Rev. bras. ortop. vol.49 número4

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rev bras ortop.2014;49(4):405–408

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Case

Report

Lumbar

stenosis:

clinical

case

夽,夽夽

Pedro

Sá,

Pedro

Marques,

Bruno

Alpoim,

Elisa

Rodrigues,

António

Félix,

Luís

Silva,

Miguel

Leal

∗

UnidadeLocaldeSaúdeAltoMinho,VianadoCastelo,Portugal

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Articlehistory:

Received7March2013 Accepted8October2013 Availableonline3May2014

Keywords:

Spine

Spinalstenosis Laminectomy

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Lumbarstenosisisanincreasinglycommonpathologicalconditionthatisbecomingmore frequent withincreasingmeanlife expectancy,withhighcostsforsociety.Ithasmany causes,amongwhichdegenerative,neoplasticandtraumaticcausesstandout.Mostofthe patientsrespondwelltoconservativetherapy.Surgicaltreatmentisreservedforpatients whopresentsymptomsafterimplementationofconservativemeasures.Here,acaseof severestenosisofthelumbarspineatseverallevels,inafemalepatientwithpathological andsurgicalantecedentsinthelumbarspine,ispresented.Thepatientunderwenttwo differentdecompressiontechniqueswithinthesameoperation.

Estenose

lombar:

caso

clínico

Palavras-chave:

Colunavertebral Estenoseespinal Laminectomia

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Aestenoselombaréumapatologiacadavezmaisfrequente,queacompanhaoaumentoda esperanc¸amédiadevidaequecomportacustoselevadosparaanossasociedade.Apresenta inúmerascausas,entreasquaisdestacam-seadegenerativa,aneoplásicaeatraumática. Amaioriadospacientesrespondebemàterapêuticaconservadora.Otratamentocirúrgico estáreservadoparaaquelesdoentesqueapresentemsintomatologiaapósaimplementac¸ão demedidasconservadoras.Éapresentadoum casodeestenosegravedacolunalombar emváriosníveis,numadoentedosexofemininocomantecedentespatológicos/cirúrgicos dacolunalombar,naqualforamaplicadasduastécnicasdistintasdedescompressão,no mesmoatocirúrgico.

夽

Pleasecitethisarticleas:SáP,MarquesP,AlpoimB,RodriguesE,FélixA,SilvaL,etal.Estenoselombar:casoclínico.RevBrasOrtop. 2014;49:405–408.

夽夽

WorkperformedintheAltoMinhoLocalHealthcareUnit,VianadoCastelo,Portugal. ∗ _{Corresponding}_author_.

E-mail:pmgs4@iol.pt(M.Leal).

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rev bras ortop.2014;49(4):405–408

Introduction

Lumbarstenosisisdefinedasapathologicalnarrowingofthe vertebralcanaland/orintervertebralforamensthatleadsto compressionofthethecalsacand/orthenerveroots.Itmaybe confinedjusttoonesegment(twoadjacentvertebraeandthe intervertebraldisc,jointfacetsandcorrespondingligaments) or,insituationsofgreaterseverity,itmayencompasstwoor moresegments1_and_present_several_etiologies.

As mean life expectancy increases, people of greater agearepresentingactivelifestyles.Consequently,functional limitation and pain caused by symptomatic degenerative pathologicalconditionsofthespinehavebecomemore fre-quentandlumbarstenosishasbecomeanimportantdisease. Themainclinicalmanifestationsarelumbalgia,generally associatedwithirradiationtothelowerlimbs,andneurogenic claudication.

Radiologicalexaminations,especiallylumbarX-rays, com-puted tomography (CT) and magnetic resonance imaging (MRI),areusefulandessentialtoolsfordiagnosingand char-acterizinglumbarstenosis.

Therapyforthisconditioncontinuestobeaclinical chal-lenge,withvariousoptionsavailable.

Case

report

Thepatientwasa53-year-oldwhitefemalewhowasobserved inanorthopedicoutpatientconsultationwithacomplaintof lumbalgiaintheL5–S1regioninsituationsofconstantloading, withirradiationtobothlegs.Theconditionhadbeenevolving foraround twoyears,despiteconservativetherapy consist-ingofanalgesia,NSAIDs,musclerelaxantsandphysiotherapy, whichhadbeeninstitutedbythefamilydoctor.Thepatient reportedhavingneurogenicclaudication.Shedidnothaveany previoushistoryoftrauma.

Shereportedhavingpersonal antecedentsofadisc her-nia,whichwaspresentintwosegmentsofthelumbarspine (L3–L4 and L4–L5),and havingundergoing classical lumbar discectomy.

Onphysical examination,shepresented painon palpa-tionofthelumbarspineapophysesandparavertebralmasses. ShewasbilaterallypositiveforLasègue’ssign.Aneurological examinationrevealedafootinclinedtotheright.

LumbarMRIshowedabulgingintervertebraldisc, hyper-trophyofthejointfacetsandyellowligamentsatthelevels L2–L3,L3–L4,L4–L5andL5–S1,whichcausednarrowingofthe spinalcanal,withimpairmentoftherootsofL4,L5 andS1

Fig.1–MRIofthelumbarspine(sagittalslice),inwhich lumbarstenosiscanbeseenatL2–S1.

(Figs.1and2AandB).Electromyographywasalsoperformed onthelowerlimbs,andthisrevealedsevereradiculopathyat L5andS1.

Fromthis,adiagnosisoflumberstenosisatL2–L3,L3–L4, L4–L5andL5–S1wasestablished,associatedwith neurologi-caldeficits,andsurgicaltreatmentwasproposed.Thepatient underwentlumbarrecalibrationofL2–L3andL3–L4bymeans oftheSenegastechniqueatL4–L5andL5–S1with laminec-tomyandfixationusingtranspedicularscrewsand postero-lateralarthrodesis,withanautologousbonegraft(Fig.3).

The patient presented regression of the neurological deficits aftertheoperation.Currently,sheisbeingfollowed upasanoutpatientandisasymptomatic.

Discussion

Theincidenceoflumbarstenosisinthegeneralpopulationis between1.7%and8%,anditincreasesfromthefifthdecade oflifeonwards.2

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Fig.3–X-rayofthelumbarspineaftersurgerywith arthrodesisatL4–S1.

Itcanbeclassifiedaccordingtoeitherits etiology orits anatomy.Theetiologicalclassificationisdividedinto congen-italstenosisandacquired/degenerativestenosis.Congenital stenosisischaracterizedbynarrowingofthevertebralcanal thatiseitheridiopathicorsecondarytobonedysplasiasuchas achondroplasia.Acquired/degenerativestenosismayoccuras aresultofmetabolicdisease(suchasPaget’sdisease),tumors, infections, osteoarthritic alterations or instability with or without spondylolisthesis. The anatomical classification is usedtoidentifyspecificareas ofstenosisand isusedas a “guide”tosurgicaldecompression.Fourtypesofstenosiscan bedefined:(1)central;(2)lateralrecess;(3)foraminal;and(4) extraforaminal.

Adultdegenerative lumbar stenosis, which was present inthisclinicalcase,isalmostalwaysassociatedwith osteo-phytic/degenerativeincreases inthejoint facets,andthese alterationsarecausedbysegmentalinstability.Itisbelieved thatthis entire degenerative process startswith degenera-tion of the intervertebral disc, followed by collapseof the disc space.3 _This _gives_rise _to _abnormal _movement

kinet-ics,withconsequentosteoarthrosis/hypertrophyofthejoint facets,whichresultsindiminutionofthecentraland inter-vertebralportionofthe vertebralcanal.Becauseofthe loss ofdisc heightand hypertrophyofthejointfacets, shorten-ingandthickeningoftheyellowligamentisseen,whichalso contributestowarddiminishingthecentralspaceofthe ver-tebralcanal.Insomepatients,degenerativecystscanalsobe seeninthesynovialregionofthejointfacets,whichcausea “mass”effectandcontributetowardagreaterdegreeoflumbar stenosis.

The classical clinical presentation of lumbar stenosis consists of bilateral neurogenic claudication, along with chroniclumbalgiawithirradiationtothelowerlimbs,which

worsens with standing up for prolonged periods, physi-cal activity and lumber extension. Some patients describe improvementofthesymptomswhen theysit downand/or flex thelumbarspine.Neurogenicclaudication needstobe distinguishedfromvascularclaudication.Thelatterdoesnot presentworseningwhilethepatientisstandingupforalong time, and it is not alleviated through flexion of the lum-barspine,unlikewhatisseenwithneurogenicclaudication. Objectiveexaminationonpatientswithvascularclaudication showsthattheygenerallypresentabnormalitiesofthearterial pulse,alongwithtrophicalterations(thinnerandshinierskin). Efforttestsmaybeusefulindistinguishingbetweenthesetwo clinicalentities.Asmallnumberofpatientspresentpriapism and/orsphincterdysfunctioninassociationwithneurogenic claudication,whichrevealsamoreseveredegreeoflumbar stenosis.Alterationstothesensitivityofthelowerlimbsand tendonreflexesmayalsobepresent.

There are several pathological conditions that present similar symptoms, and it is necessary to make a differ-ential diagnosis. It is important to rule out tumors (both primarytumorsandmetastases),Paget’sdisease,infections, trochantericbursitisandcoxarthrosis/gonarthrosis.4

Thediagnosisoflumbarstenosiscanbeconfirmedthrough using computed tomography (CT) and magnetic resonance imaging(MRI).CTistheexaminationthatpresentsbetter cost-efficacy,anditprovidesanexcellentlevelofdetailingofthe bonestructures,especiallyintheregionofthelateralrecess. MRIprovidesabetterviewofthesofttissues,whichisvery usefulinevaluatingthepathologyoftheintervertebraldisc, anditsefficacy isbetterthanthatofCTandmyelography.5

Electromyography,whichteststhevelocityofnerve conduc-tionandassessestheevokedsomatosensorypotentials,does notformpartofthe routineevaluationoflumbarstenosis. Itis usefulfor distinguishingradiculopathy because ofthe lumbarcompressionanddiabeticneuropathythataffectthe peripheralsensory-motornerves.

There are two main variants of treatments for lumbar stenosis:conservativeandsurgical.

Thepillarsofconservativeconsistofuseofdrugs, phys-iotherapy,corsetryandepiduralinjectionsofcorticosteroids. Use of non-steroidal anti-inflammatory drugs provides an improvement in the symptoms, though diminishing the inflammatoryresponseassociatedwithcompressionofneural elements.Physiotherapyisbasedonstretchingand strength-ening exercises for the lumbar spine, along with aerobic exercises(staticbicycle).Corsetrymaybeusefulfor alleviat-ingthesymptoms,throughdiminishinglumbarlordosis,and itpresentsbetterresultsinpatientswithspondylolisthesis.6

Injectionofcorticosteroidsfortreatinglumbarpathological conditions, notably lumbar stenosis, remains a controver-sialprocedure.7_To_date,_several_studies_have_been_unable_to

demonstrateanyeffectiveresponsefrominjectionsfor resolv-ingradiculopathy.7

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approachenablesdirectviewingofthenerverootsandtheir decompressionalong theentirepath.Lessinvasive decom-pressive surgical techniques that preserve posterior bone andligamentstructureshaverecentlybeendevelopedinan attempttodiminishthepostoperativeinstability.These tech-niquesinclude laminectomywith angular resection ofthe anteriorandlateralportionsofthelamina,selective unilat-eral/bilaterallaminectomy,partiallaminectomyandlumbar laminoplasty.8–10_In_certain_cases,_it_is_possible_to_apply_several

surgicaltechniquesatdifferentvertebrallevelsinthesame patientand toreservestandard laminectomyforthelevels thatpresentstenosisofgreaterseverity.5_The_clinical_results

from surgicaldecompressionoflumber stenosishavebeen favorable,11_with_remission_of_the_symptoms,_although_recent

studieshaveindicatedthattheinitialclinicalimprovement tendstodeterioratewiththepassageoftime.12

Spondylolis-thesisfollowingdecompressionwithoutlumbararthrodesisis oneofthecommonestcomplications.Therefore,arthrodesis ofthelumbarspinewithautologousgraftsandfixationwith transpedicular screws shouldbe performed onall patients who present instabilitydue toresectionofthe joint facets during decompression.13 _It _is _essential _to _perform _lumbar

arthrodesisonpatientswithlumbarstenosisand spondylolis-thesisordegenerativescoliosis.13

Through presenting this case, the aim is to highlight the fact that this was a patient with pathological/surgical antecedentsinthelumbarspine,whopresentedsevere steno-siswithinvolvementofthelumbarspineatdifferentlevels, and towhom twodistinct decompression techniqueswere appliedinthesamesurgicalprocedure,withgoodresults.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.SpivakJM.Currentconceptsreview.Degenerativelumbar spinalstenosis.JBoneJointSurgAm.1998;80(7):1053–66. 2.LiebermanJR,PensakMJ.Preventionofvenous

thromboembolicdiseaseaftertotalhipandknee arthroplasty.JBoneJointSurgAm.2013;95(19):1801–11. 3.Kirkaldy-WillisWH,WedgeJH,Yong-HingK,ReillyJ.

Pathologyandpathogenesisoflumbarspondylosisand stenosis.Spine(PhilaPA1976).1978;3(4):319–28.

4.JönssonB,StrömqvistB.Symptomsandsignsindegeneration ofthelumbarspine.Aprospective,consecutivestudyof300 operatedpatients.JBoneJointSurgBr.1993;75(3):381–5. 5.PostacchiniF,AmatrudaA,MoraceGB,PerugiaD.Magnetic

resonanceimaginginthediagnosisoflumbarspinalcanal stenosis.ItalJOrthopTraumatol.1991;17(3):327–37. 6.WillnerS.Effectofarigidbraceonbackpain.ActaOrthop

Scand.1985;56(1):40–2.

7.RydevikBL,CohenDB,KostuikJP.Spineepiduralsteroidsfor patientswithlumbarspinalstenosis.Spine(PhilaPA1976). 1997;22(19):2313–7.

8.KanamoriM,MatsuiH,HiranoN,KawaguchiY,KitamotoR, TsujiH.Trumpetlaminectomyforlumbardegenerative spinalstenosis.JSpinalDisord.1993;6(3):232–7.

9.AryanpurJ,DuckerT.Multilevellumbarlaminotomies:an alternativetolaminectomyinthetreatmentoflumbar stenosis.Neurosurgery.1990;26(3):429–32.

10.TsujiH,ItohT,SekidoH,YamadaH,KatohY,MakiyamaN, etal.Expansivelaminoplastyforlumbarspinalstenosis.Int Orthop.1990;14(3):309–14.

11.TurnerJA,ErsekM,HerronL,DeyoR.Surgeryforlumbar spinalstenosis.Attemptedmeta-analysisoftheliterature. Spine(PhilaPa1976).1992;17(1):1–8.

12.PostacchiniF,CinottiG,GuminaS,PerugiaD.Long-term resultsofsurgeryinlumbarstenosis.8-yearreviewof64 patients.ActaOrthopScandSuppl.1993;251:78–80. 13.BoothJrRE,SpivakJ.Thesurgeryofspinalstenosis.Instr