Lumbar Spinal Stenosis and Lower Extremity Arthroplasty

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1 The Journal of Arthroplasty Vol. 8 No Lumbar Spinal Stenosis and Lower Extremity Arthroplasty Michael J. McNamara, MD, Kimberly G. Barrett, RN, BSN, Michael J. Christie, MD, and Dan M. Spengler, MD Abstract: Because of their prevalence in elderly patients, tile clinical symptoms of acquired lumbar spinal stenosis and degenerative joint disease of tile lower extremity can often be present in the same patient. This study reports 14 patients who had diagnoses of both lower extremity degenerative disease and acquired lumbar spinal stenosis. Five of the 14 patients presented with concomitant symptoms, while 9 of 14 patients presented with clinical symptoms of spinal stenosis an average of 9.3 months following joint arthroplasty surgery. Comparison of the preoperative hip and knee scores between the concomitant and sequential groups demonstrated no differences. Seven of the nine patients in the sequential group required subsequent decompression for their spinal steuosis. Stenosis of the lumbar spine must be considered in patients who complain of continuing symptoms of neur6genic claudication in the postoperative period. In addition, these patients should be specifically counseled before their arthroplasty procedures that subsequent spinal surgery may be necessary. Key words: lumbar spinal stenosis, arthroplasty, lower extremity, degenerative joint disease. Spinal stenosis has long been recognized as a cause of insidious back, hip, and leg pain in elderly patients (age 70 and over). One classic pain pattern of spinal stenosis is neurogenic daudication, which may include combinations of unilateral leg pain or bilateral hip pain. 1"3"6 Arthritis also commonly occurs in the lower extremity in this age group. The causes of arthritis can be muhifactorial and include avascular necrosis, spondyloarthropathy, and osteoarthropathy, s'9 The most common presenting symptoms of degenerative joint disease are pain and limitation of range of motion. As arthritic changes progress, gait disturbances may occur. We report the association of acquired lumbar spinal stenosis and lower extremity degenerative disease. The association of spinal stenosis with peripheral vascular disease has been previously reported. 4 From the Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee. Reprint requests: Michael J. McNamara, MD, Department of Orthopaedics and Rehabilitation, D-4208 MCN, Vandcrbih University Medical Center, Nashville, TN Materials and Methods The population for this study was identified by a retrospective review of patients who presented for evaluation of lower extremity degenerative disease and acquired lumbar spinal stenosis at Vanderbilt University Medical Center (Nashville, TN) from 1985 to During this period, 2,515 patients presented for evaluation of degenerative joint disease and 1,480 patients underwent reconstructive arthroplasty. Fourteen patients who underwent lower extremity arthroplasty also carried the diagnosis of spinal stenosis. These patients' charts and radiographs were reviewed for this study. Patients were evaluated at initial presentation for their complaints, which usually focused on the lower extremity. Initial imaging did not include the lumbar spine unless indicated by history or physical examination. A'iThroplasty was performed on the Adult Reconstructive Service by a single surgeon (M. J. C.). Implants employed were selected by the surgeon on 273

274 The Journal of Arthroplasty Vol. 8 No. 3 June 1993 a per case basis. Both cemented and noncemented femoral implants were used. All acetabular implants were noncemented.

2 274 The Journal of Arthroplasty Vol. 8 No. 3 June 1993 a per case basis. Both cemented and noncemented femoral implants were used. All acetabular implants were noncemented. All knee components were cemented, and patellar resurfacing was always performed. Patients underwent postoperative mobilization according to the following protocols. Patients with noncemented implants were treated with touchdown weight bearing for 6 weeks, followed by onethird body weight bearing for 2 weeks and two-thirds body weight bearing for 2 weeks, and then permitted to progress to full weight bearing at 3 months. Patients with cemented femoral,~omponents and cemented knees were permitted immediate partial weight bearing and allowed to progress to full weight bearing at 6 weeks after surgery. Anhroplasty follow-up examinations were performed at routine intervals at 6 weeks, 3 months, 6 months, and each subsequent year. Each follow-up visit inclu~ted radiographic evaluation and recording of the Harris hip score or Brigham knee score. The diagnosis of spinal stenosis was initially made on the basis of the patient's pain pattern. The diagnosis was confirmed by magnetic resonance imaging and/or myelogram and postmyelogram computed tomography. All patients were initially managed without surgery, with nonsteroidal antiinflammatory medications and an exercise program. The exercise program consisted of abdominal strengthening and aerobic conditioning. Prior to surgery for spinal stenosis, patients underwent imaging of the lumbar spine using metrizamide myelography and postmyelogram computed tomography scanning. All patients underwent preoperative lateral bending films to exclude segmental instability. Operative decompression was performed after a thorough medical evaluation. All levels demonstrating stenosis as defined by Bolender 2 underwent decompression and foraminotomy. Patients who had segmental instability were managed with transpedic- ular instrumentation using VSP screws and plates (Acromed, Cleveland, OH) of unstable motion segments. Autogenous iliac crest bone graft was used for posterolateral fusion. After surgery, patients were managed with an abdominal binder and encouraged to ambulate as tolerated. Lumbar conditioning using resistance equipment was added at 6 weeks emphasizing both abdominal conditioning and lumbar extensors. Patients undergoing fusion were maintained in molded thoracolumbar sacral orthoses for 3 months. At 3 months, bracing was discontinued and patients began lumbar conditioning with resistance equipment. The results of the surgical treatment of stenosis were based on the subjective assessment of the patients as described by Johnsson. 7 Patients were categorized as excellent (symptom free), good (improved with residual back or leg pain), unchanged (no improvement), or worse (increased pain). Results Fourteen patients (5 men, 9 women) were identified who had undergone lower extremity arthroplasty and were symptomatic with acquired lumbar spinal stenosis. The average age at the time of the first surgical procedure was 70.3 years. Tile patient population can be categorized according to when they presented with symptoms of spinal stenosis. Five patients initially presented with symptoms of joint disease and spinal stenosis. Nine patients became symptomatic from spinal stenosis after their lower extremity reconst/-uction. Table 1 presents tile data from the group of patients presenting concomitantly with spinal stenosis and lower extremity arthroplasty. Only two of five patients in this group required surgical decompression for treatment of their spinal stenosis symptoms. The data from the group who developed symptoms Table 1. Patient Data: Concomitant Presentation of Spinal Stenosis and Lower Extremity Arthroplasty Age at Preoperative Follow-up Date of Patient No. Sex Presentation Arthroplasty Score Score Laminectomy 1 M 59 L THA R TttA /10/87 2 F 86 L TKA R TKA PT 3 F 75 L TttA /28/90 4 F 81 R THA PT 5 M 66 L TKA PT L, left; R, right; TttA, total hip arthroplasty; TKA, total knee arthroplasty; PT, trunk strengthening and aerobic conditioning.

3 Lumbar Spinal Stenosis 9 McNamara et al. 275 Table 2. Patients Presenting Sequentially With Symptoms of Spinal Stenosis Patient No. Time From Primary Preoperative Postoperative Arthroplasty to Onset Treatment of Hip/Knee Hip/Knee Age/Sex Procedure of Stenosis Symptoms Stenosis Score Score 6 82 F L knee 3 mo Lumbar F R hip 12 mo Lumbar L hip lamincctomy M L TKA 5 mo Lumbar lamincctomy 9 79 M R TKA 6 mo PT I. TKA F R TKA 15 mo Lumbar L TKA M L THA 21 mo PT F L hip 17 mo Lumbar F L TKA 12 mo Lumbar F L THA 6 mo Lumbar lalninectomy L, left; R, right; TKA, total knee arthroplasty; THA, total hip arthroplasty; PT, trunk strengthening and aerobic conditioning. of spinal stenosis after lower extremity arthroplasty are presented in Table 2. These patients have lower preoperative arthroplasty scores, although a statistical significance could not be demonstrated. Seven of nine patients in this group required decompressive. The average time to presentation with symptoms of spinal stenosis after arlhroplasty was 9.3 months. The average follow-up period from was 12 months. All patients experienced relief of neurogenic claudication. Three patients continued to complain of intermittent back pain. One patient continued to have radicular symptoms. Of nine patients undergoing decompression, eight were considered to have good or excellent subjective results at the last follow-up evaluation. The average follow-up period from arthroplasty was 24.8 months (range, months). The postoperative hip and knee scores in Table 2 are the scores obtained at the time of presentation with spinal stenosis. One patient required repeat revision arthroplasty at 18 months for recurrent dislocation. Discussion This study describes the association of clinical acquired lumbar spinal stenosis with lower extremity degenerative arthritis. There are two types of presentations, concomitant and sequential. In the concomi- tant group, the symptom complex includes back pain, lower extremity pain, and neurogenic claudication. Because Of tile excellent results achieved with arthroplasty, total joint arthroplasty was performed first in all patients in this review. No attempt was made to differentiate the joint pain from spinal stenosis. After recovery from arthroplasty, three of five patients in the concomitant group had their stenosis successfully managed conservatively. This gr6up also had higher preoperative hip and/or knee scores than the seqnential group, although a significant difference was not demonstrated. In the second group of patients (sequential), symptoms of spinal stenosis were masked by the extent of the joint disease (Fig. 1). With the improved function that resulted from successful arthroplasty, these patients developed symptoms consistent with lumbar stenosis (Fig. 2). Seven of nine patients required decompression of their spinal canals. Symptoms usually developed in this patient population during the first year following arthroplasty. The results of surgical decompression in our patients are consistent with previous reports. 5,7 Eightyfive percent of patients who underwent lumbar decompression had good to excellent results. 5-7 Treatment of spondylolisthesis with decompression alone has been associated with a worse outcome compared with decompression and fusion. ~~ We recommend that patients who demonstrate preoperative segmen-

276 The Journal of Arthroplasty Vol. 8 No. 3 June 1993 Fig. 1. (A) Preoperative anteroposterior radiograph of a pelvis demonstrating protrusio acetabuli and degenerative joint disease.

tal instability be treated with spinal fusion at the time of lumbar decompression. This study reports the association of acquired lumbar spinal stenosis and lower extremity arthroplasty.

steno- sis. In patients who present with stenosis and degeneratiye disease concomitantly, preoperative joint injectionmay be useful to assess the pain contribution of each process.

4 276 The Journal of Arthroplasty Vol. 8 No. 3 June 1993 Fig. 1. (A) Preoperative anteroposterior radiograph of a pelvis demonstrating protrusio acetabuli and degenerative joint disease. (B) One-year postoperative (after sequential total hip arthroplasties) anteroposterior radiograph ot"a pelvis. Patient symptomatic with neurogenic claudication. tal instability be treated with spinal fusion at the time of lumbar decompression. This study reports the association of acquired lumbar spinal stenosis and lower extremity arthroplasty. With the improvement in function and correction of contractures following arthroplasty that allow a more upright gait and a higher activity level, patients may become symptomatic from their lumbar steno- sis. In patients who present with stenosis and degeneratiye disease concomitantly, preoperative joint injectionmay be useful to assess the pain contribution of each process. ~ Two operative procedures may be necessary to treat the lower extremity symptoms. In this patient population, the surgeon must be aware that treatment of the patient's hip pain may require two surgical procedures. In our concomitant Fig. 2. (A) Radiograph of a patient who underwent lateral myelogram demonstrating evidence of acquired lumbar spinal stenosis. (B) Axial computed tomography after myelography demonstrating central stenosis. Patient under,vent decompressive L2--~L5.

5 Lumbar Spinal Stenosis 9 McNamara et'al. 277 group, three of five patients were managed without surgery for their stenosis symptoms. Patients should be informed prior to the first procedure that a second procedure may be necessary for the alleviation of symptoms. References 1. Blau JN, Logue V: Intermittent claudication of the cauda equina. Lancet 1:1081, Bolender N, SchOnstrom N, Spengler DM: Role of computed tomography and myelography in the diagnosis of central spinal stenosis. J Bone Joint Surg 67A: 240, Brish A, Lemer MB, Braham J: Intermittent claudication from compression of cauda cquina by a narrowed spinal canal. J Neurosurg 21:207, Dodge Larry, Bohlman HH, Rhodes R: Concurrent spinal stenosis and peripheral vascular disease. Clin Orthop 230:141, ttall S, Bartelson JD, Onofrio BM et al: Lumbar spinal stenosis: clinical features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med 103:271, Harris WH: Etiology of osteoarthritis of the hip. Clin Orth 213:20, Harrison MHM, Schajowicsz P, Trueta J: Osteoarthritis of the hip: a study of the nature and evolution of the disease. J Bone Joint Surg 35B:598, }terkowitz tin, Kurz LT: Degenerative lumbar spondy- Iolisthesis with spinal stenosis: a prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg 73A:799, Joffe R, Appleby A, Arjona J: Intermittent ischemia of the cauda equina due to stenosis of the lumbar canal. J Neurol Neurosurg Psychiatry 29:315, Johnsson KE, Willner S, Johnsson K: Postoperative instability after decompression for lumbar spinal stenosis. Spine 11:107, Kleiner JB, Thorne RP, Curd zig: The value of Bupivcaine hip injection in the differentiation of cox arlhrosis from lower extremity neuropathy. J Rheumatol 18: 422, 1991

Cover Page. The handle holds various files of this Leiden University dissertation.

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