powerpoint presentation · 2019. 3. 14. · at the end of the presentation participants will be...
TRANSCRIPT
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Non Operative
Management
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/ Presenter Disclosures
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
Understand the non operative management options
Definitions
Patho-anatomical classification
1. Congenital
2. Spondylolisthesis
3. Iatrogenic
4. Other diseases/metabolic
5. Acquired- degenerative joint/ disc disease
Neurogenic Claudication and
Lumbar Spinal Stenosis
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Chung et al Skeletal Radiol 2000 Chung et al Skeletal Radiol 2000
Ahn et al Neurol Med Chir 2009
Takahashi et al, Spine 1995
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]
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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 Diagnosis
Hip Disease- OA
Vascular Claudication
Peripheral Neuropathy
Trochanteric Bursitis
[Ammendolia 2014]
Imaging
MRI or CT Scan
30% False Positive > age 55 [Boden 1995]
Diagnosis Diagnosis
Imaging
MRI imaging of choice
In the absence of RED FLAGS
If not progressive and not surgical no MRI needed
Chou et al CPG 2007
Diagnosis
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
Suri et al, JAMA 2010
Lumbar Disc Herniation
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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 2013
Non Operative Treatment
Treatment- Neurogenic Claudication
Intervention Effectiveness
Calcitonin Not likely
NSAIDS, Vit B12, Gabapentin,
Prostagladins
?
Epidural Injections ?
Physical Therapy/ manual therapy ?
Multi-modal ?
Surgery ?
Ammendolia et al Spine 2012, Ammendolia et al Cochrane Library 2013,
Ammendolia et al Euro Spine J 2014
Surgery vs. Physical Therapy
Delitto et al. Ann Int Med 2015
• RCT N= 169
• Decompression vs. 6 weeks PT
• At 2 years no difference
57% cross over PT to Surgery
Epidural Injections (EDI)
Friedly JL et al New Engl J Med 2014 RCT N=400 EDI
Glucocorticoids plus lidocaine vs. lidocaine alone
No difference
Despite the lack of evidence, 25 % of all epidural injections are performed for symptoms of lumbar spinal stenosis
Treatment- Neurogenic Claudication
Intervention Effectiveness
Opioids ?
Pregabalin ?
Markman et al, Spine 2015 RCT N=24 Oxymorphone hydrocholide vs Propoxyphene/acetaminophen vs Placebo no difference in walking ability, pain or disability scores
Markman et al, Neurology 2015
Pregabalin vs Placebo RCT cross over study, N= 29 no difference in walking ability, pain or disability scores
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• Self management • Self monitoring • Flexion exercises • Strength training • Manual therapy • Body re-positioning • 2x w- 6weeks
Intervention: Boot Camp Program Lumbar Spinal Stenosis
Emphasis on standing/walking/functional abilities
Cognitive Behavoural Approach
Takahashi et al, Spine 1995
Position and Epidural Pressure in LSS
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Retrospective Study
0
10
20
30
40
50
60
ODI
Me
an
Sc
ore
Outcome Measure
Comparison of Outcome Measures at Baseline and 6-week Follow Up
Baseline
Follow up
0
1
2
3
4
5
6
7
8
ODI Walk SSS Pain SSS Function NPS LBP NPS Leg Pain SSS TreatmentSatisfaction
Me
an
Sc
ore
Outcome Measure
Comparison of Outcome Measures at Baseline and 6-week Follow Up
Baseline
Follow up
**All differences in outcomes were both clinically and statistically significant
University of Toronto
Lumbar Spinal Stenosis Study
The Arthritis Society
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
“A Comparison of
Non-Surgical Treatment
Methods for Patients
With Lumbar Spinal
Stenosis”.
Patient Centered Outcomes
Research Institute (PCORI)
USA
Contact info: [email protected]
Carlo Ammendolia
Funded by the Canadian Chiropractic Research Foundation
and The Arthritis Society
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