LUMBAR SPINAL STENOSIS

Lumbar Spinal Stenosis (LSS)

Background:
· Primary (congenital, or disorder of postnatal development) or Secondary (acquired stenosis from degenerative changes, local infection, trauma, surgery)
· Degenerative the commonest (usually L3-5)
· Anatomical based, however size of stenosis does not determine severity of sx
· LSS is the commonest reason for surgery in older adults
· Anatomy – can affect central canal, lateral recess, foramina or any combination of these locations Dynamic Lumbar Problem – Flexion causes a 12% increase in foramen size, extension 15% decrease in size
· Pathophysiology – ? vascular compromise to cauda equine
Or nerve root constriction caused by:
1) direct obstruction to blood flow to central canal
2) Intraosseious and cerebro spinal pressure change affected by pressure
3) A direct neuronal compression of nerve rootsClinical Symptoms:
Symptoms often related to patient’s posture – classic flexion decreases pain, ext increasesNeurogenic claudication – Leg symptoms, pain in buttock, groin, anterior thigh pain, and radiation down posterior leg to feet. Fatigue, heaviness, weakness, paraesthesia, nocturnal leg cramps and neurogenic bladder symptoms. The distance walked is more variable compared to vascular claudication, also tendency for it to improve walking uphill.
Bilateral more common than unilateral.
May have a wide-based gait

Investigations:
Xray – assess for degenerative changes lateral foraminal stenosis, also spondylolisthesis
CT or MRI – 20% of asymptomatic patients >60 will have signs of stenosis

Treatments:
Walker-aid, flexion exercises, education, NSAIDs, limaprost, opiates, gabapentin, epidurals, physiotherapy, surgical laminectomy and decompression.

ABSTRACT:
INTRODUCTION: Degenerative Lumbar Spinal stenosis has the potential of being a debilitating condition for affected adults. Symptoms can be brought on with basic walking or standing for short periods of time. The purpose of this review is to determine the efficacy of surgery in treating this difficult condition for patients.
METHODS: Literature review of articles on Lumbar stenosis and surgical treatments. 3 Articles reviewed for their population sizes and comparison to non-surgical.
RESULTS: 3 studies on Lumbar Spinal stenosis compared to non-surgical options were reviewed: MAINE2, SPORT6, and the European Lumbar Spinal Stenosis RCT Study5. Highly variable non-surgical comparison including non-evidence based treatments. Surgery was found to be superior in 2 for LSS symptoms however long-term there was no to little benefit from surgical compared to nonsurgical treatments groups
CONCLUSION: After reviewing 3 journal articles, one of which did not report any side effects. There does appear to be some benefit at least initially from a surgical option. This effect diminishes over time and in fact non surgical groups appear to improve further past the surgical groups in studies up to 6 years in follow up length.

Introduction: Lumbar Spinal Stenosis (LSS) is a condition whereby either through a vascular compromise to the spinal components or direct constriction of nerve roots pain is generated in either or both a patient’s back and/or radiating symptoms down the patient’s lower limbs. LSS will symptomatically affect 1 in 1000 pateints over 65 and 5 in 1000 over 50.7 Surgical treatments involved decompression of the stenosing elements.

Methods: A university of Toronto Libraries search for journal articles containing: Lumbar Spinal Stenosis, surgical treatment, laminectomy and/or non-surgical treatment was performed. Articles were chosen for direct comparison of adult patient populations with Lumbar spinal stenosis receiving either surgical treatment or non-surgical treatment.
Limits included English language and publications later than 1995.

Results:
• The MAINE Lumbar Spine 8-10 year follow-up study2 was a prospective observational cohort study. Baseline imaging included (CT, MRI or myelogram). There were 105 (67%) of the original patients alive from the original cohort. The main surgical intervention was laminectomy. The non-surgical interventions included 10 different treatment options ranging from rest to medications, epidural injections and physiotherapy (PT). Surgical group reported worse sx at baseline than nonsurgical group. Post-operative results from years 1- 4 favoured surgical treatment. However at 8-10 yr both reported similar improvement. 23% had further surgery and 39% of the nonsurgical group ended up having surgery. The surgical group reported greater improvement in leg related symptoms. There was a high crossover of groups in the results, and no comparison of surgery versus an individual non-surgical treatment option.
• Spine Patient Outcome Research Trials Lumbar Spinal Stenosis6
Was a randomised/observational cohort of Spinal stenosis without spondylolisthesis. There were 289 patients in the randomized cohort and 365 in the observational cohort. A large crossover was noted in the results as 43% of RCT and 22% of observational nonsurgical cohorts went on to have surgery
Non surgical care included: PT (68%) epidural (56%) chiropractic (28%) NSAIDs (55%) Opioids (27%). Surgical care was posterior decompressive laminectomy. There was a 2 year postoperative followup. Surgery superior to nonsurgical in relieving symptoms and improving function
There was little harm from either treatment group and the nonsurgical

group did not appear to worsen over time. Once again a great variability in nonsurgical treatments and no comparison to any single nonsurgical treatment.

· European Lumbar Stenosis RCT Study5
94 patients with a 2 year follow up. The surgical treatment was laminectomy +/- transpedicular-instrumented fusion. Surgery provided improved functional ability, perceived back and leg pain compared to conservative treatment. The surgical effect diminished with time. After 6 years the Oswell Disability Index results were still superior to conservative. There was a
small population size. Crossover of treatment groups was also present in this study as well. There was no mention of side effects from surgical treatment.
SURGICAL COMPLICATIONS6:

Complications from surgery:
Mean blood loss 314 mL
10% required intraoperative transfusion
5% required postoperative transfusion
9% had a dural tear
88-91% had no intra/post operative complications or events

Conclusion:
Surgery does appear to be an effective treatment for Lumbar spinal stenosis reducing pain and improving function. Surgical treatment appears to be more effective for radicular pain and less effective for back-specific pain. Studies have failed to compare surgery to individual conservative therapies. More research is required to look at specific conservative therapies.

Summary:
• Little evidence for conservative treatments used, not always standardized
• Crossover common in all 3 studies
• Surgery provided significant improvements early, however less difference>4 years out
• Surgery likely best option for those with severe symptoms for faster relief
• Surgery in SPORT Trial ~90%complication free
• Long term follow ups showed no worsening of non-surgical groups

References:

1. Atlas SJ, Deyo, RA, Keller RB, Chapin AM, Patrick DL, Long JM and Singer DE
The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis Spine, 1996, Volume 21, Issue 15, p. 1787
2. Atlas SJ, Keller RB, Wu YA, Deyo RA and Singer DE Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study Spine, 2005, Volume 30, Issue 8, pp. 936 – 943
3. Genevay S and Atlas SJ Lumbar spinal stenosis Best practice & research. Clinical rheumatology, 2010, Volume 24, Issue 2, pp. 253 – 265
4. Katz JN, Harris MB Lumbar Spinal Stenosis The New England Journal of Medicine, 2008, Volume 358, Issue 8, pp. 818 – 825
5. Slatis P, Malmivaara A, Heliovaara M, Sainio P, Herno A, Kankare J, Seitsalo S, Tallroth K, Turunen
V, Knekt P, Hurri H Long-term results of surgery for lumbar spinal stenosis: a randomised
controlled trial Eur Spine J (2011) 20:1174–1181
6. Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Blood E, Hanscom B, Herkowitz H, Cammisa
F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H and SPORT Investigators Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis The New England journal of medicine, ISSN 0028-4793, 02/2008, Volume 358, Issue 8, pp. 794 – 810
7. Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. Jul 2009;9(7):545-50.