Week 9 Spinal Stenosis Ddx Flashcards
(47 cards)
Diagnosis requires which 3 factors?
- Characteristic signs/symptoms
- Radiographic (MRI or CT) evidence of lumbar spinal stenosis
- Exclusion of other causes of back and leg pain
Ddx for patients with low back and leg pain
Neuropathic:
- Nerve root: disc herniation, SOL (tumor, cyst, hematoma), osteophyte, compression fracture, spinal infection
- Peripheral neuropathy: piriformis syndrome, diabetes, herpes zoster, compartment syndrome, peroneal nerve compression
Referred:
- facets, deranged disc, MFTP, trochanteric bursitis, hip OA
- PAD, medial tibial stress syndrome, stress fracture of tibia or fibula, muscle strain
At what age is spinal stenosis at the top of the ddx for neuropathic leg pain?
> 60
Stenosis occurs in
__% of patients ___ -___ y.o. with leg pain
____% of patients >___ y.o. with leg pain
25%, 60-70
64%, >70
What are other ddx for patients over 60 with neuropathic pain? (A list and B list)
A list
- IVF encroachment (osteophyte secondary to DJD)
- SOL (cancerous tumor, less likely cyst)
B list
- radicular: degenerative spondylolisthesis, structural instability, spinal infection
- peripheral: diabetic, other peripheral neuropathy, piriformis syndrome
What are causes of IVF encroachment?
Spur/osteophyte
IVF stenosis
What are signs and symptoms of IVF encroachment? (4)
- no neurogenic claudication or CES symptoms
- often unilateral, sometimes a single dermatome
- positive kemp’s with pain into leg (suggest IVF is compromised)
- may not be as sensitive to pure flexion or extension loads
How do you ddx spinal stenosis from spur/osteophyte?
Advanced imaging
Tumor (especially malignant) are more likely in patients ___
> 50
What are signs/symptoms of tumor
- neurological deficits or cord signs (long track) may be present
- sometimes leg pain is accompanied by little or no back pain
- spinal percussion may be very sensitive
- may have classic red flags
- positive lab and imaging tests
What should you be concerned about in a patient >50 with leg pain and no back pain
Tumor
What are red fags for tumor
- prior history of cancer
- unexplained weight loss
- increase pain when lying supine
- unremitting pain affected by spinal positioning
What are positive ab findings for tumors?
- anemia
- increased ESR/CRP
- increase ALP (metastatic prostate cancer, osteoblastic cancer)
- proteins (on blood chem panel, multiple myeloma)
- hypercalcemia (osteolytic like metastatic breast cancer)
Spinal infections are very rare in the (long bones/spine?) and occur more in the (long bones/spine?)
Very rare in spine
More in long bones and extremities
What age are spinal infections most common?
> 50
What are some signs/symptoms of spinal infection? (6)
- rapid or but usually slow indolent course
- prior history of infection (kidney/bladder infection) or immune compromised patient
- may run fever (65% of cases)
- usually very sensitive to spinal percussion (90% of cases)
- very high ESR (>50-100) ver common (80-90% of cases)
- may have neuro deficits. Positive tension tests
What is the top of ddx list for neuropathic pain in patients <40? What are other causes?
- Disc herniation
- radicular: spondylolysis/spondylolisthesis, structural instability, spinal infection, nerve root adhesions, fracture, spinal stenosis
- peripheral: diabetic, other peripheral neuropathy, piriformis syndrome
spinal stenosis vs disc herniation: age
> 50-60
<40-50
spinal stenosis vs disc herniation: flexion load
- may improve leg symptoms (shopping cart sign)
- may increase leg symptoms
spinal stenosis vs disc herniation: sitting
- improve leg symptoms
- increase leg symptoms (may be rapid)
spinal stenosis vs disc herniation: sustained/repetitive loading?
- may aggravate leg symptoms if done in extension
- may centralize or improve leg synths (done in any direction, although extension is most common)
spinal stenosis vs disc herniation: extension loads?
- may aggravate back or legs
- may aggravate back (and could improve leg symptoms)
spinal stenosis vs disc herniation: valsalva, dejerine’s triad
- negative
- positive (aggravating back or legs)
spinal stenosis vs disc herniation: axial compression (double ASLR)
- less likely to be positive
- more likely to be positive (especially if acute)
