This video explains Lumbar Stenosis. When arthritis begins to encroach around the spinal cord and neural elements this is called Lumbar Stenosis. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Stenosis/Arthritis feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1

1. Lumbar Stenosis Pablo Pazmi ño, MD Curitiba, Brazil

11. PLL Posterior Longitudinal Ligament This is a ligament that sits against the bone and thickens with arthritis It is a Denticulated flat broad attachment at level of disc and has a narrower course across midportion of concave posterior wall of the vertebral body Sagitally oriented deep layer connects periosteum along vert body, T/Y shaped in transverse sections. Vertical T dissappears at disc level Dual aspect Proprioceptive function Suspensory ligament for dural sac

13. Ligamentum Flavum: Posterior Epidural Region Yellowish 80% Elastin fibers Spans between the adjacent laminae and fills the interlaminar space. The capsular part of the ligament is thinner than the interlaminar portion. 2 Layered aspect: firmly attached, diverge caudally at the upper rim of laminae, superficial thickness 2.5-3.5mm / 1mm deep OlszewskiSpine ’96:21 Tented recess filled with homog epid adipose adherent at the apex of the ligament.

14. Nerve root organization This is how the nerves are arranged within the thecal sac

17. Diurnal Changes Diurnal changes in fluid content, disc height, and disc bulge. 19mm variation, from 1.5mm ht of each lumbar disc. Sleep: loading on discs reduced and discs absorb fluid and increase vol Absorbed fluid is expelled during day with loading through Creep/Walking: Lose height, increase bulge

19. Spinal Stenosis Normal is on Top Left Stenosis is on Bottom Right

21. Pathophysiology This is an “Axial View” Look at the Arthritis/Stenosis that develops

23. Flexion Foraminal size increases in flexion, and decreased in extension. Nondegenerated foramina>>Degenerated foramina Foramina open 24% during flexion and closed 20% during extension Less significant changes with lateral bending and axial rotation Stenotic spines: Flexion increases SAC by reducing disc bulge, stretching ligamentum flavum, Panjabi Spine’83:4

25. Fibrous border of NP coalesces with AF and after 2nd decade indistinct. Next as disk degenerates its unable to absorb load at the nucleus pulposus. The force is redirected unequally down the annulus fibrosus, causing it to tear circumferentially and these combine and expand radially to the periphery of the endplate. Dessication, degeneration, cavitation and calcium deposition. Due to mechanical changes the disc space collapses Collapse leads to posterior fissuring and bulging along PLL

30. Mechanical Theory: Intraneural edema formed as a result of compression injury leads to an intraneural compartment syndrome. Venous congestion at 5-10mmHg ◙ Rate dependent: More pronounced after rapid than slow onset compression ◙ Long standing edema leads to intraneural fibrotic scar ◙ This delays long convalescence scenario ◙ Impairs nutrition Olmarker Spine ’89:14

32. Notice the Fibrosis/Scarring that develops with time inside the Foramen This is what happens with Stenosis with time !!!!

33. Mechanical and Vascular Theories: Decrease in Cross Sectional Area Neurogenic claudication began with venous congestion of the nerve root and DRG. With increasing compression motor and sensory deficits occurred and blockage of axoplasmic flow (50-75%). Constriction of more than 50% was the critical point that resulted in loss of Cortical evoked potentials, neurologic deficits and histologic abnormalities. Delamarter JBJS ’90A:110

37. Comparison of Neurogenic and Vascular Claudication in Spinal Stenosis Symptom or Sign Neurogenic Claudication Vascular Claudication Distal pulses Normal Diminished or absent Skin changes None Mottled or atrophic Loss of pretibial hair growth Positional change Pain improved with lumbar flexion (eg, sitting, stooping) Pain unaffected by lumbar posture Walking distance Variable Fixed distance before onset Increased pain with increased distance ambulated Relationship of pain to cessation of ambulation

38. Physical Exam No definitive signs or findings Gait: Posture: LB: ROM: Neurologic exam : Tension signs Pulses and trophic changes: Radiologic imaging studies confirm stenosis, clarify Forward flexed posture with limited pelvis rotation Forward flexed, coronal imbalance No specific tenderness, spasm (HNP) Pt tenderness overf SI jts/Sciatic Notch Good forward flexion, painful extension Often normal L4-5 Level Commonly: Weakness EHL, Tib Ant SLR often negative Reflex testing unreliable, absent/hypoactive common, hyperactive reflexes and long tract signs prompt search for compressive lesion (SLR,Naffziger,Kemp,Cram)are often negative unless Foraminal involvement Vascular

43. Reading CT/MRI Disc: Herniated Vertebrae: Endplate, Osteophytes Facets: Orientation, Arthroses, Synovial Cysts, Capsular hypertrophy, Tropism, Subluxation Nerve Root entrapment Foramina Lateral Recess Thecal Sac: Degree of deformity Canal: Trefoil, round, etc Instraspinal Masses Fat: Prominent epidural fat, epidural lipomatosis Ligamentum Flavum

47. Axial T1 MRI shows disc and osteophyte protruding in the foramen, which obliterates the fat anterior to the Nroot

58. Natural Course of NonOperative versus Operative Treatment

59. Operative Treatment This condition will not progress to paralysis or bowel/bladder dysfunction, if activities are curtailed symptoms may generally relieve This ultimately is about the Quality of life and level of function/activity desired by the patient Significant ability to walk/stand due to claudicant leg pain.

60. One year Outcomes Surgical procedures increase the relative odds of definite improvement 2.6 fold compared with nonop Atlas Spine ’96: 21 Maine observational cohort study: Although improvement 55% nearly twice as good 28% improvement by conservative.

61. Surgical Decompression Divided into decompressive procedures With and Without a fusion

63. Laminectomy Bilateral Laminectomy : Lamina and Lig Flavum are removed on both sides of stenotic level(s) to the lateral recess. Proceed Caudal to Cranial. Decompressed until lateral edge of the nerve root is decompressed Preserve Pars Interarticularis- to minimize instability by inadvertent sacrifice of superior facet. If disc herniation: Discectomy is performed,then consider arthrodesis. Finally lateral decompression of the foraminae(probe foramen dorsal and ventral to Nerve root, and rtrxn 1cm medially).

66. Indications for Fusion

73. Degenerative Discs: Blackened, Bone on bone, decreased in height

74. L3 4 Stenotic Canal (Triangular shape)

75. L 4 5 Stenosis trefoiled/triangular canal Synovial cyst

76. L5 S1

79. Dr Pazmiño: Orthopaedic Spine Dr Lauryssen: Neurological Spine

81. Iguacu Falls. Brazil