Lumbar spinal stenosis + non-mechanical nerve root lesions

• Lumbar Spinal Stenosis


  Also known as Neurogenic claudication and pseudo claudication
• Lumbar Spinal Stenosis Syndrome

  • 2 Types: Radicular LLS, Cauda Equiria LLS
• Cannot rely solely on imaging, high clinical false the rate of May only have major stenosis at one level
• Imaging helps exclude non-mechanical causes
• Predisposed to by congenital stenosis
• Exclusion of imperior vena cava stenosis syndrome >Quite rare cause
• Neurogenic Claudication


  Over 50 w/vong history of LBP, Proximal, initially Lx, buttocks, legs Radiates distally
• Vascular Claudication


  Over 50, Dishal, buttocks, thigh calves, Radiates proximally
• Type of Pain 


  • Neurogenic Claudication =weakness, burning, numbness or tingling
  • Vascular Claudication = cramping, aching + squeezing
• Onset


  • Neurogenic Claudication = Walking (uphill + downhill) distance walked varies and prolonged standing
  • Vascular Claudication = Walking a set distance each time and especially uphill
• Relief


  • Neurogenic Claudication = Lying down, flexing spine, may take 20/30 mins
  • Vascular Claudication = standing still =a fast relief and slow walking
• Associated Symptoms

  • Neurogenic Claudication = Bowel bladder symptoms
  • Vascular Claudication = impotence, rarely paraesthesia or weakness
• Physical exam


  • Neurogenic Claudication - pulses present
  • Vascular Claudication - pulses usually present, sometimes reduced
• Radicular Syndrome can arise from non-mechanical pathology such as Schumannova, neurocibanua, maningarina, perineural cysts, metastatic disease, uportion, wen
• Midura Cauda Equina Lesion

  • e.g. Lipora, desmoid agat/tumour, ependymana (tumout of filuminate), Affects 55-4-1 roots bilaterally, Dull LBP over area of tumour, Loss of social coining rectal pain, loss ankle jerks (may be only signs)
• Nerve Sheath Tumaus


  • Schwannava, neuropibroma, ganglioneurona, neurofibrosarcoma, Most are intradural/extramedullary, Some can be dumbell or hourglass in appearance, Multiple lesions may occur with sourfibromatosis, x-ray shows enlarged inf. posterior body erasion, Best viewed with special imaging
• Benign cysts humours are much less common causes & radicular pain / radiculopathy
• Patients symptoms may be reproduced with provocative neuro-orthopaedic manoeuvres
• Benign spinal humours can be treated conservatively for a while BUT always re-assess for RED FLAGS
• Lateral Conus Lesion


  • E.g. A neurofibroma on L3, produces pressure effect on L2 + L4 roots, can also cause lateral cord compression, Anterior thigh pain, may have LBP, Absent knee jerk, UMNL of lower leg due to lateral cord compression
• Perineural (Tariev's) cysts


  Formed by a space between the endoncarum perineunim, Most are asymptomatic, Most commonly involves sacral & coccygeal nerve costs, Can cause LBP, leg pain + sacrococcygeal pain, Symptoms occur because expanding cyst impinges upon adjacent needs
• Synovial Cysts


  • Most frequent at L4/5 + L5/S1, May contain loose or dense fibrous tissue, hyperplastic synovial membrane, Most are asymptomatic, Occasionally cause LBP + leg pain, Symptoms occur because expanding cyst impinges upon adjacent nerve roots
• Meningioma


  • Relatively common spinal neoplasms of accounting for as much as 1/4 of intraspinal expansile lesions
  • Slow growing, almost always benign,
  • Most common in Tx region, can occur in Cx spine,
  • Radicular pain may arise as lesion expands signs of cord compression become obvious
• Metastatic Disease


  • Mets is most common in L spine, Most symptoms arise from direct compression of expanding tumair mass from the vertebral body or lamina, Symptoms also arise from bony destruction & vertebral collapse or direct invasion of newe root, May be associated LBP from bany infiltration
• Vertebral osteomyelitis


  • Pyogenic inpections can appact vertebral body flor IVD, Source may be haomasogerous spread of durrict from pareign body or surgical intervention, Children are more likely to develop discitis, Adults are more likely to develop osteomyelitis, Acute expansive lesion may occur if weakened supporting structures give way under axial load abscess
• Herpes Zoster (Shingles)


  • Dogal root disease, Most common in thoracic region, If lumbar are me affected 62,3,4, Characterised by radicular pain followed by vesicular eruptions, in corresponding dermatome within 3 weeks
• Other Infections


  • Aids related polyradiculopathies, Lyme disease - transmitted by tick, 60% of patients with stage 2 des disease develop radiculitis
• Diabert Radiculopathy, Adyradiculopathy, Amyotrophy

  • Originates in one or all of L2,3 +4 NR or femoral nerve,
  • Occurs in non-insalin dependent diabetic,
  • More common in males,
  • Characterised by excruitiating pain down the pront of thigh often to medial leg,
  • Within a few days of onset the pain exacerabates + patient develops a rapid wasting weakness of quads,
  • Usually a history of rapid weight loss + general - ill health,
  • Condition eventually improves in 6 months - can take up to 2 years,
  • To help recovery, high diabetic conted with insulin is needed