1/28/2015. Lumbar Spinal Stenosis. Learning Objectives. Faculty/ Presenter Disclosures. Neurogenic Claudication and. Faculty: Dr.

Transcription

1 Faculty/ Presenter Disclosures Lumbar Spinal Stenosis Carlo Ammendolia, DC, PhD Assistant Professor, IHPME University of Toronto Staff Clinician/Associate Scientist, Mount Sinai Hospital Adjunct Scientist, Institute for Work Health Professorship in Spine, Dept. of Surgery U of T Faculty: Dr. Carlo Ammendolia Relationships with commercial interests: None Funding: Canadian Chiropractic Research Foundation (CCRF) Mount Sinai Hospital Boot Camp for Lumbar Spinal Stenosis- Not-for-Profit Learning Objectives At the end of the presentation participants will be able to: Understand the burden of symptomatic LSS Understand the etiology and patho-anatomy Make the diagnosis and differential diagnosis Case Mr. DR: History D.R. Age 74 retired lawyer Long history of LBP 1 1/2 years of posterior buttock to calf pain bilaterally with standing and walking (VAS 9/10) with limited walking to few blocks Sitting/stoop posture and lying down immediate relief No night pain HBP, CHD (stent), OA knees Lyrica and 5-6 Tylenol daily Understand the non operative management options Definitions Neurogenic Claudication and Lumbar Spinal Stenosis Patho-anatomical classification 1. Congenital 2. Spondylolisthesis 3. Iatrogenic 4. Other diseases/metabolic 5. Acquired- degenerative joint/ disc disease 1

2 Chung et al Skeletal Radiol 2000 Chung et al Skeletal Radiol 2000 Ahn et al Neurol Med Chir

3 Position and Epidural Pressure in LSS Prevalence 9.3% of the general population have symptomatic LSS [Yoshita 2012] Primary care - 47% of adult patients with leg pain and numbness (mean age 65 yrs for males and 54 yrs in females) [Konno 2007] 25% of Canadian pop > 65 yrs in 2031 (10M) [Stats Can 2006] Takahashi et al, Spine 1995 Burden A leading cause disability & loss independence in elderly [Kalichman 2009] Functional limitations > CHF, COPD or SLE [Fanuele 2000] Walking limitation > OA hip or OA knee [Winter 2010] Most common spine surgery age > 65 [AHCRQ 2001] Medicare in US- $1.7 B per year surgical cost alone [Deyo 2010] Neurogenic Claudication Differential Hip disease- OA Vascular Claudication Peripheral neuropathy Trochanteric bursitis [Ammendolia 2014] Imaging MRI or CT Scan 30% False Positive > age 55 [Boden 1995] 3

4 False Negative Imaging Ahn et al Neurol Med Chir 2009 Imaging MRI imaging of choice In the absence of RED FLAGS If not progressive and not surgical no MRI needed Most useful Age > 70 Age < 60 Bilateral buttock or leg pain No pain when seated Symptoms worse standing/walking Symptoms improve when bending forward Positive Rhomberg / wide stance gait Urinary disturbances Chou et al CPG 2007 Suri et al, JAMA 2010 Lumbar Disc Herniation Neurogenic Claudication (LSS) v.s. Lumbar Radiculopathy (LHD) NC- Lumbar Stenosis LR- Disc Herniation Demographics > 65 40s Lumbar flexion Relief Worse Sitting Relief Worse Level L4-5 L5-S1 SLR Negative Positive Suri 2012, Katz 2008, Rainville

5 Treatment- Neurogenic Claudication Intervention Effectiveness Non Operative Treatment Calcitonin NSAIDS, Vit B12, Gabapentin,? Prostagladins Epidural Injections? Physical Therapy/ manual therapy? Not likely Multi-modal? Surgery? Ammendolia et al Spine 2012, Ammendolia et al Cochrane Library 2013, Ammendolia et al Euro Spine J 2014 Intervention: Boot Camp Program Lumbar Spinal Stenosis Position and Epidural Pressure in LSS Self management Self monitoring Flexion exercises Strength training Manual therapy Body re-positioning 2x w- 6weeks Cognitive Behavoural Approach Emphasis on standing/walking/functional abilities Takahashi et al, Spine

6 6

7 7

8 Mean Score Mean Score Retrospective Study Comparison of Outcome Measures at Baseline and 6-week Follow Up Baseline Follow up University of Toronto Lumbar Spinal Stenosis Study 10 0 ODI Outcome Measure 8 Comparison of Outcome Measures at Baseline and 6-week Follow Up The Arthritis Society 7 6 **All differences in outcomes were both clinically and statistically significant ODI Walk SSS Pain SSS Function NPS LBP NPS Leg Pain SSS Treatment Satisfaction Baseline Follow up Self-Management to improve walking ability in degenerative lumbar spinal stenosis: the evaluation of four novel strategies. Carlo Ammendolia, Raja Rampersaud, Pierre Côté, Brian Budgell, Claire Bombardier and Gillian Hawker Outcome Measure Carlo Ammendolia A Comparison of Non-Surgical Treatment Methods for Patients With Lumbar Spinal Stenosis. Contact info: cammendolia@mtsinai.on.ca Patient Centered Outcomes Research Institute (PCORI) USA Funded by the Canadian Chiropractic Research Foundation 8