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Home , Lumbar spinal stenosis, Neurogenic claudication, Spinal stenosis, Spondylitis

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Lumbar Spinal

Lumbar is caused by narrowing of the or neural foramina producing root ischaemia and neurogenic . Stenosis of the spinal canal is most often caused by a combination of loss of disc space, and a hypertrophic ligamentum flavum. Not all patients with narrowing develop symptoms. , therefore, refers to a clinical syndrome of lower extremity pain caused by mechanical compression on the neural elements or their blood supply.[1] Epidemiology It most often occurs in those aged 60 years or older.[2] Although symptoms may arise from narrowing of the spinal canal, not all patients with narrowing develop symptoms.[1]

Risk factors Congenital narrowing of the spinal canal (much less common than degenerative). Degenerative, . Hyperparathyroidism. Paget's disease of bone. Ankylosing . Cushing's syndrome. Acromegaly. Presentation See also the separate article on Examination of the Spine.

Gradual onset of unilateral or bilateral leg pain (with or without ), numbness, and weakness developing after the patient walks a predictable distance. Affected patients may have less difficulty walking uphill rather than downhill. About half of all patients present with back pain, which is usually bilateral and diffuse over the buttocks. Neurogenic intermittent claudication: leg fatigue and/or weakness and leg numbness and/or paraesthesiae. Pain: Bilateral leg pain with burning or cramping. Involves the buttocks and thighs and spreads to the feet. The neural canal and neural foramen are narrowed with the spine in backward extension and opened in forward flexion; neural compression is usually intermittent and provoked by lying prone or extending (arching) the lumbar spine, and when upright, particularly when walking. Cycling does not usually cause significant problems. The pain is usually relieved by sitting, leaning forward, putting the foot on a raised cushion or stool, or lying supine.

May cause cauda equina compression: This is caused by any narrowing of the spinal canal that compresses the nerve roots below the level of the . It may be due to trauma, disc herniation, spinal stenosis, spinal , and inflammatory or infectious conditions. Features of cauda equina compression include , unilateral or bilateral , saddle and perineal anaesthesia, bowel and bladder disturbances, and weakness, sensory deficits and reduced or absent reflexes in the legs.

Assessment requires a complete motor and sensory , which is often normal. Page 2 of 3 Lower limb vascular examination is also necessary to rule out vascular claudication. Other causes of back pain. Peripheral vascular disease. Spinal tumours: benign, malignant and metastatic. Large central disc herniation. : degenerative lumbar vertebral subluxation. Lumbar spine trauma or vertebral fracture. Epidural abscess. Inflammatory arachnoiditis. Investigations Lumbar spine X-ray: Initial assessment for a possible alternative diagnosis. Degenerative spine changes: disc space narrowing is a poor predictor of symptoms. May demonstrate underlying abnormality - eg, occult , spondylolisthesis.

Lumbar spine MRI (the preferred investigation) or CT scan: MRI is the first choice because is invasive.[3] CT scan alone is not as helpful but it is an alternative if MRI or CT myelogram is not available. Management Non-surgical management consists of non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy and epidural injections. However, moderate and high-quality evidence for non-operative treatment is currently lacking.[4]

If non-surgical management is unsuccessful and neurological decline persists or progresses then surgical treatment (most often ) is indicated.[5]

Weight reduction if overweight. Physiotherapy with forward flexion exercises. NSAIDs; other for pain relief as appropriate. Epidural anaesthetic blocks may be helpful for a minority of patients. Epidural have an additional benefit.[6] [7] However, one recent study found no benefit with epidural steroid injections.[8] Surgical decompression: decompressive laminectomy may be effective for those patients who do not respond to conservative measures.[9] There is only limited evidence for the benefits of surgical intervention for degenerative lumbar spinal stenosis.[9] Evidence suggests that active rehabilitation following surgery for lumbar spinal stenosis is effective in improving both short-term and long-term (back-related) functional status.[10] Interspinous distraction procedures: Involve the insertion of a device that is implanted between the spinous processes that reduces backward movement at the symptomatic level (most commonly L3-L5) but allows forward movement and unrestricted axial rotation and lateral bending. The guidance from NICE is that these procedures are effective for carefully selected patients in the short and medium term, although failure may occur and further surgery may be needed.[11]

Cauda equina compression usually requires urgent surgical decompression. Prognosis The prognosis of conservative treatment is relatively good. One study found about half of patients did not have any restriction of usual activities of daily living on long-term follow-up.[12] Page 3 of 3 Further reading & references Lumbar Stenosis; Wheeless' Textbook of Orthopaedics

1. Truumees E; Spinal stenosis: pathophysiology, clinical and radiologic classification. Instr Course Lect. 2005;54:287-302. 2. Snyder DL, Doggett D, Turkelson C; Treatment of degenerative lumbar spinal stenosis. Am Fam Physician. 2004 Aug 1;70(3):517-20. 3. de Schepper EI, Overdevest GM, Suri P, et al; Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests. Spine (Phila Pa 1976). 2013 Apr 15;38(8):E469-81. doi: 10.1097/BRS.0b013e31828935ac. 4. Ammendolia C, Stuber KJ, Rok E, et al; Nonoperative treatment for lumbar spinal stenosis with . Cochrane Database Syst Rev. 2013 Aug 30;8:CD010712. doi: 10.1002/14651858.CD010712. 5. Issack PS, Cunningham ME, Pumberger M, et al; Degenerative lumbar spinal stenosis: evaluation and management. J Am Acad Orthop Surg. 2012 Aug;20(8):527-35. doi: 10.5435/JAAOS-20-08-527. 6. Koc Z, Ozcakir S, Sivrioglu K, et al; Effectiveness of and epidural steroid injections in lumbar spinal stenosis. Spine (Phila Pa 1976). 2009 May 1;34(10):985-9. doi: 10.1097/BRS.0b013e31819c0a6b. 7. Botwin KP, Gruber RD; Lumbar epidural steroid injections in the patient with lumbar spinal stenosis. Phys Med Rehabil Clin N Am. 2003 Feb;14(1):121-41. 8. Radcliff K, Kepler C, Hilibrand A, et al ; Epidural steroid injections are associated with less improvement in patients with lumbar spinal stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976). 2013 Feb 15;38(4):279-91. doi: 10.1097/BRS.0b013e31827ec51f. 9. Gelalis ID, Stafilas KS, Korompilias AV, et al; Decompressive surgery for degenerative lumbar spinal stenosis: long-term results. Int Orthop. 2006 Feb;30(1):59-63. Epub 2005 Nov 25. 10. McGregor AH, Probyn K, Cro S, et al; Rehabilitation following surgery for lumbar spinal stenosis. Cochrane Database Syst Rev. 2013 Dec 9;12:CD009644. doi: 10.1002/14651858.CD009644.pub2. 11. Interspinous distraction procedures for lumbar spinal stenosis causing neurogenic claudication, NICE Interventional Procedure Guideline (November 2010) 12. Miyamoto H, Sumi M, Uno K, et al; Clinical outcome of nonoperative treatment for lumbar spinal stenosis, and predictive factors relating to prognosis, in a 5-year minimum follow-up. J Spinal Disord Tech. 2008 Dec;21(8):563-8. doi: 10.1097/BSD.0b013e31815d896c.

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Original Author: Current Version: Peer Reviewer: Dr Colin Tidy Dr Colin Tidy Dr John Cox Last Checked: Document ID: © EMIS 23/01/2014 2403 (v23)

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