Spinal stenosis

Classification according to ICD-10
M48.0	Spinal (canal) stenosis (including: lumbar spinal (canal) stenosis)
M99.3	bony stenosis (including narrowing of the spinal canal)
M99.4	Connective tissue stenosis (including narrowing of the spinal canal)
ICD-10 online (WHO version 2019)

The term spinal stenosis ( spinal canal stenosis or spinal stenosis ) describes a narrowing of the spinal canal . It is more common in the elderly. The lumbar spine or the cervical spine is usually affected , less often the thoracic spine .

history

Although the French doctor Antoine Portal described the narrowing of the spinal canal as a disease entity as early as 1803 and the French neurologist Joseph Jules Dejerine described the theory of ischemia as the cause of the restricted walking distance as early as 1853 , it lasted until 1976 when a group of American doctors used the term Delimited spinal stenosis and defined it as an independent clinical picture. It was not until 1996 that spinal stenosis was established as an independent disease in the German-speaking area through a review by Klaus-Peter Schulitz in the Deutsches Ärzteblatt .

causes

Because people walk upright , the lower lumbar spine is subject to high mechanical loads. Degenerative changes are age-dependent and stress-dependent and are widespread in mild forms.

As part of the normal aging process, the intervertebral discs lose height and osteochondrosis intervertebralis occurs : on the one hand, bulging of the intervertebral disc and, on the other hand, bony extensions on the vertebral bodies ( spondylophytes ). Arthritis of the small vertebral arch joints ( spondylarthrosis ) also develops . This combination creates an hourglass-shaped narrowing of the spinal canal.

In rare congenital diseases, there are spinal canal stenoses that occur early, e.g. B. in acrodysostosis .

Clinical picture and diagnosis

As the population ages, the problem of symptomatic degeneration of the cervical and lumbar spine becomes increasingly important. Around 80% of all people in industrialized countries will suffer from acute or chronic back problems in the course of their lives.

The main symptom of lumbar spinal stenosis is pain in the legs and back, which is load-dependent and often occurs when walking or standing and improves when you sit down or lean your upper body forward. Cramps in the legs can also occur. A leaning forward posture and limited walking distance can indicate lumbar spinal stenosis, but this is often absent. Some patients may have limited walking distance to 100 m. This relieving posture is adopted, as the spinal canal becomes relatively wider through bending and the irritation of the nerve structures is reduced. The associated finding is the so-called. Intermittent claudication spinal provided by the intermittent claudication must be deferred to a peripheral vascular disease refers. While it is sufficient to stand still in the case of arterial occlusive disease, in the case of lumbar spinal stenosis only sitting down or leaning forward leads to relief. Accordingly, cycling is often not restricted.

The stenosis can progress. After a few years, however, there is usually no further deterioration. Neurological failures are rare. The cause of these symptoms is a narrowing of the spinal nerve running in the spinal canal.

The diagnosis can be confirmed by imaging tests such as computed tomography (CT), magnetic resonance imaging (MRI), or myelography . A radiologically confirmed spinal stenosis does not allow any statement about the extent of the pain.

therapy

Conservative therapy

In spinal canal stenosis, only the symptomatic patient is treated, a pathological radiological finding alone is not an indication for treatment. Various conservative measures are pursued, which have the common goal of improving the pain symptoms and increasing the walking distance of the patient. This is to be achieved by relieving and stabilizing the affected vertebral segments and by promoting general physical performance. A combination of drug, physiotherapy and physical strategies is called a multimodal therapy concept.

The drug treatment consists of the administration of analgesics (depending on the degree of severity, non-steroidal anti-inflammatory drugs, NSAIDs or possibly opioids are administered) and anti-inflammatory agents, as well as muscle relaxants. Cortisone and vitamin B preparations are also used. Epidural injections with local anesthetics and steroids are also recommended. The physiotherapeutic strategies include flexion exercises, training therapy to strengthen the abdominal and back muscles as well as treadmill and ergonomics training. The physical measures include the use of a support corset to correct posture or heat treatment to relieve muscle tension. Electrotherapy is also used, such as transcutaneous nerve stimulation (TENS).

However, depending on the clinical picture, this treatment does not always work. The effectiveness of the measures has so far neither been proven nor refuted, as only a few studies have dealt with the effectiveness of individual measures.

Surgical therapy

Indications for surgical treatment are disabling pain, neurological deficits, unsuccessful conservative therapy over a period of at least three months, and congruent clinical and radiological findings based on the imaging methods already mentioned. Several studies suggest that surgical therapy is superior to conservative therapy. On average, 60% of patients show a significant improvement in symptoms after surgical interventions, while this success occurs in only 25% after conservative therapy. In contrast to conservative treatment, the goal of surgical treatment is not only aimed at alleviating the symptoms, but rather at eliminating compression in order to relieve the nerve root.

There are different surgical methods that are chosen individually for each patient. Microsurgical operation methods are standard. These are divided into pure decompression procedures or decompression procedures with additional stabilizing measures (fusions). An additional fusion must take place if load-bearing joint parts are removed. The decompression methods are further subdivided into interlaminar decompression and the complete laminectomy, in which the vertebral arch including the spinous process is removed up to the medial pedicle delimitation, depending on the extent of the removed segment parts. The intervention of choice for degenerative spinal stenosis is interlaminar decompression.

In some cases, for example with extraforaminal disc herniations, an endoscopic procedure is advantageous, especially if no bone tissue has to be removed. In rare cases, it may be sufficient to widen the narrowed spinal canal with the help of special implants, so-called spreaders.

The vertebra is accessed through a skin incision. Parts of the back muscles are loosened from the spine and pushed aside just like the skin. Various types of milling cutters are used for bone resection, including articulated ball-head cutters, atraumatic micro cutters, normal and diamond cutters. This is used to remove bone substance until the access to the spinal canal is exposed and the dura is exposed . Thickened ligaments are then removed endoscopically and bone growths are milled away from the side. The spinal canal is usually accessed via the arched plate of the vertebra, the so-called lamina , even if the narrowing occurs on the opposite side in the area of the vertebra . This part of the operation, in which the surgeon reams into the bone without direct visual control, harbors the greatest risk of injury, as the dura is not visible and the process cannot be ended indolently when the bone is broken through. It happens that the cutter literally shreds the dura and also damages nerve roots. The complication rate of these operations is stated differently in the literature and is 5–18%. There is no reliable information about the frequency of dural injuries, and a high number of unreported cases can be assumed. After injuring the dura, there is a risk that a CSF pillow or CSF fistula will develop, which can lead to meningitis with serious consequences.

In motion-preserving surgical procedures such as flexible spinal column stabilization, a dynamic implant is used that stabilizes the spine and at the same time maintains the movement in the operated spinal segment.

Individual evidence

↑ Klaus-Peter Schulitz, Peter Wehling, Josef Assheuer: The lumbar vertebral canal stenosis . Deutsches Ärzteblatt 1996, Volume 93, Edition 50 of December 13, 1996, pages A-3340 - A-3345
^ G. Antoniadis, E. Kast, H.-P. Richter: Lumbar spinal stenosis and its operative treatment . In: The neurologist . tape 69 , no. 4 , ISSN 0028-2804 , p. 306-311 , doi : 10.1007 / s001150050275 ( springer.com [accessed October 5, 2016]).
↑ ^a ^b ^c Thome, C., Die degenerative lumbale Spinalknalstenose, Deutsches Ärzteblatt J. 105, Issue 20, pp. 373–379, 2008
↑ AJ Haig, HC Tong, KS Yamakawa, DJ Quint, JT Hoff, A. Chiodo, JA Miner, VR Choksi, ME Geisser, CM Parres: Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. In: Arch Phys Med Rehabil. 2006 Jul; 87 (7), pp. 897-903, PMID 16813774 .
↑ Spinal stenosis: therapy. In: pharmacies look around. Retrieved October 5, 2016 .
↑ ^a ^b [1] Krämer, J. et al., Orthopedics and Orthopedic Surgery, Chap. 11, Spinal canal stenosis, Georg Thieme Verlag, Berlin, 2004
↑ ^a ^b S. Ruetten, M. Komp, P. Hahn, S. Oezdemir: Decompression of the lumbar recess stenosis . In: Operative Orthopedics and Traumatology . tape 25 , no. 1 , February 1, 2013, ISSN 0934-6694 , p. 31-46 , doi : 10.1007 / s00064-012-0195-2 ( springer.com [accessed October 5, 2016]).

[1] Klaus-Peter Schulitz, Peter Wehling, Josef Assheuer: The lumbar vertebral canal stenosis . Deutsches Ärzteblatt 1996, Volume 93, Edition 50 of December 13, 1996, pages A-3340 - A-3345

[2] G. Antoniadis, E. Kast, H.-P. Richter: Lumbar spinal stenosis and its operative treatment . In: The neurologist . tape 69 , no. 4 , ISSN 0028-2804 , p. 306-311 , doi : 10.1007 / s001150050275 ( springer.com [accessed October 5, 2016]).

[:0-3] Thome, C., Die degenerative lumbale Spinalknalstenose, Deutsches Ärzteblatt J. 105, Issue 20, pp. 373–379, 2008

[4] AJ Haig, HC Tong, KS Yamakawa, DJ Quint, JT Hoff, A. Chiodo, JA Miner, VR Choksi, ME Geisser, CM Parres: Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. In: Arch Phys Med Rehabil. 2006 Jul; 87 (7), pp. 897-903, PMID 16813774 .

[5] Spinal stenosis: therapy. In: pharmacies look around. Retrieved October 5, 2016 .

[:1-6] [1] Krämer, J. et al., Orthopedics and Orthopedic Surgery, Chap. 11, Spinal canal stenosis, Georg Thieme Verlag, Berlin, 2004

[:2-7] S. Ruetten, M. Komp, P. Hahn, S. Oezdemir: Decompression of the lumbar recess stenosis . In: Operative Orthopedics and Traumatology . tape 25 , no. 1 , February 1, 2013, ISSN 0934-6694 , p. 31-46 , doi : 10.1007 / s00064-012-0195-2 ( springer.com [accessed October 5, 2016]).