In recent years, domestic and international lumbar spine academic conferences have conducted systematic studies and discussions on the indications, modalities and efficacy of surgery for lumbar spinal stenosis, and some preliminary clinical guidelines have been formed. Among them, the guidelines for the diagnosis and treatment of lumbar spinal stenosis formulated by the North American Spine Society in 2011 have been more widely accepted. In China, some expert consensus on the surgical treatment of lumbar spinal stenosis was reached at the annual meeting of the Chinese Medical Association Orthopedic Branch (COA) and the annual meeting of the Chinese Medical Association Orthopedic Branch Beijing (BOA), but there is a lack of more systematic elaboration. Now, through the cooperation of several large tertiary hospitals, we have formed this expert consensus on the treatment standard of lumbar spinal stenosis, which we would like to share with our colleagues here.
I. Definition
Lumbar spinal stenosis refers to a group of syndromes caused by congenital or acquired narrowing of the lumbar spinal canal or intervertebral foramen, which in turn causes compression of the lumbar spinal nerve tissue and impaired blood circulation, resulting in pain in the buttocks or lower limbs, neurogenic claudication, and symptoms with or without lumbar pain.
II. Symptoms
As early as 1954, some scholars pointed out that intermittent claudication is a typical sign of lumbar spinal stenosis, and the current understanding of this symptom has been further developed, and it is believed that in addition to neurogenic intermittent claudication, some patients can show symptoms of neurogenic claudication in special positions, and some patients can have the above symptoms relieved in forward leaning, forward bending, and squatting positions, and aggravated in hyperextension. Patients may have low back pain and lower extremity radiating pain, mostly in the fixed spinal nerve distribution area, which may be accompanied by abnormal sensation, such as numbness, soreness, pins and needles, and coldness of the limbs. Some patients with more severe stenosis may have abnormalities or disorders of the second stool, and less often develop into incontinence manifestations. There may be weakness or inability to extend the dorsal foot, and there may also be weakness of the toes.
Physical signs
The typical feature of the disease is that there are many symptoms and few signs. Patients often have no clear positive signs on orthopedic specialist examination. Some patients may have a positive lumbar hyperextension test. Some scholars have attempted to have patients perform a walking tolerance test on a walker as a way to determine the relative degree of stenosis. Some patients may have abnormalities in muscle strength, tendon reflexes, and sensation.
IV. Imaging
X-rays show reduced lumbar convexity, which may be combined with scoliosis or slippage, collapse of the intervertebral space, formation of bony redundancy, and hyperplasia and coalescence of the synovial joints.
CT, MRI and lumbar spinal canal imaging are important diagnostic tools; CT and MRI show hyperplasia of the ligamentum flavum and synovium, osteophytes on the upper and lower edges of the diseased vertebral body, compression of nerve roots or dural sac, and protrusion of the diseased intervertebral disc compressing the dural sac, unilateral or bilateral nerve roots in the same segment; MRI also shows changes in lumbar curvature, reduced signal of the diseased intervertebral disc, and changes in signal of the upper and lower endplates of the degenerated segment. For those who do not see obvious dural sac or nerve root compression on CT and MRI, lumbar spinal canal imaging can be considered. Positive results can show defective or poor filling of the dural sac or nerve root sleeves with contrast, especially in power position imaging, which can show dural sac and nerve root compression in different positions.
V. Diagnosis
The diagnosis of lumbar spinal stenosis is mainly dependent on symptoms and imaging features, which are usually heavy on symptoms and light on signs. The diagnosis needs to be considered in combination with symptoms, signs and imaging features, and to exclude other diseases, such as intermittent claudication of vascular origin and tumor.
VI. Treatment
1, conservative treatment: conservative treatment mainly includes the following aspects: early onset of the patient bed rest more can obtain better results; instruct patients to avoid sedentary, bending, weight bearing, etc., to develop good habits of life and work, avoid cold, moderate weight loss can help improve the symptoms and delay the course of degeneration; actively carry out muscle exercise of the low back; moderate traction often has a better effect on the early onset of the degeneration is not serious cases. Some scholars believe that massage, acupuncture, electrotherapy, heat therapy and other treatments have more positive recent efficacy, but the long-term efficacy is still unclear; lumbar circumference or brace treatment can increase the stability of the lumbar spine, improve the sagittal and coronal balance of the lumbar spine, early efficacy is certain, pay attention to the same time with the lumbar back muscle exercise, to avoid long-term wear and caused by the lumbar back muscle weakness; for patients with obvious symptoms, can be given For patients with obvious symptoms, they can be treated with NSAIDS drugs, neurotrophic and repair-promoting drugs, and epidural steroid injection.
2.Surgical treatment: the indications for surgical treatment are as follows: pain in the lower limbs, symptoms seriously affecting life; the presence of objective nerve damage signs, such as lower limb sensory loss, lower limb muscle atrophy, lower limb muscle strength decline; typical neurogenic intermittent claudication symptoms, walking distance <500m, symptoms seriously affecting life; symptoms persist and conservative treatment for 3 months does not improve, symptoms seriously affecting life. Surgical principles.
(1) Individualized principle: mainly for the responsible segment and different types of lumbar spinal stenosis, combined with physical condition to choose individualized treatment plan.
(2) Principle of decompression: Full decompression, removal of all compression-causing materials (hyperplastic bone, yellow ligament, intervertebral disc, small joints) and restoration of nerve root free degree.
(3) Safety principle: optimize the decompression sequence (starting from the relatively light compression, mostly in the midline and gradually decompressing the vertebral plates, ligamentum flavum, and small joints on both sides), pay attention to fine operation during surgery, and use intraoperative neurophysiological monitoring if necessary.
(4) Biomechanical principles: limited decompression, preservation of the middle and posterior spinal column structures as much as possible, avoiding excessive removal of the synovial joints, and simultaneous fusion and internal fixation if decompression causes lumbar segmental instability.
(5) Minimally invasive principle: shorten the operation and anesthesia time as much as possible, reduce bleeding, reduce soft tissue traction and injury, and reduce the surgical incision.
(6) Control social cost: strictly follow the stepwise treatment concept to standardize the treatment strategy and avoid unnecessary social expenditure.
VII. Rehabilitation and postoperative precautions
After surgery, according to the patient’s condition and postoperative recovery, move to the ground as soon as possible under the guidance of medical staff and guide functional exercise. Regularly review the X-ray at 1, 3, 6 months and 1 year after surgery.
MRI examination should be performed if necessary. Patients should be advised to strengthen the exercise of low back muscles, avoid prolonged sitting and standing, and bending and weight-bearing.