Medical symptom checker- Back pain cause- Spinal stenosis

Spinal stenosis

Spinal stenosis occurs as a result of narrowing of the spinal foramen and spinal canal. It is cause due to compression of the lumbar spinal elements as a result of arthritic changes such as narrowing of the disc space, hypertrophied of ligamentum flavum and formation of bone spurs. This condition will leads to buttock and back pain and if foraminal stenosis occurs the pain may radiates to the lower extremities.

In term of general prevention there are no known way to prevent this condition. However, any condition that may leads to the open up of the spinal foramen or spinal canal such as leaning forward when walking.

In term of epidemiology, spinal stenosis mostly occurs as a result of wear and tear of the spine due to its arthritic condition of the normal spine. The prevalence of spinal stenosis increase with age as it commonly develop during the 5th and 6th decades of life. It is equally happens on both sex (no sexual predominance ). However it is 4 time more common in women if she suffered from spondylolisthesis and spinal stenosis at the same time. It is as high as 8% of the population in term of incidence. As mention earlier the prevalence increases with age and it can achieve as high as 100% by investigation which is based on radiographic studies on elderly patient. However not all symptomatic patient present with radiographic spinal stenosis.

The most common risk factor of developing spinal stenosis includes increasing ages as well as spinal arthritis but not genetic linkage is identified as a causative factor.

The pathology behind spinal stenosis includes the dehydration of the disc ( disc dehydration which leads to loss of height follows by the bulging of ligamentum flavum and bulging of annulus into the spinal canal which later increase joint loading of facets.This condition will later develop osteophytic bone growth and reactive sclerosis which worsen the condition by causing compression of the neural elements that present in spinal foramen and spinal canal.

Other etiologies include, congenital cause of spinal stenosis or congenitally narrowed spinal canal , idiopathic, degenerative causes, iatrogenic, chondrodystrophy, primary or metastatic tumor and post traumatic as well as osteoarthritic changes of the lumbar spine.

Patient will complains of longstanding back pain that will radiates to the buttock and lower extremities. Patient may also develop the sensation of numbness, pain, tightness and weakness of lower extremities which is subjective. ( Signs of neurogenic claudication). The symptoms are worsen while the patient is walking , back extension and standing.However the symptoms will improve with resting, leaning forward or sitting.

In term of history , the patient will provide information such as the onset which is insidious onset, which later progress slowly before becoming worse when the patient walking upstairs ( uphill ) and improve by resting, leaning forward and sitting.

On physical examination, the patient will present with loss of motion of lumbar spine, alteration of the gait ( need to differentiate between intracranial pathology or cervical myelopathy ). Patient may also complain of pain while extension of the lumbar spine is performed and the patient may also loss of the lumbar lordosis. If nerve root entrapment is present, the straight leg raise test may be positive. In L5 distribution, the muscle weakness is most commonly present.

The diagnosis of spinal stenosis is confirm from history, physical examination, investigation and imaging studies.

The lab investigation include, full blood count, CRP and ESR if cancer or infection are one of the differential diagnosis.

The imaging studies such as radiography ( anteroposterior (AP) and lateral radiographs of the spine ) of the spine will shows a changes of the spine such as spondylolisthesis or degenerative changes of the spine and rule out other causes such as tumor, infection or fracture. The view of the patient in flexion and extension will help to evaluate the instability.

Any compression of the neural elements will be demonstrated with MRI. Another alternative to MRI include, CT myelography which is an invasive procedure by injecting the dye that associated with post spinal headache. CT myelography may also detect the compression of the neural element.

In certain case, where there are multiple sites of compression of the neural and the finding is unclear,a injection is performed to localizes the source of pain. If the patient continue to be symptomatic after the non- operative or non invasive treatment, surgical decompression is the definitive treatment.

As a summary the pathological finding of spinal stenosis includes narrowing of spinal canal and foramina which leads to intervertebral instability as a result of facet hypertrophy and decreased in disc height.

Spinal stenosis may also be confused with vascular claudication which cause pain in the calf ( calf pain ) after walking/ambulation. The difference between vascular claudication is that there are no back pain or buttock pain present and vascular claudication will not improve with leaning forward. Other differential diagnosis includes cervical myelopathy and disc herniation.

There are no randomized controlled studies which focus on operative and non operative treatment of spinal stenosis .The general procedure or protocol of spinal surgeon is to perform non operative treatment initially unless the symptom effect or impede the patient 's life. The most effective surgical treatment to alleviate the symptom is decompression which also can be performed with fusion . However , fusion may leads to further problems such as spondylolisthesis.

Surgery is only require to reduce or alleviate the pain ( pain relief) which allow and improve the patient mobility and life. Besides that spinal stenosis is not causing any neurological damage.

For short term corset or brace is helpful. However for long term it should be avoided as it may leads to paraspinal muscle weakness. Weight loss is also recommended and being active and do a lot of exercise is recommended as long as no other pathology present such as fracture or gross instability to prevent deconditioning. Optimized nutritional status is required if the patient is undergoing surgery.

Special therapy such as aquatic therapy is beneficial for muscle condition. other therapies include abdominal muscle strengthening, back extensor muscle strengthening and gait training.

The first line of drugs requires include acetaminophen, anti inflammatory medication and enteric coated aspirin. While the second line of drug is lumbar epidural steroids

Surgery is perform to patient who is unresponsive to non operative/invasive treatment and cannot achieve the quality of life required. A thorough pre operative preparation is required. The patient should get the clearance from the cardiologist, anesthesiologist or internist as necessary.The mainstay of the treatment is decompression of the neural element . This generally involve laminectomy, discectomy and foraminotomies when neural compression present.The new device known as X STOP is introduced that is be able to decompress the canal by lodging between the spinous process with minimal surgery. Instrumentation with pedicle screw is required to perform fusion. Fusion is requires in case where extensive decompression and instability is present. ( with disruption or interruption of more than 50% of articular facets or pars interarticularis.)

The patient with spinal stenosis may require routine follow up at 6 weeks, 3months, 6 months, 1 years , 2 years and every 2 years .

The patient is admitted to the hospital if he complains of progressive or acute neurological deficit or pain which is unremitting and affect the daily life function.

The patient with spinal stenosis will be discharge from the hospital if the pain is remitting an d neurological deficit is gone.

The patient is refer to the spine surgeon if the spinal deformity is getting worse and the patient is unwilling to live with the pain and not response to non operative treatment and suffers from neurological deficit.

In term of prognosis spinal stenosis is worsen with time and surgical approach will improve the patient condition .

In term of complication the patient may suffer from bladder and bowel dysfunction in case of severe spinal stenosis while the complication from the surgery includes chronic pain, neurological injury, infection, disability and pseudoarthrosis.

Patient is monitor for any complication after non - operative and operative procedure, improvement of the symptoms and for fusion when performed.

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