Diseases, Disorders information

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Spinal stenosis, something that you will see in an older aged group and as the population ages, this is something we are looking at more and more as far as attempts to define the optimum care of these patients. Remember, with spinal stenosis, the classic symptom is neurogenic claudication, that is bilateral lower extremity pain, heaviness in relation to activity. That is differentiated from vascular claudication in the way that they relieve the pain. Vascular claudication on the basis of aortoiliac disease will present as pain related activity as well. The patient with vascular claudication just has to stop and stand still and the symptoms will get better. The patient with neurogenic claudication actually has to flex and change positions, and that makes sense, because what they are trying to do when they flex, they are trying to open up the canal diameter, by reversing the lordosis, you are trying to increase neural foraminal dimensions in the central canal diameter, so these patient’s will have a flexion preference and a sitting preference.
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The other thing you see is the shopping cart sign, ask somebody if they do their own grocery shopping, they say os yes, I can walk much better as long as I lean over a cart. They have neurogenic claudication until proven otherwise. The neurologic examinations of these individuals is normal as a rule, you are not going to find a motor deficit or a sensory deficit to any degree of regularity. Conservatively, there is an increasing body of circumstantial evidence that epidural steroid therapy may help, there are actually some specific physical therapy protocols for this that have been investigated in the literature, nothing conclusive yet, although intuitively, it’s hard to imagine you are really opening things up in a lasting way in the setting of a degenerative stenosis, perhaps transcutaneous electrical nerve stimulation that has been studied a bit more in the pain literature and then surgical, and of course hallmark of the surgical treatment is a laminectomy to decompress the nerve roots, classically that was thought to be successful in about 85% of people, long term followup studies from Scandinavia have shown the success rate is probably closer to 65 or 70% as far as long term relief of symptoms, the two problems are that many patient’s after laminectomy will complain of back pain, which again is not something a laminectomy is designed to resolve, you are dealing with a nerve compression and the claudication, number two is remember, that degenerative disease is progressive, and five years later, anywhere from 20 to 50% of patient’s may have problems at adjacent levels, so-called junctional syndromes with stenosis at the level at which the decompression was stopped, not because the surgery was done incorrectly, but because the degenerative disease has progressed.