Lumbar spinal stenosis, laminectomy, prolapsed intervertebral disc

Lumbar spinal stenosis, laminectomy, prolapsed intervertebral disc

1. LUMBAR SPINAL STENOSIS LAMINECTOMY/DISCECTOMY DR ASIF ALI KHAN AUTHOR OF DOD TREATMENT GUIDE

2. SPINE ANATOMY REVIEW 33 Bones in infants 26 Bones in adults 5 Regions of the Spine: Cervical - 7 vertebrae (C1-C7) Thoracic - 12 Vertebrae (T1-T12) Lumbar - 5 Vertebrae (L1-L5) Sacrum - 5 Fused Vert. (S1-S5) Coccyx – 4 Fused Vertebrae

3. Vertebral Anatomy Vertebral Body Pedicle Lamina Superior Articular Process Spinous Process Transverse Process Vertebral Foramen 4

4. SPINAL STENOSIS Spinal stenosis Refers to narrowing of the spinal canal, nerve root canals, or intervertebral foramina due to compression Can put pressure on spinal cord and nerves Commonly occurs in the neck and low back Lumbar canal stenosis is common cause of back pain Most Common indication for Spinal Surgery

5. Causes of medical view Age related wear and tear Mostly effect people over 50 Most spinal stenosis occurs when something happen to reduce the amount of space available within the spine such as: Overgrowth of bone: Osteoarthritis and bone spurs Herniated disk Thickened ligament Spinal injuries

6. CLASSIFICATION OF SPINAL STENOSIS GENERALISED/LOCALISED SEGMENTAL Central: Narrowing of the AP dimension Lateral recess stenosis Foraminal 3. ANATOMICAL Cervical Stenosis: C5-C6 > C6-C7 (Seen) Thoracic Stenosis – Seldom occurs (rare) Lumbar Stenosis– L4-L5 (Most Common)

7. 4. PATHOLOGICAL(ARNOLD’S 1976) Congenital Stenosis: Idiopathic Achondroplasia Acquired Stenosis: Degenerative (most common) Combined congenital and degenerative Spondylitic/spondylolisthetic Iatrogenic Hypertrophy of posterior bone graft. post-laminectomy: Incomplete treatment of stenotic condition. post-fusion Posttraumatic Metabolic (i.e., Paget’s disease, fluorosis)

8. Case Presenation A 65-year-old male presents to his primary care physician with complaints of lower back pain. He states this pain has been gradually worsening over approximately the last year. He describes the pain as improving when he leans forward, and radiates to his buttocks and thighs; this pain interferes with his walking. On physical exam, pedal pulses are normal. Which of the following is the best next step in the management of this patient? Prescribe NSAIDs and see the patient back in 2 weeks Perform a lumbar steroid injection Send the patient for an MRI of the lumbar spine Send the patient for a radiograph of the lumbar spine Refer the patient to physiatrist and see the patient back in 1 month

9. 3. Send the patient for an MRI of the lumbar spine The patient in this vignette most likely has lumbar spinal stenosis. The best test for this condition is an MRI scan of the lumbar spine. Lumbar spinal stenosis classically presents with weakness, back pain and referred buttock pain, pain worsens with extension (walking downhill, standing upright) and is relieved with flexion at hips and bending forward (sitting, leaning over shopping cart). Answer 1: NSAIDs are a valid treatment for lumbar spinal stenosis but only after a diagnosis has been confirmed. Answer 2: Steroid injections are a valid treatment for lumbar spinal stenosis but only after a diagnosis has been confirmed. Answer 4: X-rays are not the preferred imaging modality for this condition. Answer 5: Physical therapy is a valid treatment for lumbar spinal stenosis but only after a diagnosis has been confirmed.

10. Lumbar Spinal Stenosis Narrowing of central or lateral lumbar spinal canal caused by degenerative joint diseaseleads to compression of nerve roots. Commonly found in middle-aged or elderly people Mostly occurs at the L3-L4 and L4-L5 levels(MC)

11. Clinical Approach

12. Clinical Features Numbness and tingling sensation in your arms, hands, leg, and foot Pain in the low back and buttock region Neurogenic claudication is common symptom Pain radiates to buttocks and lower extremities. Pain or feeling of cramps in the legs after standing for a long period of time or while walking. Pain relieved by sitting or lying down and increase by standing or walking. The pain usually goes away when the person either bends forward or sits down (Pain relieved by forward flexion) Pain exacerbated by standing and walking. leg pain (often unilateral) Weakness and imbalance while walking bladder disturbances cauda equina syndrome (rare)

13. Neurogenic claudication VS Vascular claudication Features Neurogenic claudication Vascular claudication Pain distribution Dermatomal Sclerotomal Sensory loss Dermatomal Stocking type Aggravating factors Variable amount of physical activity Pain on standing (65%) Coughing (38%) Fixed amount of activity Rest pain rare Pain on standing (27%) Relief with rest Slow (> 30 min) Special posture Immediate No special posture Claudication distance Variable day to day (62%) Constant (88%) Lifting or bending Pain common (67%) Uncommon (15%) Limb elevation No pallor Profound Pulses Normal Absent or decreased Skin temperature Normal Decreased

14. Physical examination Kemp sign: unilateral radicular pain from foraminal stenosis made worse by extension of back Straight leg raise (nerve root tension sign) is usually negative Valsalva test does not worsen pain (pain is worse in the case of herniated disc) Reduced spinal mobility. Extension is more usually limited than flexion. Lumbar, paraspinal and gluteal tenderness. Neurologic examination typically normal or reveals only such a mild weakness, sensory changes and difficulty in walking.

15. Special test Stoop test: Ask patient to walk  pain develop  continue to walk   patient assumes a stooped posture  symptom disappear  the pain decreases by forward bending because the canal length increase by 2.2 mm. Lumbar extension test – (Katz et al) Ask the standing patient to hyperextend the lumbar spine for 30 to 60 second. A positive test is reproduction of the buttock or leg pain.

16. Diagnostic Approach Physical history & medical History Blood tests: CBC, ESR, C-Reactive protein Imaging: X-ray, CT Mylogram, MRI (IxCx) CT Myelogram: A CT scan combined with myelogram provides an excellent picture of the nerve details can diagnose early defects and slip shows how the bone is affecting the nerve roots. CT myelogram is a sensitive test to detect nerve impingement and can identify even minute scratches or injuries. MRI show if there is any pressure exerted on the spinal cord or its nerves (diagnose cord compression), MRI) is the best imaging test that can be helpful in diagnosing different types of stenosis. X-rays c an help in identifying any change in the bones such as bone spurs. These spurs may narrow the space within the spinal column.

17. Normal Axial Level (MRI)

18. Normal Axial Level (MRI)

19. Differential diagnosis Vascular insufficiency Hip disease Disc herniation Baastrup’s syndrome Arachnoiditis Spinal stenosis Spinal tumour Diabetic neuritis Delayed onset muscle soreness (DOMS) Functional aetiologies

20. Non-Surgical Management Steroids: Epidural Steroid injections can help reduce inflammation and relieve the pressure. As a long-term use of steroid injections has a tendency to cause weakening of nearby bones and connective tissues, these are prescribed cautiously, and only a limited number of injections are advised in a year. NSAIDs : These are effective in relieving pain and inflammation. Muscle relaxants:   Medicines reduce muscle contractions that occur occasionally with spinal stenosis. Anti-seizure drugs:   Anti-seizure drugs effective in reducing the pain caused due to nerve damage. Antidepressants:   Antidepressants relieving chronic pain/ Fibromyalgia Other drugs such as Opioids / narcotics may be advised to get relief from pain.

21. Non-Surgical Treatment Physiotherapy Tx Improve strength, endurance and tone of abdominal muscle. Back ergonomics avoiding extension attitude are taught. Lumbar corset should be used provide back support. Emphasis on flexion exercise and generalized flexion attitude avoiding extension. Gentle passive manipulation technique. Lumbar traction to relive spasm. Walking on inclined treadmill. Harness supported treadmill ambulation. Strong isometric exercise for abdomen. Single Knee to chest exercise. Spinal flexion exercise. Hamstring stretching performed by extending the knee with hip flexed 90*. Hip flexor stretching is performed by maintains posterior pelvic tilt while in a half kneeling posture. Mini squats for general lower extremity strengthing exercises.

22. Non-Surgical: Conservative Rx Tab. Naproxen sodium 550mg (Synflex) BD / 1 - 0 - 1 Cap. Pregablin 50mg (Gabica) BD /1 - 0 - 1 Tab. Mecobalamin ( M ethycobal) BD / 1 - 0 - 1 Cap. Esomeprazole 40mg (Nexum / Esso) O D / 0 - 0 – 1

23. Alternative Drugs Steroids: Dexamethasone: Inj. Decadron, Tab. Oradexon Prednisolone: Tab. Deltacotril 5mg Nandrolone Decanoate: Inj. Deca-Durabolin Triamcinolone: Injection Kenacort-A 40mg per ampule NSAIDs: Naproxen sodium: Synflex/ Neoprox (Tablets - 250mg/500mg/550mg) Diclofenac sodium: Tab Voren 25mg/50mg/100mg, Inj voren 75mg Tramadol: Tramol 100mg (Cap/Tab/Injection) Combination: Tramadol + Paracetamol ( Tab Tramol plus/ Distalgesic) Muscle relaxants: Tizanidine: Tab Ternalin Or Movax 2mg/4mg Cyclobenzaprine: Mezrel - XR (Tablets 5mg/10mg, Caps 15mg/30mg) Baclofen: Tab. Laioresal 10mg

24. Anti-epileptic drugs: Gabapentin: Caps. Gabix / Neogab 100mg, 300mg, 600mg Pregablin: Caps. Gabica 50mg, 75mg, 100mg, 150mg Lacosamide: Caps. Lecolep / Lalap 50mg/100mg Antidepressants: Duloxetine : Caps. Dulan / Lyta 30mg, 60mg Fluoxetine: Caps. Flux / Depex 20mg Amitriptyline: Tab. Tryptanol 25mg Opioids/Narcotics analgesic: Nulbuphine: Inj. Kinz 10mg , 20mg Morphine: Caps Magnus MR, Inj. Morphine 5mg/ml Pentazocine: Inj. Panatzogan 1ml/ampule Fentanyl: Inj. Fentanyl 100mcg/2ml (50mcg/ml, 0.05mg/ml) Supplement: Ossein Mineral complex: Tab. / Syp. Osnat 800mg Ossein Mineral Complex + Vit-D: Syp/Tab. Cal-One-D/ Osnate -D Cholichalciferol: Indrop-D Alendronate sodium: Tab. Drate 70mg (Weekly) Calcium vitamin-D tablets and Calcitonin

25. Indications for spine surgery Altered bladder and bowel function progressive neurological deficits Pain worsen with conservative treatment Radiculopathy/Neurogenic Claudication Cauda Equina Syndrome

26. Complications No improvement Recurrence of pain Recurrent disc prolapse Epidural fibrosis Failed back surgery syndrome Infection Disc Wound Neural injury Vascular injury CSF fistula

27. Surgical treatment Surgical treatment is indicated in patient with moderate or marked compression of the nerve root or severe cauda equina syndrome. The aim of surgery is to decompress the cord. For central canal stenosis LAMINECTOMY - Decompression laminectomy is useful. It is mostly done in central canal stenosis. DISCECTOMY - Discectomy and osteotomy of inferior articular process helps to remove the hypertrophic element.

28. For lateral canal stenosis LAMINECTOMY DISC EXCISION PARTIAL MEDIAL FACETECTOMY FORAMINOTOMY Spinal fusion to stabilize the lumbar spine is usually not required as instability is less commonly seen in lumbar canal stenosis. The neurogenic claudication respond poorly to the conservative treatment but respond well to surgical decompression.

29. In my opinion, surgery for spinal stenosis should only be considered if your quality of life has been severely affected

30. SURGICAL PROCEDURE There are seven steps of the procedure. The operation generally lasts 1 to 2 hours . Approach to the spine: Anterior (Transthoracic) Approach to the Thoracic Spine Anterolateral (Retroperitoneal) Approach to the Lumbar Spine Anterior (Transperitoneal) Approach to the Lumbar and Lumbosaccral Spine Posterior Approach to the Lumbar Spine Surgical technique for spine Minimally invasive spinal surgery Keyhole Spinal Surgery

31. Posterior Approach to the Lumbar Spine the most common approach to the lumbar spine providing access to the cauda equina and the intervertebral discs expose the posterior elements of the spine Uses Excision of herniated discs Exploration of nerve roots Spinal fusion Removal of tumors

32. Posterior Approach to Lumbar Spine Step 1: Prepare the patient Positioning: Prone “Mecca” position Anesthesia: General anesthesia (Protect airway in prone position) Localization: Between two paraspinal muscles (erector spinae) Templating, which is performed preoperatively, consists of identifying the anteroposterior axis of the spinous process and measuring its shortest depth to understand the spine anatomy for each patient and avoid overpenetration of the osteotomy into the spinal canal. The maximum anteroposterior depth of the spinous process above the spinous process junction with the dorsal lamina is chosen as the depth of the osteotomy. Using fluoroscopy, the spinous process to be osteotomized is identified and the skin is marked (Needle localization and marking of the spinous process). Skin Preparation: Scrub skin with pyodine solution

33. Position of the Patient prone position On side Flex the patient's hips and knees to flex the lumbar spine and open up the interspinous spaces

34. Landmarks Spinous processes Line drawn between the highest points on the iliac crest is in the L4-5 interspace To determine the exact level is use a radiograph

35. Step 2: Incision Landmarks can palpate spinous process (midline) highest point on iliac crest marks L4-5 interspace make midline incision 2 to 5 inch incision in the at the over the appropriate vertebrae NOTE: A midline skin incision is made, and the subcutaneous tissue is dissected until the thoracolumbar fascia is reached.

36. Incision midline longitudinal incision length of the incision depends on the number of levels to be explored

37. Step 3: Superficial dissection I ncise fat and lumbodorsal fascia to spinous process Preserve interspinous ligament D etach paraspinal muscles (erector spinae) subperiostally ( E rector spinae ( iliocostalis , Longissimus , and spinalis ), are dissected/split down the middle and moved to either side exposing the lamina of each vertebra) Dissect down spinous process and lamina to facet joint Move medial to lateral taking down or sparing the facet capsule Continue anterior to transverse process if necessary

38. Step 4: Deep dissection Ligamentum flavum: Remove ligamentum flavum by cutting attachment to edge of lamina, Ligamentum flavum attaches to the lamina halfway up the undersurface identify epidural fat and dura using blunt dissection stay lateral to dura and continue to floor of spinal canal Note: Decompress the spinal cord: Once the lamina and ligamentum flavum are removed the protective covering of the spinal cord (dura mater) is visible. The surgeon can gently retract the protective sac of the spinal cord and nerve root to remove bone spurs and thickened ligament.

39. The facet joints, which are directly over the nerve roots, may then be undercut, or trimmed, to give the nerve roots more room. (Fig 5). Called a foraminotomy, this maneuver enlarges the neural foramen (where the spinal nerves exit the spinal canal). If a herniated disc is causing compression the surgeon will perform a discectomy. After the surgeon has confirmed that all pressure has been removed from the nerve, the paraspinal muscles are sewn back together to cover the laminectomy site. Step 5: Decompress the spinal nerve

40. Step 6: Spinal Fusion (if necessary) Spinal fusion where two or more vertebrae are joined together with a section of bone to stabilize and strengthen the spine For those who has spinal instability or have laminectomies to multiple vertebrae, a fusion may be performed. Fusion is the joining of two vertebrae with a bone graft held together with hardware such as plates, rods, hooks, pedicle screws, or cages. The goal of the bone graft is to join the vertebrae above and below to form one solid piece of bone. The most common type of fusion is called the posterolateral fusion. The top most layer of bone on the transverse processes is removed with a drill to create a bed for the bone graft to grow. Bone graft, taken from the top of your hip, is placed along the posterolateral bed. The surgeon may reinforce the fusion with metal rods and screws inserted into the vertebrae. The back muscles are laid over the bone graft to hold it in place.

41. The split spinous processes are approximated using transosseous restorable sutures (Figure 7). The supraspinous and interspinous ligaments are repaired with interrupted sutures restorable closed wound suction drain placed deep to the lumbodorsal fascia if drain is required The erector spinae muscle and fascia is closed with watertight closure and skin incisions are sewn together with sutures Step 7: closure

42. Discharge instructions: Conservative Management for 3-4 weeks Keep wound clean and dry. No lifting greater than 10 pounds, strenuous activity, crawling, stooping, bending or twisting for 1 months after surgery. Watch for the development of fever or redness and drainage from the wound. Pain may require many days to resolve. Please alert your doctor of sudden onset of new pain. Call your doctor if you have any concerns. Evaluation and treatment for osteoporosis.

43. High-yield Points Spinal -- epidural abscess - Staph. aurous [50 – 60%] Cervical Spondylosis: Most common occurs at C5-6 > C6-7 levels Sciatica is the most common symptom of a lumbar herniated disc Sciatica most commonly caused by lumbar disc prolapse Piriformis muscle compression lead to Sciatica/ Sciatica-type-pain Whiplash Injury- Hyperextension of lower cervical spin Jefferson fracture is burst fracture of ring of atlas (C1) vertebrae Burst fracture is a vertical compression fracture Flexion rotation injury is the most common spinal injury followed by compression extension injury (2nd most common). Tear drop fracture is caused by combined axial compression and flexion injury Hangman’s Fracture- It occurs when a fracture line passes through the neural arch of the axis (C2) vertebrae

44. Best diagnostic test for calcification of ligaments MRI or CT Calcification of any tissue in body CT Scan is the investigation of choice. Remember C for CT scan C for Cortex and C for Calcification. M for MRI, M for Marrow. MRI is also the best radiological investigation for soft tissues and cartilage.

45. H igh yield points X-rays is done for screening (Cartilage not seen) CT Scan is done for bone Cortex and Calcification Calcification of Ligament–CT Scan MRI is done for Soft tissues/Cartilage/ Bone Marrow/Unilateral stress fractures (Investigation of choice) MRI is done for occult fracture neck femur Bone scan is done for bilateral stress fractures. (Investigation of choice) and metastasis. Metastasis–PET CT scan > Bone Scan Culture is best for infection, T.B. Spine CT guided biopsy gold standard Best radiological investigation for bone infection is MRI >Bone Scan Bone and joint infections Gold standard is always culture and sensitivity Inflammatory Joint swellings order of investigations is X-MAS X-RAY  MRI  Aspiration  Swelling of a joint

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