Spinal Claudication

Presentation and Management

Neil W Valentine FRCS

Presentation

Age 50 +Male : Female >5 : 1Usually manual workersLimited walking capacityStoop / sit / lean forward to relieve symptoms“heavy” or “tired” legs

ClaudicationSpinal : Vascular

Relieved by flexingUphill often not badCycling easy

Relieved by standingUphill badCycling bad

Examination

Diagnosis depends on historyOften no signsStooped gaitCan’t extend

Mechanism of symptom production- speculative

Effect of movementDegenerative spondylolisthesis“watershed” vascular zoneObstruction to CSF circulationArterial insufficiencyVenous engorgementIncarcerated segment

Pathogenesis

Pre-existing narrow canalDisc bulge(s)Facet hypertrophy / degenerationLigament hypertrophy / degeneration

SpinalStenosis

Canal configurations

Pathogenesis

Anatomy

Pathology

TreatmentNon - Operative

Restriction of activityPhysiotherapyAnti – inflamatoriesLumbar supportEpidural steroidCalcitonin

Often of limited benefit

X - rays

Investigation

MyelogramCombined CT / myelogramNerve conduction / EMG’sMRI

Myelogram

CT

CT myelography

MRI

TreatmentOperative

Multi – level laminectomyLateral recess decompressionNerve root decompressionStabilise and fuse if required

Posterior Hypertrophy

Multilevel decompression

Multilevel flavectomyRoot decompressionsDoes not destabilise

Central Decompression

Partial facetectomy

Lateral Recess Decompression

Subtotal Facetectomy

Root Decompression

TreatmentStabilisation and fusion

Remains unresolvedFacets disruptedPrevious instabilityPrevious decompression

Stabilisation (fusion)

Stabilisation (fusion)

Problems

Generally aged patient groupVery extensive surgery – 3 hours +High constitutional risksDifficulty in reconstructing porotic bone

Possible Developments

Limited decompressionSpinous process distraction

“X-stop”

Limited Decompression

Multi – level flavectomyLateral recess decompressionPreserve facetsNo need for stabilisation

X - stop

Complications

Dural tear 8.5%Neurological complications up to 10%“Old” nerves don’t recover as well as “young” nervesNeck problems