Spinal Stenosis

BACKGROUND The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. OBJECTIVE To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. DESIGN Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. METHODS The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency f...

Brown-Sequard Syndrome (BSS) is a rare neurological condition resulting from a hemisection injury to or unilateral compression on the spinal cord. The common causes of BSS that are amenable to be treated surgically can be divided into traumatic and nontraumatic injuries. Traumatic injuries are often reported as the main cause of BSS. However, nontraumatic injuries of the spinal cord are more seen in recent years. This study aims to classify and update surgically treatable causes of BSS. Case Presentation: Retrospective data of 17 patients operated for BSS between 2008 and 2020 were included. The long-term outcomes of these patients were evaluated. In addition, a comprehensive search in PubMed, Scopus, and CINAHL was conducted for the retrieval of all relevant studies. Results: Magnetic Resonance Image (MRI) of our patients revealed Cervical Disc Herniation (CDH), spinal canal stenosis with cervical spondylosis, epidural hematoma, and ossification of the posterior longitudinal ligament. The postoperative outcomes of our cases ranged from partial to complete recovery. While the patients with acute epidural hemorrhage achieved complete recovery after surgery, neurological deficits in the other patients, especially those with severe cervical spinal canal stenosis, persisted despite adequate surgical decompression. The systematic literature review revealed that CDH is the most common non-traumatic surgically treatable cause of BSS, followed by spinal cord herniation and spinal epidural hematoma. Conclusion: Non-traumatic injuries of the spinal cord accompanied by narrowed cervical spinal canal pathologies are prominent surgically treatable causes of BSS. Contrary to the definition made 100 years ago, BSS can occur spontaneously due to underlying pathologies rather than major traumatic injuries.

OBJECTIVECervical disc arthroplasty (CDA) has been demonstrated to be as safe and effective as anterior cervical discectomy and fusion (ACDF) in the management of 1- and 2-level degenerative disc disease (DDD). However, there has been a lack of data to address the fundamental discrepancy between the two surgeries (CDA vs ACDF), and preservation versus elimination of motion, in the management of cervical myelopathy associated with congenital cervical stenosis (CCS). Although younger patients tend to benefit more from motion preservation, it is uncertain if CCS caused by multilevel DDD can be treated safely with CDA.METHODSConsecutive patients who underwent 3-level anterior cervical discectomy were retrospectively reviewed. Inclusion criteria were age less than 50 years, CCS (Pavlov ratio ≤ 0.82), symptomatic myelopathy correlated with DDD, and stenosis limited to 3 levels of the subaxial cervical (C3–7) spine. Exclusion criteria were ossification of the posterior longitudinal ligamen...

The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (...

Low back pain after either post lumbar surgery syndrome or spinal stenosis in the absence of surgery is a vexing problem. Post lumbar surgery syndrome can occur in any age group, while low back and radicular pain from spinal stenosis is a disease of aging. As the population ages, the incidence of symptomatic spinal stenosis will increase. There are currently limited treatment options for either group. Further surgery is not uniformly effective in relieving pain after previous surgery. While therapies are being developed to treat pain due to spinal stenosis, no therapy other than adhesiolysis will treat pain due to scarring. Adhesiolysis was developed as a means of removing epidural scarring leading directly or indirectly to compression, inflammation, swelling, or a decreased nutritional supply of nerve roots. Adhesiolysis utilizes a number of modalities in the effort to break up epidural scarring, including the use of a wire-bound catheter for mechanical adhesiolysis, placement of t...

Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.

Sagittal- or coronal-plane deformity considerably complicates the diagnosis and treatment of lumbar spinal stenosis. Although decompressive laminectomy remains the standard operative treatment for uncomplicated lumbar spinal stenosis, the management of stenosis with concurrent deformity may require osteotomy, laminectomy, and spinal fusion with or without instrumentation. Broadly stated, the surgery-related goals in complex stenosis are neural decompression and a well-balanced sagittal and coronal fusion. Deformities that may present with concurrent stenosis are scoliosis, spondylolisthesis, and flatback deformity. The presentation and management of lumbar spinal stenosis associated with concurrent coronal or sagittal deformities depends on the type and extent of deformity as well as its impact on neural compression. Generally, clinical outcomes in complex stenosis are optimized by decompression combined with spinal fusion. The need for instrumentation is clear in cases of significant scoliosis or flatback deformity but is controversial in spondylolisthesis. With appropriate selection of technique for deformity correction, a surgeon may profoundly improve pain, quality of life, and functional capacity. The decision to undertake surgery entails weighing risk factors such as age, comorbidities, and preoperative functional status against potential benefits of improved neurological function, decreased pain, and reduced risk of disease progression. The purpose of this paper is to review the pathogenesis, presentation, and treatment of lumbar spinal stenosis complicated by scoliosis, spondylolisthesis, or flatback deformity. Specific attention is paid to surgery-related goals, decision making, techniques, and outcomes.

Degenerative de novo scoliosis is commonly present in older adult patients with spinal pain. The degenerative process including disc bulging, facet arthritis, and ligamentum flavum hypertrophy contributes to the appearance of symptoms of spinal stenosis in these patients. The etiology, prevalence, biomechanics, classification, symptomatology, and treatment of degenerative lumbar scoliosis in association with spinal stenosis are reviewed. Review study. Retrospective analysis of studies focused on all parameters concerning degenerative scoliosis associated with stenosis. There is a variety of treatment methods of degenerative scoliosis based on symptomatology and radiologic measurements of scoliosis and stenosis. Satisfactory clinical results reported in relevant retrospective studies after operative treatment range from 83% to 96% but with increased percentage of complications. An algorithm for operative treatment corresponding to a newly proposed classification system of degenerative lumbar scoliosis with associated canal stenosis is presented. There is an increasing prevalence of degenerative scoliosis in the aged population. Even though the exact percentage of patients with symptomatology of spinal stenosis is not known, the main goal is to provide pain relief and improved functional lifestyle with minimum intervention.

Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, societal, and health impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized - namely interlaminar, caudal, transforaminal - and for various conditions, namely - intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. A systematic review of lumbar interlaminar epidural injections with or without steroids. To evaluate the effect of lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, spinal stenosis, and chronic discogenic pain. Review of the literature and methodologic quality assessment were performed accor...

sessed the trials for the quality of their meth- ods. Subgroup analyses were performed for trials with different control groups, with different modes of epidurals (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/ sacral), and with timing of outcome measure- ment (short- and long-term). Outcome Measures: The primary out- come measure was pain relief. Other out- come measures

Purpose The purpose of this brief narrative review is to summarize the evidence derived from randomized controlled trials pertaining to the nonsurgical treatment of lumbar spinal stenosis (LSS). Source The MEDLINE (January 1950 to the fourth week of January 2010) and EMBASE (January 1980 to 2009, week 53) databases, the MESH term “spinal stenosis”, and the key words, “vertebral canal stenosis” and “neurogenic claudication”, were searched. Results were limited to randomized controlled trials (RCTs) conducted on human subjects, written in English, and published in peer-reviewed journals. Only RCTs pertaining to nonsurgical treatment were considered. Studies comparing conservative and surgical management or different surgical techniques were not included in the review. Principal findings The search criteria yielded 13 RCTs. The average enrolment was 54 subjects per study. Blinded assessment and sample size justification were provided in 85% and 39% of RCTs, respectively. The available evidence suggests that parenteral calcitonin, but not intranasal calcitonin, can transiently decrease pain in patients with LSS. In the setting of epidural blocks, local anesthetics can improve pain and function, but the benefits seem short-lived. The available evidence does not support the addition of steroids to local anesthetic agents. Based on the limited evidence, passive physical therapy seems to provide minimal benefits in LSS. The optimal regimen for active physiotherapy remains unknown. Although benefits have been reported with gabapentin, limaprost, methylcobalamin, and epidural adhesiolysis, further trials are required to validate these findings. Conclusions Because of their variable quality, published RCTs can provide only limited evidence to formulate recommendations pertaining to the nonsurgical treatment of LSS. In this narrative review, no study was excluded based on factors such as sample size justification, statistical power, blinding, definition of intervention allocation, or clinical outcomes. This aspect may represent a limitation as it may serve to overemphasize evidence derived from “weaker” trials. Further well-designed RCTs are warranted. Objectif L’objectif de cette courte synthèse narrative consiste à résumer les données probantes provenant des essais comparatifs randomisés se rapportant au traitement non chirurgical de la sténose du canal lombaire (SCL). Source Les bases de données MEDLINE (de janvier 1950 à la quatrième semaine de janvier 2010) et EMBASE (de janvier 1980 à 2009, semaine 53), le terme MESH « spinal stenosis » et les mots clés « vertebral canal stenosis » et « neurogenic claudication » ont été utilisés. Les résultats ont été limités à des essais comparatifs randomisés (ECR) menés chez des sujets humains, rédigés en anglais et publiés dans des publications évaluées par les pairs. Seuls les ECR se rapportant au traitement non chirurgical ont été considérés. Les études comparant les approches conservatrice et chirurgicale ou les études comparant différentes techniques chirurgicales ont été exclues de cette synthèse. Résultats principaux Les critères de recherche ont permis d’identifier 13 ECR. Le taux de participation moyen était de 54 sujets par étude. L’évaluation en aveugle et la justification de la taille des échantillons étaient fournies dans 85 % et 39 % des ECR, respectivement. Les données probantes disponibles suggèrent que la calcitonine administrée par voie parentérale, et non par voie intranasale, peut réduire de manière transitoire la douleur chez les patients atteints de SCL. Dans le cadre d’une anesthésie épidurale, les anesthésiques locaux peuvent réduire la douleur et améliorer la capacité fonctionnelle, mais leurs bienfaits semblent être de courte durée. Les données probantes disponibles n’appuient pas l’ajout de stéroïdes aux anesthésiques locaux. Il existe des données limitées en faveur d’avantages minimes de la physiothérapie passive en cas de SCL. Le programme optimal de physiothérapie active demeure inconnu. Bien que certains avantages aient été notés lors de l’utilisation de la gabapentine, du limaprost, de la méthylcobalamine et de la lyse d’adhérences épidurales, d’autres essais sont nécessaires afin de valider les résultats. Conclusions En raison de leur qualité variable, les ECR publiées ne peuvent offrir qu’une quantité limitée de données probantes en vue de formuler des recommandations se rapportant au traitement non chirurgical d’une SCL. Dans le cadre de cette synthèse narrative, aucune étude n’a été exclue en raison de facteurs tels que la justification de la taille des échantillons, la puissance statistique, l’insu, la définition de l’attribution d’intervention ou les résultats cliniques. Cet aspect peut constituer une limite puisqu’il peut être utilisé pour amplifier l’importance des données provenant d’essais « plus faibles » . D’autres ECR bien conçus sont nécessaires.

The dynamic neutralization system for the spine (DYNESYS®) is a pedicle screw based system intending mobile restabilization substituting physiological tissue restraints and thus approximating the unstable motion pattern to a normal pattern. It consists of titanium alloy screws, connected by an elastic synthetic compound (PET band and PCU spacer) controlling motion in any plane. DYNESYS® can be used for mono- or multilevel stabilizations in the lumbar spine. DYNESYS® is indicated in the treatment of degenerative disease of the lumbar motion segment with instability and most often in combination with functional or structural spinal canal stenosis. Primary and secondary bone tumors of the spine. Spinal fractures. Infections. Lytic/isthmic spondylolisthesis. Degenerative spondylolisthesis > I°-II°. Facetectomy. Stabilization of thoracic and cervical spine. Allergies to components of DYNESYS®. Pregnancy. Standard midline approach. Decompression of the segment by laminotomy if indicate...

Surgical decision-making in lumbar spinal stenosis involves assessment of clinical parameters and the severity of the radiological stenosis. We suspected that surgeons based surgical decisions more on dural sac cross-sectional area (DSCA) than on the morphology of the dural sac. We carried out a survey among members of three European spine societies. The axial T2-weighted MR images from ten patients with varying degrees of DSCA and morphological grades according to the recently described morphological classification of lumbar spinal stenosis, with DSCA values disclosed in half the assessed images, were used for evaluation. We provided a clinical scenario to accompany the images, which were shown to 142 responding physicians, mainly orthopaedic surgeons but also some neurosurgeons and others directly involved in treating patients with spinal disorders. As the primary outcome we used the number of respondents who would proceed to surgery for a given DSCA or morphological grade. Substa...

The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards. We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiothe...

The purpose of this article is to narrow the gap that exists in the clinical application of scientific research and empiric evidence for the evaluation and management of late whiplash. Considering that 14% to 42% of patients are left with chronic symptoms following whiplash injury, it is unlikely that only minor self-limiting injuries result from the typical rear-end impact. As psychosocial issues play a role in the development of persistent whiplash symptoms, discerning the organic conditions from the biopsychosocial factors remains a challenge to clinicians. The term "whiplash" represents the multiple factors associated with the event, injury, and clinical syndrome that are the end-result of a sudden acceleration-deceleration trauma to the head and neck. However, contentions surround the nature of soft-tissue injuries that occur with most motor vehicle accidents and whether these injuries are significant enough to result in chronic pain and limitations. The stark contras...

The natural history of degenerative lumbar spinal stenosis is documented poorly. Little is known about the efficacy of nonoperative treatments. An aggressive nonoperative treatment consisting of therapeutic exercise, analgesics, and epidural steroid injections is proposed. The clinical evaluation of the patients is reviewed and the relevance to the selection of the nonoperative treatment plans is emphasized. Efficacy of nonoperative treatment may depend greatly on the nature and severity of the patient's symptomatic and radiographic presentation. Several studies on nonoperative treatment of patients with between 1 and 5 years of followup suggest that variably 15% to 43% of patients will have continued improvement after nonoperative treatment.

Spinal stenosis is a narrowing of the vertebral canal that compresses spinal nerves and may cause leg pain and difficulty walking. The symptoms of degenerative lumbar stenosis commonly occur in elderly adults and can be treated conservatively with pain-relieving agents or aggressively with decompressive surgery. Most studies of the effectiveness of treatments are poor in quality; however, there appear to be potential relationships between treatments, patient characteristics, and treatment outcomes. Studies indicate the following: (1) local anesthetic block can reduce symptoms on a short-term basis, while epidural steroids offer no additional benefit; (2) patients with moderate or severe symptoms benefit more from surgery than from conservative therapy; and (3) patients with leg pain and severely restricted walking ability regain mobility after surgery. Definitive evidence-based conclusions about the efficacy of conservative or surgical treatments await the results of well-designed c...

The bent spine syndrome, which mimics spinal stenosis, is thought to be a focal paraspinal myopathy, but because paraspinal fatigue with ambulation is not a feature of more severe myopathies, the cause of symptoms is not clear. To evaluate electromyographic and biomechanical aspects of the bent spine syndrome. University spine clinic. A patient with severe disability from the bent spine syndrome was compared with a fortuitously discovered asymptomatic research subject with the syndrome, in terms of physical examination, magnetic resonance imaging, and electrodiagnostic testing. Both subjects had fatty paraspinal replacement on magnetic resonance imaging and electromyography. More detailed electromyography of the patient showed abnormalities medially and caudally, but changes including apparent myopathic motor units up to the high thoracic region. The research subject had no hip flexion contracture, whereas the patient had severe contracture. Correction of contracture increased ambulation from 20 to 300 meters. Bent spine syndrome is likely a paraspinal myopathy, but symptoms do not occur unless there is also a hip flexion contracture.