SOAP. – Spinal Stenosis – SỔ TAY LÂM SÀNG

Spinal Stenosis

Julie Adkins and Jill C. Cash

Definition

Spinal stenosis is a narrowing of the spaces in the spine that result in pressure on the spinal canal and/or the nerve roots. The narrowing may involve a small or large area of the spine. In the lumbar area, pressure may elicit pain or numbness in the legs. In the cervical area, it may produce pain or numbness in the shoulders and arms/hands. The stenosis occurs in up to three areas:

A.The canal in the center of the column where the nerve roots run.

B.The canals at the base of the nerves branching out from the spine.

C.The openings of the vertebrae through which the nerves pass and go to other areas of the body.

Incidence

A.Spinal stenosis is most common in men and women older than the age of 50.

B.The incidence of lumbar spinal stenosis in the United States has been estimated at 8% to 11% of the population, and an estimated 2.4 million Americans will be affected by 2021. Lumbar stenosis accounts for 75% of the cases.

Pathogenesis

A.Spine:

1.The spine consists of 26 bones that extend in a line from the base of the skull to the pelvis. Twenty-four of those bones are called vertebrae:

a.7 cervical vertebrae.

b.12 thoracic vertebrae.

c.5 lumbar vertebrae.

2.The sacrum consists of five fused vertebrae between the hip bones.

3.The coccyx has three to five bones at the lower tip of the vertebral column, which are linked together and cushioned by shock-absorbing discs.

B.Narrowing of the spinal canal may be inherited or acquired. Spinal stenosis most often results from a gradual, degenerative aging process where the ligaments of the spine may thicken and calcify. The bones and joints enlarge where surfaces of the bone begin to project from the body (called osteophytes or bone spurs), thereby decreasing the space (neural foramen) for nerve roots leaving the spine. Disc degeneration causes the same narrowing of the vertebral space.

Predisposing Factors

A.Aging with secondary changes (narrowing of the spinal canal).

B.Osteoarthritis (the most common cause of spinal stenosis).

C.Herniated disc (places pressure on the spinal cord and nerve root).

D.Trauma to the spine.

E.Bone disease such as Paget’s disease of the bone (may see structural narrowing of the spinal canal).

F.Tumors of the spine.

G.Ossification occurs when calcium deposits form, turning the fibrous tissues of the ligament into bone and in turn pressing on the nerves of the spinal canal.

H.Rheumatoid arthritis.

I.Spinal surgery.

Common Complaints

The neck or back may not be painful, but if the narrowed space is pushing on a nerve root, symptoms will associate with the nerve root in the arms or legs.

A.Numbness in arms or legs.

B.Weakness in arms or legs.

C.Cramping in arms or legs.

D.Pain radiating down the leg (sciatica), causing difficulty in walking.

Other Signs and Symptoms

A.Symptoms develop slowly over time.

B.Pain comes and goes, generally not continuous.

C.Pain worsens during certain activities such as walking or change of position.

D.Some symptom relief by rest and/or any flexed forward position (lumbar).

Potential Complications

A.Incontinence.

B.Paralysis.

C.Unresolved presenting symptoms or worsening of symptoms.

D.Surgical risks include infection, tear in the membrane covering the spinal cord, blood clot formation, and neurological deterioration.

Subjective Data

A.When were the symptoms first noticed? Ask patient what brought about or preceded the episode.

B.Have the symptoms worsened over time? Describe the pain and note certain times of the day that symptoms were more prominent.

C.Describe pain, as well as radiation of pain, or effect (numbness or tingling) on other body parts—hips, thighs, knees, calves, ankles, feet, arms, hands, fingers.

D.What makes the pain worse? What makes the pain better?

E.Have the patient rate pain on a scale of 0 to 10, with 0 being no pain.

F.Ask the patient to list all medications currently being taken, particularly substances not prescribed and illicit drugs.

G.Are there any other medical problems or chronic conditions that may contribute to symptoms?

H.Any incontinence issues with bowel or bladder? If so, when did symptoms begin, and how are they changing?

Physical Examination

A.Vital signs: Check temperature, pulse, respirations, and blood pressure.

B.Inspect:

1.Inspect and observe general appearance, gait, assistive devices used, positioning of affected portion of the spine, and overall appearance of pain.

2.Inspect for gross abnormalities of weakness of arms or legs, foot drop or drag.

3.Inspect legs for edema/swelling, skin rashes or discolorations of skin of arms/hands or leg/feet; skin temperature changes or symptoms of stasis; and fatty masses (lipomas) in the area of the low back, which may be a sign of spina bifida.

C.Auscultate:

1.Heart.

2.Lungs.

D.Palpate: Cervical spine and lumbar spine:

1.Neck:

a.Palpate the neck with the patient in the supine position; the muscles of the neck are relaxed in this position and the bony structures are more defined.

b.Palpate the anterior neck while supporting the base of the neck.

c.Palpate the hyoid bone (situated above the thyroid cartilage), which is opposite the C3 vertebral body.

d.Palpate the Adam’s apple, which marks the C4 body, whereas the lower portion of the Adam’s apple is the C5 level. The first cricoid ring, inferior to the sharp lower edge of the thyroid, is opposite the C6 body. This ring is immediately above the site for an emergency tracheostomy. Too much pressure on palpation may cause the patient to gag. The carotid tubercles are at the horizontal level of C6 and located laterally about one inch from the first cricoid ring. The carotid tubercles should be palpated separately to avoid restriction of flow

to both carotid arteries at the same time. C1 can be located as a small hard bump which lies between the angle of the jaw and the styloid process.

e.Palpate the posterior neck while standing behind the patient, cupping the anterior neck to avoid tension on the muscles. The posterior aspect includes the occiput, spinous processes, mastoid process, and the facet joints. Begin at the base of the skull, palpating C2 (C1 lies deep). Palpate from C2 to T1 for normal curvature of the spine. If the vertebra is uncertain, it can be determined with the anterior structures of the anterior neck.

f.Palpate the lumbar spine while sitting on a stool behind the standing patient. Place the fingers on the top of the iliac crest with the thumbs on the midline of the back (L4–L5) and palpate spinous processes downward. Pain referred from the spine may be reproduced in the back of the legs during palpation. Pain with palpation of the coccyx is usually the result of direct blow trauma. Palpate the anterior aspect of the spine, with the patient lying supine with knees bent to relax the abdominal muscles. The umbilicus lies at L3 to L4. L4 to S1 are palpable below the aorta’s division into the common iliacs. L5 to S1 may be palpated when palpating below the umbilicus and pushing into the abdomen with abdominal relaxation.

g.Palpate the soft tissues of the neck and lumbar spine:

i.The anterior triangle: This is made up of the two sternocleidomastoid muscles, superior by the mandible and inferior by the suprasternal notch.

ii.The posterior aspect involves the trapezius muscles and the greater occipital nerves at the base of the skull, as well as the superior nuchal ligament that extends to the C7 process.

iii.Soft tissue palpation of the lumbar spine involves the following:

•The midline raphe (supraspinous and interspinous ligaments and the paraspinal muscles).

•The iliac crest (gluteal muscles).

•The posterior superior iliac spine (sacral triangle).

•The sciatic area (sciatic nerve—the largest nerve in the body runs vertically down the midline of the posterior thigh, giving off branches to the hamstring muscles, and then divides into the tibial and peroneal areas).

•The anterior abdominal wall and inguinal areas. Pain in the inguinal area usually indicates disorders of the hip joint.

h.Assess the ROM of the cervical and lumbar spine with basic movements of flexion, extension, lateral rotation to the left and right, and lateral bending to the left and right:

i.Rotation: Ask the patient to shake his or her head from side to side.

ii.Flexion and extension: Ask the patient to touch his or her chin to his or her chest and to look up at the ceiling.

iii.Lateral bending is assessed by having the patient try to touch his or her ear to his or her shoulder without lifting the shoulder to his or her ear.

iv.Normal lateral bending is 45 degrees toward each shoulder.

v.Vertebral motion is greatest where the disc is the thickest and larger joint surfaces are present (L4, L5, S1) so motion taking place is greater than between L1 and L2.

vi.ROM of the lumbar spine includes flexion (bend as far forward as patient can with knees straight and try to touch toes—measure the distance from floor to fingertips), extension (place palm on his or her back and have patient bend backward as far as possible—estimate the range of extension), lateral bending (lean to the left and then lean to the right as far as possible—estimate the degree and compare sides), and rotation (rotate the pelvis and compare ranges of rotation).

i.Perform a neurological exam that includes muscle testing and examination of the entire upper extremities for weakness or disorders of sensation. There are eight nerves exiting the cervical spine. Stenosis or disorders such as a herniated disc frequently reflected to the upper extremity usually originate from the C5 to T1. The primary nerves involved in the sensory distribution of the upper extremities are the following:

i.C5—lateral arm, axillary nerve.

ii.C6—lateral forearm, thumb, index, and half of middle finger, musculoskeletal nerve.

iii.C7—middle finger.

iv.C8—ring and little finger, medial forearm, medial antebrachial-cutaneous nerve.

v.T1—medial arm, medial brachial cutaneous nerve.

The neurological exam of the lumbar spine is completed by performing an assessment of the ROM.

j.Assess reflexes and sensation: Biceps reflex and lateral arm axillary nerve indicates primarily origination from C5 to C6:

i.Assess C6 by the brachioradialis reflex tested proximal to the wrist. C6 supplies sensation to the lateral forearm, the thumb, the index, and half of the middle finger. To assess, form the number six with your thumb, index, and middle finger by pinching your thumb and index finger and extending the middle finger.

ii.Access C7 (radial nerve) by having the patient begin extension of the tricep/elbow from a position of flexion as motion is resisted. C7 also involves the median and ulnar nerves. To test wrist flexion, ask the patient to make a fist and flex the wrist as you resist against the palmar aspect of the closed fist. To test the radial nerve (C7), press on the dorsum of the patient’s extended fingers. To test the reflex of C7, tap the triceps tendon where it crosses the olecranon fossa at the elbow. Sensation testing is supplied to the middle finger by C7.

iii.C8 has no reflex, muscle strength, or sensation test to determine integrity.

iv.To test nerves emanating from T12, L1, L2, and L3—the iliopsoas is the main flexor of the hip—have patient sit on a table, place hand over the iliac crest, and ask the patient to actively raise his or her thigh from the table.

v.Sensation testing of L1, L2, and L3 is over the area of the anterior thigh between the inguinal ligament and the knee.

vi.Muscle testing of L2, L3, and L4—femoral nerve—is performed by having the patient sit on the edge of the table, stabilizing the distal end of the thigh, and instructing the patient to extend his or her knee while offering resistance to the motion.

vii.To test the obturator nerve (hip adductors)—instruct the patient to abduct the legs after placing a hand on the medial sides of the knee and ask to abduct knees to resistance.

viii.L4 muscle testing involves the tibialis anterior tested by resistance to dorsiflexion and inversion by pushing against the dorsal medial aspect of the first metatarsal bone.

ix.Reflex testing of L4 involves the patellar reflex and sensation testing of the medial side of the leg below the knee.

x.Neurological muscle testing of L5 involves the deep peroneal nerve by placing your thumb on the dorsal surface of the foot so that the patient must dorsiflex his or her great toe to reach it. Oppose this motion by pushing on the nailbed of the great toe. To test the superior gluteal nerve (L5)—have the patient lie on his or her side and instruct him or her to abduct the leg and then push against the lateral side of the thigh for resistance. Reflex testing of L5—test the tibialis posterior reflex.

xi.Muscle testing of S1 involves the superficial peroneal nerve and is performed by securing the patient’s ankle and having him or her plantar flex and evert the foot and oppose the motion by resistance pushing. The inferior gluteal nerve is tested by having the patient flex the knees and extend the hips as resistance is applied to hip extension while palpating the gluteus maximus for tone.

xii.The Achilles tendon reflex is the tendon reflex mediated by the S1, S2 tibial nerve.

xiii.Pathological reflexes (the significance of their presence or absence is the reverse of the normal reflexes). These include the following:

•The Babinski test: Run a sharp instrument across the plantar surface of the foot from the calcaneus to forefoot—if negative, the toes either do not move or bunch up uniformly. If positive, the great toe extends while the other toes plantar flex and splay. Results should be negative in adults.

•The Oppenheim test: Run your fingernail along the crest of the tibia. Normally, there should be either no reaction, or the patient should complain of pain; if abnormal, the great toe extends while the other toes plantar flex and splay.

k.Perform complete abdominal exam.

E.Mental status: Assess for any psychopathological component impacting symptomology and diagnosis.

Diagnostic Tests

A.Diagnostic imaging: MRI scan or a CT scan with and without myelogram. Plain CT scans are of limited value unless they are made with very fine segmental scan slices.

B.Bone density or dual-energy x-ray absorptiometry (DEXA) scan testing is used to assess for osteopenia and/or osteoporosis.

C.Electrophysiological studies are mainly used to rule out differential diagnosis of spinal cord lesions or disorders of the nervous system, but may be helpful when the patient presents with multisegmental symptoms. These studies are often complicated with coexisting conditions such as diabetes mellitus or polyneuropathy affecting the nerves.

D.Laboratory tests can help to rule out inflammatory processes: complete blood count (CBC), C-reactive protein (CRP), renal function test, basic metabolic panel (BMP), erythrocyte sedimentation rate.

Differential Diagnosis

A.Spinal stenosis.

B.Conditions that may mimic cauda equina (ruptured abdominal aortic or iliac aneurysms, acute aortic dissection, acute leg ischemia, or deep vein thrombosis [DVT]).

C.Claudication (presentation of intermittent leg pain may indicate claudication—arterial, peripheral, or neurogenic).

D.Diabetic polyneuropathy.

E.Paget’s disease:

1.Paget’s disease is a chronic disorder typically resulting in enlarged and abnormal bones—the spine is one of the most common sites affected by this disease. The lumbar spine is affected in at least half of the cases. Paget’s disease may present symptoms of disc prolapse with nerve root entrapment and with the increased vascularity of the pagetic vertebrae, which may diminish the spinal cord or nerve root blood supply; this causes pain.

F.Amyloidosis associated with hemodialysis or amyloid tumors may cause spinal stenosis or even cauda equina syndrome.

Plan

A.General interventions:

1.Symptoms of cauda equina are a rare form of spinal stenosis. It occurs because of the compression of the cauda equina, and symptoms may include loss of bowel control, bladder or sexual dysfunction, pain, or weakness or loss of feeling in one or both legs. Cauda equina syndrome is serious and requires urgent medical attention. Patients should be transported to the hospital immediately.

2.Spinal stenosis of the cervical spine can be far more dangerous by compressing the spinal cord, leading to major body weakness or even paralysis, and requires urgent medical attention. Patients should be transported to the hospital immediately.

3.Physical therapy:

a.Build strength and endurance.

b.Maintain flexibility and stability of spine.

c.Improve balance and gait.

d.Reduce pain.

4.Alternative therapies (chiropractic treatment and/or acupuncture).

5.Bracing may be used for lumbar stenosis to help support those patients with weak abdominal muscles or multilevel degeneration and also help regain or maintain stability.

B.Patient teaching:

1.Home treatments may include hot or cold packs as necessary.

2.Assistive ambulatory devices such as canes or walkers may be used to relieve pain and provide stability and fall prevention. Instruct patient on the proper use of these devices.

3.Encourage the use of home exercises. Provide patient with proper back exercises.

C.Pharmaceutical therapy:

1.Pain control:

a.Nonsteroidal anti-inflammatory drugs (NSAIDs) if not contraindicated.

b.Muscle relaxants to treat the muscle spasms associated with spinal stenosis.

c.Antidepressants such as amitriptyline can help ease chronic pain.

d.Antiseizure medications such as Neurontin or Lyrica may be used to reduce pain caused by damaged nerves.

e.Opioids may be considered to control severe pain. All patients must be assessed individually for comorbid conditions, as well as medication interactions and precautions, before prescribing medications. Fall risk assessment; independence of activities, driving; and mental capabilities should also be evaluated.

2.Steroid trigger injections to decrease irritated and swollen areas may help reduce inflammation and relieve pain. Repeated steroid injections can weaken bones and connective tissue, so injections should be limited.

Follow-Up

A.Follow-up is determined by patient’s needs: complications from surgery, continued pain and inflammation, or assessment of functional status with nonsurgical therapy interventions.

Consultation/Referral

A.Refer to a neurosurgeon if nonsurgical modalities fail. The extent of the patient’s pain and the patient’s preferences all factor into whether to have surgery.

B.Urgent surgical consult should be obtained immediately if a patient has numbness or weakness that interferes with walking, impaired bowel or bladder function, or other neurological involvement.

C.Pain management specialists should be considered if conservative measures are not meeting patient’s needs.

D.Refer to physical/occupational therapy for evaluation and treatment.

Individual Considerations

A.Geriatrics:

1.When the elderly patient can no longer walk sufficiently to care for himself or herself and perform essential tasks, then surgery is usually recommended. The priority of surgery is to increase the patient’s activity tolerance with lessened pain.

2.Booklet for exercise: A guide from the National Institute on Aging is available free of charge to educate patients on exercises-motivation-safety, along with self-tests, benefits, and nutrition. This booklet can be obtained from NIA Information Center, PO Box 8057, Gaithersburg, MD 20898-8057.

3.Nonpharmacological measures to treat spinal stenosis in the adult and elderly population are becoming more acceptable for conservative spinal pain management among patients and their medical providers. Recent studies postulated that according to a satisfaction score, acupuncture for spinal stenosis pain was significantly more effective than physical exercises and medications.

4.An intraspinous spacer for geriatrics is less invasive and studies have indicated it to be effective in many cases. However, if spinal instability is confirmed with flexion/extension and radiograph vertebral destruction is verified, then fusion must be considered.

5.Complex/simple fusions have higher costs than decompression and may have more complications with geriatrics. Comorbidities of depression, scoliosis, depression, and cardiovascular disease predict worse surgical outcomes.

6.Although there are increased risks with spinal surgery in the aging population, the posterior lumbar interbody fusion with screw augmentation is recommended for extreme cases of pain and quality of life dysfunction (after the surgeon’s careful clinical judgment regarding specific patient candidacy).