Lumbar Spinal Stenosis and Lower Extremity Pain in a 77-year-old Male
This surgeon is a consultant of Medtronic, but received no compensation for this case discussion.
The patient is a 77-year-old Caucasian male. He underwent recent elective quadruple coronary artery bypass graft 12 months prior with good recovery.
He complains of bilateral buttock pain that radiates through his thighs and calves. Pain is exacerbated by standing and ambulation. He is unable to walk for more than 10 minutes or 2 to 3 blocks due to pain. He considers lower extremity pain to significantly affect his quality of life and has recently experienced weight gain due to inability to remain active.
Previously treated with anti-inflammatory medicines and physical therapy
- Full lower extremity motor strength
- Normal deep tendon reflexes and sensory exam
- Negative straight leg raise
Figure 1. Pre-operative sagittal T2 MRI (left) and axial image at L4-L5 (right) demonstrates severe lumbar spinal stenosis secondary to hypertrophic ligamentum flavum and facet arthropathy.
Multi-level lumbar spinal stenosis with neurogenic claudication
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Medtronic's METRx® System was used for minimally invasive hemilaminectomies, bilateral dorsal, and lateral recess decompression through a unilateral approach.
Figure 2. Post-operative T2 MRI images at 18 months demonstrates continued adequate decompression of the thecal sac.
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- At 2 months post-operative, the patient's leg pain had completely resolved.
- Over the next 12 months the patient had recurrence of progressive lower extremity pain with ambulation. Follow-up lumbar MRI failed to show any recurrent lumbar stenosis.
- Given the patient's history of prior occlusive vascular disease, referral to vascular surgeon to investigate potential lower extremity vascular claudication was obtained. Vascular studies indicated aortoiliac disease with exercise-induced claudication. The patient elected not to undergo surgical intervention at this time.
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This case represents classic neurogenic claudication due to lumbar spinal stenosis, but it might be helpful to comment on the differential diagnosis and treatment. An important differential diagnosis is vascular claudication, which can be suspected by careful history and examination. Some elderly patients have co-existent vascular and neurogenic claudications. It is also important to rule out tandem cervical and lumbar spinal stenosis, presenting with gait difficulty and balance problems.
MRI confirmed the patient's moderate to severe lumbar spinal stenosis at L3-L4 and L4-L5 in the central canal and lateral recess that correlated with the patient's symptoms. Frequently, in patients with primary stenosis at the L4-L5 motion segment and above, the L5-S1 motion segment may also be involved with lateral recess and/or foraminal stenosis and it should not be overlooked during surgery. There is no evidence of instability on MRI but some patients show subtle spondylolisthesis on standing or flexion-extension radiographs that may change the treatment plan.
Once the diagnosis of lumbar spinal stenosis is made, treatment options should be discussed with the patient. Even the Spine Patient Outcome Research Trial (SPORT) study on spinal stenosis showed better outcome with surgery than conservative treatment. The conservatively treated cohort fared reasonably well without any significant neurological sequelae.1 Conservative treatments, such as analgesics, anti-inflammatory medications, injections, and exercise are an option for patients with spinal stenosis without significant neurological deficits and the symptoms are not too severe to significantly affect the patient's quality of life. Only when and if the symptoms are severe and non-responsive to conservative treatment, is surgery indicated. The patient should make the decision to have or not to have surgery based on the literature, and benefits and risks of surgery, as informed by the surgeon.
Surgical options include decompression by open or minimally invasive (MIS) techniques. There is no solid evidence in the literature that MIS techniques are superior to traditional open techniques for long-term outcome, but if the surgeon is well-trained and experienced, MIS techniques can help facilitate the post-operative course. In theory, preserving the midline structures will help spinal column stability and cause less destruction to the paraspinal musculature.
In severe stenosis, a unilateral approach to decompress central and bilateral lateral recess stenosis becomes more technical and should be approached with caution. The author of this case should be congratulated for excellent management of the patient from initial diagnosis to appropriate treatment selection and ultimately, a good outcome for the patient.
1. Weinstein JN, Tosteson TD, Lurie J, Tosteson AN, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An HS: Surgical versus non-surgical therapy for lumbar spinal stenosis. N Eng J Med. 2008. 358:794-810.