Lumbar spinal stenosis, laminectomy, prolapsed intervertebral disc

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

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

Vertebral Anatomy
Vertebral
Body
Pedicle
Lamina
Superior
Articular
Process
Spinous
Process
Transverse
Process
Vertebral
Foramen
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

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:
1. Overgrowth of bone: Osteoarthritis and bone spurs
2. Herniated disk
3. Thickened ligament
4. Spinal injuries

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

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

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?
1. Prescribe NSAIDs and see the patient back in 2 weeks
2. Perform a lumbar steroid injection
3. Send the patient for an MRI of the lumbar spine
4. Send the patient for a radiograph of the lumbar spine
5. Refer the patient to physiatrist and see the patient back in 1 month

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.

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)

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
1. Pain radiates to buttocks and lower extremities.
2. Pain or feeling of cramps in the legs after standing for a long period of time or
while walking.
3. Pain relieved by sitting or lying down and increase by standing or walking.
4. The pain usually goes away when the person either bends forward or sits
down (Pain relieved by forward flexion)
5. Pain exacerbated by standing and walking.
• leg pain (often unilateral)
• Weakness and imbalance while walking
• bladder disturbances
• cauda equina syndrome (rare)

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

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.

Special test
1. 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.
2. 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.

Diagnostic Approach
• Physical history & medical History
• Blood tests: CBC, ESR, C-Reactive protein
• Imaging: X-ray, CT Mylogram, MRI (IxCx)
1. 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.
2. 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.
3. X-rays can help in identifying any change in the bones such as bone
spurs. These spurs may narrow the space within the spinal column.

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

Non-Surgical Management
1. 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.
2. NSAIDs: These are effective in relieving pain and inflammation.
3. Muscle relaxants: Medicines reduce muscle contractions that occur
occasionally with spinal stenosis.
4. Anti-seizure drugs: Anti-seizure drugs effective in reducing the pain
caused due to nerve damage.
5. Antidepressants: Antidepressants relieving chronic pain/ Fibromyalgia
6. Other drugs such as Opioids / narcotics may be advised to get relief
from pain.

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

Non-Surgical: Conservative Rx
1. Tab. Naproxen sodium 550mg (Synflex)
BD / 1 - 0 - 1
2. Cap. Pregablin 50mg (Gabica)
BD /1 - 0 - 1
3. Tab. Mecobalamin (Methycobal)
BD / 1 - 0 - 1
4. Cap. Esomeprazole 40mg (Nexum / Esso)
OD / 0 - 0 – 1

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

 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

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

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

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
1. LAMINECTOMY - Decompression laminectomy is
useful. It is mostly done in central canal stenosis.
2. DISCECTOMY - Discectomy and osteotomy of
inferior articular process helps to remove the
hypertrophic element.

 For lateral canal stenosis
1. LAMINECTOMY
2. DISC EXCISION
3. PARTIAL MEDIAL FACETECTOMY
4. 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.

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

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

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

Posterior Approach to Lumbar Spine
 Step 1: Prepare the patient
1. Positioning: Prone “Mecca” position
2. Anesthesia: General anesthesia (Protect airway in prone position)
3. Localization:
1. Between two paraspinal muscles (erector spinae)
2. 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.
3. 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.
4. Using fluoroscopy, the spinous process to be osteotomized is identified
and the skin is marked (Needle localization and marking of the spinous
process).
4. Skin Preparation: Scrub skin with pyodine solution

• 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

• 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

 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.

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

 Step 3: Superficial dissection
 Incise fat and lumbodorsal fascia to spinous process
 Preserve interspinous ligament
 Detach paraspinal muscles (erector spinae) subperiostally
(Erector 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

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.

 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

 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.

 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

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

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

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.

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

Lumbar spinal stenosis, laminectomy, prolapsed intervertebral disc

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