complication of spinal stenosis is important in the diagnosis and management of such patients and in evaluating their ultimate prognosis.[ncbi.nlm.nih.gov]
- Approximately one-third to one-half of patients with mild to moderate LSS symptoms may have a favorable prognosis.[ncbi.nlm.nih.gov]
- Future prospective studies are needed to evaluate whether such muscle parameters are associated with prognosis and functional recovery following surgical treatment.[ncbi.nlm.nih.gov]
- The prognosis of conservative treatments for lumbar spinal stenosis. Spine 2005 ; 30: 2458 - 63.[doi.org]
Etiology
- The etiology behind this finding is likely multifactorial but may represent medico-legal concerns in the US, or the phenomenon of provider inducement. Copyright 2017 Elsevier B.V. All rights reserved.[ncbi.nlm.nih.gov]
- The etiology of the condition is understood in only 75% of cases. There have been no prior reports of this condition following lumbar spine surgery carried out under hypotensive anesthetic.[ncbi.nlm.nih.gov]
- The etiology is unknown but it is seen in achondroplasia 2. Central canal narrowing is the pertinent feature - various values have been proposed (AP mid-sagittal diameter 2,3.[radiopaedia.org]
- The etiology is unknown but it is seen in achondroplasia 2 . Central canal narrowing is the pertinent feature - various values have been proposed (AP mid-sagittal diameter 2,3 .[radiopaedia.org]
- Classification Etiologic classification acquired degenerative/spondylotic changes (most common) post surgical traumatic (vertebral fractures) inflammatory (ankylosing spondylitis) congenital short pedicles with medially placed facets (e.g., achondroplasia[orthobullets.com]
Epidemiology
- Congenital lumbar spinal stenosis is a type of spinal canal stenosis and has a different epidemiology with less severe degenerative change compared to acquired/degenerative lumbar spinal stenosis.[radiopaedia.org]
- Congenital lumbar spinal stenosis is a type of spinal canal stenosis and has a different epidemiology with less severe degenerative change compared to acquired/degenerative lumbar spinal stenosis .[radiopaedia.org]
- Wisniewski: Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 127 Parran Hall, Pittsburgh, PA 15261. Dr. Fye: University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213. Dr.[annals.org]
- Introduction Narrowing of central or lateral lumbar spinal canal caused by degenerative joint disease leads to compression of nerve roots Epidemiology middle-aged or elderly Presentation Symptoms back pain and referred buttock pain neurogenic claudication[step2.medbullets.com]
Pathophysiology
- For this reason, the pathophysiology must be considered when selecting the suitable surgical procedure.[doi.org]
- References 1 Baron EM Young WF : Cervical spondylotic myelopathy: a brief review of its pathophysiology, clinical course, and diagnosis.[doi.org]
- A role for vascular factors in the pathophysiological process has been proposed, but not yet proved ( 6 ).[aerzteblatt.de]
- The pathophysiology of spinal stenosis is related to cord dysfunction elicited by a combination of mechanical compression and degenerative instability.[emedicine.medscape.com]
- The pathophysiology is thought to be compression or ischemia, or both, of the lumbosacral nerve roots due to narrowing of the lateral and central vertebral canals, usually as a consequence of osteoarthritic thickening of the articulating facet joints,[doi.org]
Prevention
- The prominent epidural fat could have prevented rapid disbursement of the injected fluid which could have further served to propagate the pressure increase throughout the epidural compartment.[ncbi.nlm.nih.gov]
- Can lumbar spinal canal stenosis be prevented or avoided? Lumbar spinal canal stenosis cannot really be prevented because it seems to be a part of getting older.[familydoctor.org]
- There is an urgent need for interventions aimed at reducing sedentary behavior and increasing the overall level of physical activity in LSS, not only to improve function but also to prevent diseases of inactivity.[ncbi.nlm.nih.gov]
- At 12 weeks, many cross-overs prevented further analysis.Low-quality evidence from a single study including 191 participants favoured the interspinous spacer versus usual conservative treatment at six weeks, six months and one year for symptom severity[ncbi.nlm.nih.gov]
References
Article
- Alvarez JA, Hardy RH. Lumbar Spine Stenosis: A Common Cause of Back and Leg Pain. Am Fam Physician. 1998;57(8):1825-1834.
- Machado GC, Ferreira PH, Harris IA, et al. Effectiveness of Surgery for Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis. Shamji M, ed. PLoS ONE. 2015;10(3):e0122800.
- Ciricillo SF, Weinstein PR. Lumbar spinal stenosis. West J Med. 1993;158(2):171–7.
- Genevay S, Atlas SJ. Lumbar Spinal Stenosis. Best Pract Res Clin Rheumatol. 2010;24(2):253-265.
- Benoist M. The natural history of lumbar degenerative spinal stenosis. Joint Bone Spine. 2002;69(5):450–457.
- Turner JA, Ersek M, Herron L, Deyo R. Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature. Spine. 1992;17(1):1–8.
- Jenis LG, An HS. Spine update. Lumbar foraminal stenosis. Spine. 2000;25(3):389–94.
- Inui Y, Doita M, Ouchi K, et al. Clinical and radiologic features of lumbar spinal stenosis and disc herniation with neuropathic bladder. Spine. 2004;29(8):869–73.
- Matsumoto M, Watanabe K, Tsuji T, et al. Nocturnal leg cramps: a common complaint in patients with lumbar spinal canal stenosis. Spine. 2009;34(5):E189–94.
- Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-9.
- Chou R, Qaseem A, Snow V, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.