Download SPINAL STENOSIS, A CAUSE OF CAUDA EQUINA

SPINAL
STENOSIS,
JOSEPH
In
the
1934
lumbar
that
SCHATZKER
Mixter
region.
dominant
cause
in the
present
an
A
CAUSE
and
and
Barr
described
then
the
of low
back
atypical
picture
of
abnormality.
and
sciatica.
canal
In
or
the
ONTARIO,
of the
ruptured
disc
1953
patients
root
COMPRESSION*
TORONTO,
syndrome
cauda
has
been
Schlesinger
with
and
herniated
equina
CANADA
intervertebral
disc
considered
to be the
Taveras
compression.
many
causes
that
it
in
pointed
intervertebral
out
discs
may
in
1954
Verbiest
that structural
narrowing
of the spinal
canal
alone
between
the capacity
and the contents
of the lumbar
of the roots
of the cauda
equina
in the absence
in spite of these observations,
the
stenosis
is a localised
narrowing
Despite
EQUINA
intervertebral
spinal
multiple
made
the significant
observation
if it resulted
in an incongruity
canal,
give rise to compression
herniation.
Yet,
Definition-Spinal
the
herniated
pain
of a narrow
CAUDA
F. PENNAL,
GEORGE
Since
presence
OF
could,
spinal
of disc
spinal
canal
has received
little attention.
of the spinal
canal
due to a structural
may
if it gives
have,
rise
to
cauda
equina
compression,
such narrowing
results
in a specific
symptom
complex,
has a common
pathogenesis
of cauda
equina
compression,
and demands
the same treatment.
It is for these reasons
that
we consider
it prudent
to regard
spinal
stenosis
as a syndrome
rather
than to deal with each
cause
of stenosis
as a separate
entity.
THE
Symptoms-Patients
(Blau and Logue
Cauda
legs
those
true
“
comes
on
of vascular
nature
OF
with this syndrome
1961) or of unremitting
equina
which
SYNDROME
claudication
with
insufficiency
of the
experienced
at rest,
and
movements
such
coughing
as
and
that
symptoms
present
back
by
weakness
on
or
may
rarely
sneezing
weakness
The
the
progresses
become
a prominent
aggravate
the pain.
usual mechanical
type of aggravation
of symptoms
in frank
disc
Some
patients
present
symptoms
and signs far more severe
than
basis of disc herniation.
Back pain is often accompanied
by bilateral
often
in the
femoral
as well
as in the
sciatic
unremitting
and frequently
not relieved
by rest.
that clinically
either
a tumour
of the cauda
equina
Numbness
and weakness
occur,
but are usually
measures
invariably
Signs-Spinal
fail
stenosis
musculo-skeletal
If signs
of lumbar
peripherally.
being
the
most
signs.
lumbar
and
Pathological
responsible
*
Based
Nordisk
606
upon
the
patient’s
systems.
are present
movement
Impairment
severely
of deep
affected.
tendon
Sensory
Ortopaedisk
paper
presented
Forening
at
the
in London,
Combined
September
resemble
out
some
before
pain
the
may
be
symptom.
Unguarded
This is in contrast
to
protrusion.
can be explained
on the
asymmetrical
radiation
distribution.
It is bizarre
and
progresses.
specific
Indeed,
they consist
and straight
first sacral
dermatomes.
findings-All
forms
of spinal
for the nerve
root compression,
a
by
in the
closely
Indeed,
so severe
and diffuse
is this pain
or gross functional
overlay
is diagnosed.
not the initial
symptoms.
Conservative
disability
characterised
or neurological
limitation
of any
and
is not
nerve
numbness
so
is carried
disease
the
of pain,
and
symptoms
arteriography
As
effort
“
rest.
infrequently
is appreciated.
of cauda
equina
claudication”
bizarre
radicular
radiation.
by pain,
is relieved
not
STENOSIS
symptoms
pain with
is characterised
“
walking
SPINAL
clinical
symptoms
in varying
leg raising.
reflexes
changes,
stenosis
namely,
Meeting
abnormalities
may
degrees
Motor
of
be present
share
two
shallowness
British
the
absence
of paravertebral
spasm
and
weakness
is most
evident
occurs
in most
patients,
the
if present,
are predominant
of the
either
in the
abnormalities
of the lateral
Orthopaedic
ankle
reflex
in the fifth
which
are
recess
and a
Association
and
the
1967.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
SPINAL
STENOSIS,
decrease
in the
space
bounded
dorso-ventral
by the medial
by
laterally,
the
pedicle
vertebral
the
adjacent
recess
in
body,
its
disc
contains
of the
by
lip
The
nerve
limited
space
is most
vulnerable
Shallowness
and
below.
this
root
diameter
portion
superior
the
A CAUSE
OF CAUDA
of the spinal
of the superior
point
canal
is reached
can
no
.
its contents,
cauda
longer
then
equina
It is
‘
.
recesses
‘
and
recesses,
but
as
becomes
compression
more
marked
is always
compression
are
Diagnosis-The
but
.
usually
be
in
“----
root
the
and the
posterior
more
and
of spinal
1
FIG.
Diagrams
irreversible,
made
before
the myelographic
:#{149}
:‘-
‘
Nerve
Note
to show
the
the
pathomorphology
of spinal
stenosis.
of the lateral
recess and the decrease
diameter ofthe spinal canal. On the right
shallowness
the dorso-ventral
the
striations
show
canal
medially
lying
postero-lateral.
once
stenosis
the
extent
that is necessary
of the
compression
further
operation
only
by myelography.
appearance
of the different
column
of
compression
In
to
order
is essential
be
radiographs
to
the
millilitres
the
been
or
any
lateral
encroachment.
is encountered
it
two
below
the
VOL.
50 B,
NO.
3,
AUGUST
1968
the features
and posterior
fluid.
which
areas
2).
punctures
may
British
that
space.
possible
Ten
is
injected
routes,
required
posterior
the
in
House.
to
postero-
If a complete
also
important
of the stenosis.
be necessary.
Drug
have
filling
or
block
the
patient
whether
the
it
of
the
greatest
cisternal
the
extent
*
FIG. 2
and lateral
myelographs
to show
stenosis.
Note the postero-lateral
defects
in the column
of radiopaque
and
myelographically
or
the
in
(Fig.
with
Ethiodan,*
to give
visualise
fluid
the
roots
ensure
the
subarachnoid
of
demonstrate
above
the
taken
lumbar
found
evaluate
to
employed
be
of
namely
defects
demonstrate
these
defects
that an adequate
amount
fluid
opaque
severity.
symptoms
opaque
of
The
the
there
are certain
stenosis,
there
is
anatomically
of
by
in
to all,
posterior
and
correspond
stenosis
for
patient’s
common
postero-lateral
upright
filling
the
Although
of spinal
feature
the
compression.
responsible
it increases
by
forms
decompression
reduced,
occurred
suggested
the
lateral
the lateral recess.
come
under
the changes
has
is usually
of the
to unroof
becomes
roots
As
one
Oblique
of spinal
S
.
-__-
of the
(
‘
.
.#{149}.
‘
accommodate
diagnosis
it can
variations
at which
-__
t7
The compression
.
first in the lateral
the dorso-ventral
diameter
manifest
is that
above,
#{149}
‘
#{149}‘
results.
becomes
1). The lateral
recess
facet and the lamina
lateral
that
the nerve
to compression.
compression
canal
(Fig.
articular
the
the
decrease
in
the
dorso-ventral
diameter
of the spinal
canal thus result
in a decrease
of its capacity.
If a
critical
607
COMPRESSION
and
root.
lateral
EQUINA
block
to
segment
order
Thus,
to
608
J. SCHATZKER
AND
G.
TABLE
.‘
Case
Age in Occupation
number
years
DEVELOPMENTAL
Duration
of
PENNAL
I
SPINAL
“
STEN05IS
Myelographic
findings
symptoms
Mode
F.
of presentation
Extent of
laminectomy
: cauda
equina
71
Pensioner
1 year
2
63
Machinist
1 year
59
Stockbroker
I year
4
76
Pensioner
2 years
partialfacetectomy
L.3 to L.5
inclusive
Narrowing
of
the L.2canalto L.5
from
Laminectomy
and
partialL.2 facetectomy
to L.5
Complete
at L.4/5
narrowing
canal L. 1
Narrowing
Mode
5
57
Carpenter
of presentation
27 years
creasing
6
73
7
42
Pensioner
Housewife
block
with
of the
to L.5
: unremitting
Chronic low
back pain with
gradual
onset
of severe
with
22
Student
Treatment-The
which
must
Complete
relief
of symptoms
with return
to work
2 years
Failure.
I 4 years
See discussion
4 months
Complete
relief
of symptoms
with return
to
light work
L.5
and,
complete
narrowing
at L.4/5
Recurrence
facetectomy
L.3 to L.5
inclusive
j
Narrowing
at
L.3/4, L.4/5 and
L.5/S. 1
6 months
Laminectomy
and
complete
facetectomy L.3 to L.5
with resection
of
NarrowingatL.l/2
and L.4/5 most
severe but column
also flattened
in between
after
initial relief.
See discussion
Relief
7 months
of sciatica.
Back pain
improved
but
not relieved
facets at L.5/S.1
8 months
:
to work
Laminectomy
and,
facetectomy
L.3
to L.5 inclusive
myelograph
sciatica
8
Complete
relief
ofwithsymptoms
return
years
Central
laminectomy
L.3, L.4 and
Laminectomy
last 1 years.
Complete
incapacity
Complete
relief
of symptoms
back pain and sciatica
inPoor
l
Laminectomy
and
partialfacetectomy
L. 1 to L.5
inclusive
of the
Narrowing
of
canal at L.3/4,
L.4/5 and L.5/S.1.
Most severe
at L.4/5
over
2 years
inclusive
canal at L.2/3
with a complete
block at L.4/5
10 years
increasing
over
last 2 years
and
Complete
block
at L.3/4
inclusive
3
Results
claudication
Laminectomy
I
Length of
follow-up
Central
laminectomy
and
discotomy
L.4/5
Recurrence
after
initial relief.
See discussion
6 months
I
only form ofsuccessful
treatment
be sufficient
both longitudinally
and
is surgical
laterally
and it consists
ofa
to relieve
completely
decompression
the stenosis.
A midline
laminectomy
never completely
relieves
the compression
in spinal
stenosis.
This is
the most
important
and fundamental
fact to appreciate
in the treatment.
The compression
of the roots
occurs
in the lateral
recesses.
It is only when sufficient
resection
of the superior
articular
facets
is carried
out to unroof
the whole
of the lateral
recesses
that the roots
are
adequately
decompressed.
The facetectomies
should
be carried
out in the vertical
plane.
As much
as possible
of both the superior
and inferior
articular
facets should
be preserved
to
safeguard
to unroof
against
possible
instability.
the lateral
recess,
then this
If, however,
a complete
must be done.
THE
facetectomy
JOURNAL
OF
becomes
BONE
AND
necessary
JOINT
SURGERY
SPINAL
STENOSIS,
A CAUSE
CAUSES
The
causes
degenerative
of
spinal
stenosis
spondylolisthesis
6) diseases
of the
OF
OF
may
CAUDA
SPINAL
be
system,
“
(1954,
1955)
compression
associated
propose
to denote
this
were
found
equina
to
have
SPINAL
Epstein
with
developmental
form of narrowing
as
“
this
claudication
Epstein,
form
and
four
of
1) Developmental;
; 4) iatrogenic
and
2)
; 5) traumatic;
Paget’s
disease.
(1962)
described
MATERIAL
DEVELOPMENTAL”
and
follows.
achondroplasia
CLINICAL
Verbiest
as
spondylolisthesis
especially
609
COMPRESSION
STENOSIS
summarised
; 3) spondylolytic
skeletal
EQUINA
STENOSIS
and
Lavine
narrowing
developmental
narrowing
(Table
of unremitting
“
I).
back
pain
root
of the lumbar
spinal
canal.
We
spinal
stenosis.
Eight patients
“
“
nerve
Four
with
presented
bizarre
symptoms
sciatica.
of
cauda
A suggestion
of
FIG. 3
“
Developmental
of the
spinal
stenosis
consisted
was
radio-opacity
described
cannot
serve
Although
stenosis,
VOL.
gained
50 B,
stenosis.
3,
of the
AUGUST
the
Note
in the
approximation
spacing
and
the radiological
interlaminar
neural
appearance
space,
arches
et a!. were
criteria.
and
also
The
antero-posterior
radiograph
ofthe
spine
approximation
spacing,
it approached
the
noted.
spine
more
These
shown
of
and
oval
(Fig.
the
narrowing
appearance
3). These
of the
7 and
of
“
changes
facets
to
the
a change
in the
plane.
The more
however,
in Figures
the
articular
occasionally
the sagittal
features,
all the morbid
anatomical
changes
abnormalities
could
be discerned.
1968
the
of the articular
facets to the midline,
the plane of the zygoapophysial
joints.
of normal
interpedicular
articulation
so that
by Epstein
as diagnostic
it demonstrates
no radiographic
NO.
from
of the
preservation
zygoapophysial
foramina
and
spinal
interlaminar
space,
normal
interpedicular
in narrowing
midline
with
plane
of the
marked
“
intervertebral
were
8 was
developmental
inconstant
radiographed.
“
spinal
610
J. SCHATZKER
A definite
complete
lumbar
diagnosis
of spinal
AND
stenosis
blocks
of the
canal
were
found
interspace
(Fig.
4).
Often
there
could
be made
at one
were
G. F. PENNAL
or two
bilateral
only
by myelography.
levels,
usually
waist-like
at the
defects
Partial
third
in the
or
oil
or
fourth
column
4
FIG.
Figure
complete
4
5
FIG.
Note the
the block.
The second
needle
introduced
below
the block
has been
removed.
Figure
5-”
Developmental
“
spinal stenosis.
Lateral
myelograph.
Note the typical posterior
defect at the level
of the block (lower arrow) and the dorsal flattening
of the fluid column
above (upper arrow).
Only the lower needle is shown : the upper needle has been removed.
above
and
it revealed
extensive
4-S’
below
Developmental
“
spinal
stenosis.
Antero-posterior
myelograph.
block and the waist-like
defects in the column
of fluid above and below
the
block.
Operative
findings-All
No disc herniations
were
configuration
It was
the pathognomonic
dorsal
flattening
of the
the
lateral
projection,
however,
posterior
and postero-lateral
of the oil column
(Fig. 5).
patients
found.
neural
arch
B
that
defects
was diagnostic
and
the
because
occasional
more
were
operated
The narrowing
upon
and
ofthe
spinal
and
The laminae
of the involved
segments
exceeded
ten millimetres
in thickness.
were foreshortened,
overlapped,
ended
its elements.
the pathology
carefully
studied.
canal was caused
by an abnormal
bulbous
articular
in a dorso-ventral
facets
plane,
spinal canal and
The interlaminar
further
space
and slanted
thus jutting
diminishing
was virtually
FIG.
“
Developmental
“
spinal
often
They
in large
markedly
into the
its height.
obliterated
6
stenosis
with (right)
a normal
spine for comparison.
Note (left) the narrowing
of the
interlaminar
space, the large bulbous
articular
processes
and the foreshortening
of the laminae
with approximation of the articular
processes
to the posterior
spines.
FIG.
6
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
SPINAL
FIG.
by the
overlap
to the midline
STENOSIS,
of the
laminae
(Figs.
and
6 to 9).
resection
of
and
it bulged
into
The ligamentum
in its substance.
variable
portions
dural
(Fig.
sac
I).
SPINAL
(1950)
Macnab
VOL.
50 B,
NO.
with
3,
EQUINA
approximation
under
611
COMPRESSION
laminectomy
flavum
was
In the midline
1968
large
circumstances
bulbous
was
of
the
was
relieved
STENOSIS
FROM
flavum.
adequate
superior
and
articular
difficult.
facets
The
dural
hole, it lacked
its usual
epidural
fat
thickened
and in two instances
plaques
the dural
sac was compressed
by both
FIG. 9
fifth lumbar
vertebra
for comparison
(right)
vertebra
from the spine shown in Figure 8.
and Newman
(1963)
spondylolisthesis-has
the syndrome
of
AUGUST
of the
these
the
the thickened
ligamentum
the canal.
It was only after
compression
of the
were decompressed
arch-degenerative
Two
patients
by the
Laminectomy
On the left is a normal
fifth lumbar
laminae
decompress
OF CAUDA
7
sac was under
pressure,
and it failed to pulsate.
of calcium
were found
the
not
A CAUSE
with
the
A midline
laminectomy,
however,
did
lateral
decompression,
which
necessitated
articular
that
DEGENERATIVE
the
facets,
roots,
trapped
that
the
in the
postero-lateral
lateral
recesses,
SPONDYLOLISTHESIS
recognised
that spondylolisthesis
with an intact
neural
the highest
incidence
of nerve
root compression.
spinal
stenosis
were
found
to have
degenerative
612
J. SCHATZKER
AND
G. F. PENNAL
FIG.
10
FIG. 11
FIG. 12
Figure
10-Degenerative
spondylolisthesis.
Lateral
myelograph
showing
the posterior
indentation
in the fluid
column
at the level of the slip.
Figure
1 1- Degenerative
spondylolisthesis.
Oblique
myelograph
showing
a
postero-lateral
indentation
of the fluid column
at the level of the slip. Figure 1 2-Degenerative
spondylolisthesis.
Lateral myelograph
showing
complete
block at the level of the slip (bottom
of figure).
spondylolisthesis.
back
pain
lumbar
One
and
four
indentations
complete
had
sciatica.
on
five.
in the
block
at
fifth
the
were
lumbar
the
claudication,
women
first,
fluid column
the level
of
in their
(Figs.
10 and
the slip (Fig.
It was only after
that decompression
which
were
and
tightly
the
forties,
myelography
diagnostic
of spinal
laminectomy
roots.
excised
roots
equina
were
In
encroachment,
a finding
Surgical
findings-Complete
decompress
vertebra
cauda
Both
other
and
had
both
revealed
severe
had
posterior
and
forward
the superior
was achieved
compressed
slipping
articular
of both
in the
lateral
slip
did
little
beneath
the superior
To stabilise
the segintertransverse
fusion
be-
an
tween
the
vertebrae
fourth
was
As
the
and
fifth
lumbar
done.
forward
displacement
spondylolisthesis
osteoarthritic
change
much
Degenerative
the
ofthe
arises
S
changes
spondylolisthesis.
which
take
the
FIG.
place
of
13
The
in the
stippled
areas
superior
articular
.
the
indicate
outgrowths
spinal
canal
centrally
more
result
and
are
in
marked
responsible
form
vertebra
outgrowths
which
are
.
forwards
a shelf
for
and medially
the inferior
as if to
facets
of
.
narrowing
for
articulations
superior
facets
develop
large
.
directed
facets
the
osteophytic
caudal
osteophytic
S
caudal
vertebra,
and illustrate
how the spinal
stenosis
and how the compression
of the lumbar
roots occurs.
These
zygoapophysial
1963).
The
(Newman
in
occurs,
develops
degenerative
Nerve.
Root
to
the fifth lumbar
sac and of the
facets.
ment
at
a
recesses
articular
.
of
revealed
postero-lateral
vertebra
facets
of
the dural
one
postero-lateral
1 1); in the second,
myelography
12) caused
by posterior
and
stenosis.
of the
unremitting
a grade
the
forward
of the
nerve
root
THE
JOURNAL
slipping
lateral
cephalad
compression
OF
vertebra.
recesses
BONE
and
(Fig.
AND
JOINT
of
the
13).
SURGERY
SPINAL
STENOSIS,
A CAUSE
STENOSIS
FROM
SPINAL
A sixty-four-year-old
Chinese
OF CAUDA
EQUINA
SPONDYLOLYTIC
cook
presented
613
COMPRESSION
SPONDYLOLISTHESIS
an eight
months’
history
of totally
disabling
pain, thought
by the physicians
to be characteristic
of intermittent
claudication.
Aortography
and arteriography
were, however,
normal.
In the course
of investigation
a grade
one lumbar
four
on
lumbar
five
spondylolisthesis
with
(Fig.
14). Although
the patient
clinical
findings
of nerve
root
a sharp
angulation
lateral
and
was
posterior
in the
a defect
pars
gave no history
of previous
compression,
myelography
present
in the
encroachments
fluid
(Fig.
column,
interarticularis
was
discovered
back pain or sciatica
and had no
was done.
At the level of the slip
and
oblique
views
disclosed
postero-
1 5).
FIG.
14
FIG. 15
Figure
14-Spondylolisthesis
at L.4-5 with defect in the pars interarticularis.
Figure
15-Lateral
and oblique
myelographs.
Note
in the lateral
projection
the sharp
angulation
with a posterior
defect in the column
of fluid at the level of the slip. The
oblique
projection
shows a postero-lateral
defect in the column
of fluid.
Surgical
findings-At
large
masses
of
interarticularis.
wide
Decompression
excision
dural
was
sac
tissue
was found
to be compressed
postero-laterally
which
pouted
from
the
defects
in the
by removal
of the loose lamina
of lumbar
achieved
osteocartilaginous
of lumbar
three
third
post-operative
without
be free
the
of
laminectomy
On the
corridor
the
surgery
osteocartilaginous
and
He
difficulty.
tissue
lumbar
day the
has
since
A myelograph,
of
the
done
some
inevitable
time
scarring
after
from
operative
but
conclude
no
that
a keyhole
50 B,
L
pars
interarticularis
able
to walk
to work,
and
the
one
length
year
and
of the
later
by
a
hospital
continues
to
NO.
note
disc
often
herniation
spinal
stenosis
laminectomy,
3,
AUGUST
reads:
operation.
.
.
the
found.”
may
be produced
a liberal
roots
and
If pain
herniations.
to varying
and finally
was
require
1968
“.
STENOSIS
a laminectomy
search
The
SPINAL
the
is often made for new disc
solid,
the patient
is frequently
subjected
anti-inflammatory
drugs, epidural
cortisone,
present,
VOL.
the
of symptoms.
because
of
was
returned
IATROGENIC
tissue,
from
five.
patient
by
pars
four,
fusion,
and
is difficult
to interpret
neurological
signs
new
are
If none is found
and the fusion
appears
periods
of bed rest,
physiotherapy,
a limited
exploration
may be performed.
were
Experience
with
iatrogenically,
decompression.
quite
tight
two
and
patients
and
that
bound
down
in scar
leads the authors
to
such patients,
instead
614
J. SCHATZKER
AND
G. F. PENNAL
E
FIG.
16
Case 12. Figure
16-Note
in the antero-posterior
projection
the marked
density
of the fourth and fifth lumbar
vertebrae.
In the lateral
projection
there is massive
bone formation
posteriorly
with pseudarthroses
at L.4-5
and at L.5-S.l.
Figure
17-Antero-posterior
myelograph
showing
a defect in the column
offluid
on the right
at the level of L.4-5.
There is also marked
narrowing
of the fluid column
distally.
Case
years
12-A
apart
he became
movement.
forty-three-year-old
for continuing
back
man had had two laminectomies
and attempted
pain and sciatica.
Despite
operations
his symptoms
more and more disabled.
The findings
indicated
leg raising,
a positive
sciatic
nerve
showed
massive
bone
formation
fusions
done
progressed
He had tenderness
with much spasm and restriction
a fifth root compression
on the right, with limitation
stretch
test,
posteriorly
and appropriate
motor
and sensory
deficits.
with the presence
of a double
pseudarthrosis
five
and
of lumbar
of straight
Radiographs
(Fig.
16).
The myelograph
revealed
a defect between
the fourth and fifth lumbar
vertebrae.
was the narrowing
of the opaque
column
(Fig. I 7). At operation,
exposure
extremely
difficult because
his laminae
had become
incorporated
into very thick
Even more striking
of the dural sac was
blocks of bone which
tightly
sacral
enveloped
generous
relieved
Case
vertebra
and
decompression
of all pain and
13-A
compressed
the
dural
sac
and
thirty-five-year-old
to the sacrum.
He
man
developed
had had
a painful
13-Antero-posterior,
fifth
lumbar
a laminectomy
pseudarthrosis
FIG.
Case
the
and
was carried out. No stabilisation
was attempted.
had remained
so when seen eleven months
after
lateral
and
oblique
first
The patient
operation.
roots.
A very
was immediately
and fusion
from
the fourth
between
the fourth
and fifth
lumbar
lumbar
18
myelographs.
Note
THE
the
defects
JOURNAL
in the
OF
BONE
dye
AND
column
JOINT
(arrows).
SURGERY
SPINAL
vertebrae
which
STENOSIS,
was repaired
A CAUSE
by means
OF CAUDA
of two
dowel
EQUINA
grafts
COMPRESSION
inserted
into
615
the pseudarthrosis.
Almost
immediately
the patient’s
symptoms
became
more intense,
and in addition
to his back pain he
increasingly
severe right leg pain, markedly
aggravated
by effort,
and signs offifth
lumbar
and
root compression.
A myelograph
done five months
later showed
a large
posterior
defect
column
corresponding
in level to the two dowel
grafts
(Fig. 18). At surgery
the right half of
mass
was excised
(Fig.
19).
The roots
were found
to be tightly
compressed
from
behind
developed
first sacral
in the dye
the fusion
by a thick
Site
plug of Clowcird
L5
Sac
compressed
loose
of bone
Fibrous
fragments
band
S
19
FIG.
bar of bone
(Fig.
20).
on the
side.
The
right
for almost
severe
on
persistence
A complete
decompression
patient
immediate
had
a year. He then developed
the left side.
A myelograph
of his spinal
further
surgery
of the remaining
20
FIG.
Reproduction
of an original
sketch
operation.
Figure 19 shows excision
of
shows how the roots were found to be
bar
stenosis
made
by Dr Peerless
at the time of the
the right half of the fusion mass.
Figure 20
tightly compressed
from behind
by a thick
of bone.
was not carried
relief
of his
back
out because
and
gradually
increasing
bilateral
done two years following
with
more
and the findings
could
fusion mass occurred
marked
sciatica
his last
compression
all his symptoms
leg symptoms
on the
and
were
remained
well
which was now much more
decompression
revealed
the
left
side.
not be confirmed.
It seems likely, however,
with further
narrowing
of the spinal canal.
The
patient
refused
that
further
growth
DISCUSSION
Developmental
spinal stenosis-Patients
capacity
of their
spinal
canal.
Any
size.
Whether
the
developmental
defect,
relationship
can
emphasised
that
and
intrusion
be
a disc
will
that
has
is the
already
herniation
symptoms
of a much
larger
The structural
abnormality
with
intrusion
give
rise
severity
developmental
into the
spinal
to symptoms
of their
is determined
structural
been
pointed
out
into
a spinal
canal
space-occupying
in developmental
spinal
stenosis
canal
will
by
by the
narrowing.
Schlesinger
narrow
lesion.
spinal
have
further
and
at one
stenosis
level
is such
a diminished
diminish
severity
How
its
of their
critical
this
Taveras
(1953)
who
can
rise
give
that
not
to signs
only
are
the lateral
recesses
very shallow
but the posterior
articular
facets
are much
closer
to the
midline
than normally.
In this way intrusions
from
the floor of the lateral
recess,
such as
a posterior
osteophyte
or disc herniation,
or from its roof from an anterior
osteophyte
on the
zygoapophysial
articulation,
can diminish
the capacity
of the spinal
canal.
As no disc
herniations
were
found
in our
series
it appears
that degenerative
changes
play a significant
role in diminishing
the capacity
of the spinal
canal
in spinal
stenosis.
The age of onset
of
symptoms
severity
is thus
determined
by
both
the
severity
and age of onset of the degenerative
changes.
The three
failures
in our series of
developmental
“
principles
and
In the
fourth
VOL.
50 B,
in the
management
of such
3,
AUGUST
1968
“
developmental
stenosis
spinal
illustrate
stenosis
and
by the
important
cases.
first, Case 4, despite
definite
myelographic
lumbar
vertebrae
(Fig.
21) the surgeon
NO.
of the
evidence
satisfied
of stenosis
between
himself
with doing
the third
a central
616
J. SCHATZKER
FIG.
..
Developmental
“
spinal
stenosis.
21
Figure
AND
G.
F. PENNAL
21-Antero-posterior
and
FiG. 22
niyelographs.
lateral
In
the
antero-
posterior
projection
note the block at the level of L.4-5 and the waisting
of the fluid column
opposite
the L.2-3
and L.3-4 interspaces.
In the oblique
projection
note that the block at L.4-5 is due to a posterior
encroachment,
that there is an extensive
flattening
of the fluid column
above
due to posterior
compression,
and that the
stenosis
extends
to the level of L.2-3.
Figure 22-Antero-posterior
radiograph
showing
the central
laminectomy
at the lumbar
three, four and five levels.
laminectomy
the
of
of the
lumbar
the dural
but
he also
ln the
third,
fourth
and
fifth
lumbar
vertebrae
to
relieve
four/five
level.
sac returned.
Lateral
decompression
was not done (Fig.
Not only did the surgeon
fail to decompress
disregarded
the
second
patient,
higher
Case
myelograph.
Difficulty
with
stenotic
6, great
area.
difficulty
myelography
in
because
not only is the interlaminar
the needle,
but also the subarachnoid
space very narrow
space
is tight
a successful
spinal
tap
and
free
flow
of
fluid,
was
encountered
developmental
“
“
in
spinal
with consequent
because
ofexternal
not
a complete
22)
uncommonly
block
because
the lateral
carrying
stenosis
at
pulsation
recesses
out
the
is frequent
difficulty
in introducing
compression.
Despite
both
a subarachnoid
and
subdural
injection
of the contrast
medium
results.
Such a myelograph
must not be accepted
for diagnostic
purposes.
If lumbar
myelography
fails then a cisternal
puncture
must be done.
Although
in Case 6 the myelograph
was not of a good
diagnostic
quality
it did show
posterior
at the
encroachment
lumbar
myelograph
At operation,
spinal
stenosis
was encountered.
A complete
done.
The patient
was initially
improved,
was
effort
returned.
at
immediate
an
A very
A second
myelograph
exploration
failed.
the spinal
clot was
thin
epidural
complication
of
evaluation
of the patient
was, however,
relieved.
following
decompression.
level.
Because
and a cisternal
puncture
dural sac was extremely
The
junction.
clinical
operation
was not repeated
exposure
ofthe
four/five
the
of the
difficulties
was not done.
difficult
and typical
decompression
from lumbar
but six months
later pain
Three
hours
later
encountered
‘developrnental”
three to the sacrum
and leg weakness
on
the patient
became
paraplegic;
stenosis
was found
to extend
to the thoraco-lumbar
the cause
of his paraplegia
which
regressed
following
paraplegia
his second
makes
it impossible
to
decompression.
THE
JOURNAL
The
OF
BONE
give
pain
AND
an
accurate
he had
before
JOINT
SURGERY
SPINAL
In the
marked
third
was
patient,
Case
myelographic
to the lumbar
decompression
changes
The
with
the
These
cases
clearly
is by myelography,
stenosis
lateral
and
was
at the
three
recurrences
and longitudinally.
not
an
indication
instability.
permanently.
the
myelograph
relieved
him
indicate
that
and
patients
the
from
In such
facetectomy.
seen,
cases
further
only
certain
the
signs
more
pointed
the surgeon
to do a limited
was opened
but no herniation
within
six
months
distribution.
method
his
symptoms
A second-and
of evaluating
the
can only be expected
In this series
patients
decompression
have
remained
the decompression
emphasise
the fact
facetectomy
fitted
with
free
was
that
has
more
extent
of the
if an adequate
whose
stenosis
of symptoms.
The
not adequate
both laterally
return
of dural
pulsation
is
been
brace
spondylolisthesis-Patients
in whom
but
with
no
in
and
herniation,
and
were
be
with
has not
vertebral
encouraged
to use
it
spondylolisthesis,
postero-lateral
must
patients
spondylolisthesis
of mechanical
with degenerative
posterior
disc
practised
of the spine,
pain
suggestive
a lumbo-sacral
wide decompression
Such a segment
should
forward
and
and
symptoms.
without
stabilisation
complained
of
compression,
are
but
one/two
symptoms
decompression.
degenerative
of root
at lumbar
nerve
relief of symptoms
is carried
out.
complete
were
improved,
femoral
of all
first
spinal
stenosis
have
any patients
stenosis
evidence
initially
in the
“
All
with
was
of an adequate
developmental
developed,
nor
to prevent
prompted
The disc
of their
partial
“
stenosis.
complete
his extreme
youth
lumbar
vertebrae.
and
fifth
stenosis
617
COMPRESSION
patient’s
were in those
in whom
These
cases further
Although
Spinal
time
EQUINA
evident
and that
decompression
longitudinal
relieved
CAUDA
four/five-the
of pain
radical-decompression
OF
8-despite
patient
addition
A CAUSE
at lumbar
four/five
segment
ofthe
fourth
and
encountered.
returned
STENOSIS,
encroachments
considered
in
to have
spinal
of the canal
is necessary,
even if it requires
then be stabilised
by an intertransverse
fusion
displacement.
Spinal
stenosis
from spondylolytic
spondylolisthesis-Patients
with
spondylolisthesis
with
a
defect
in the pars interarticularis,
who present
symptoms
and signs of root compression,
and
in whom
posterior
and postero-lateral
indentations,
with no disc herniation,
are seen in the
myelograph,
have spinal
stenosis.
In these,
in addition
to a central
laminectomy,
wide lateral
the
removal
of
fibrous
on the
bands
patient’s
the
forward
osteocartilaginous
tissue
from
or adhesions
is essential.
age.
In the older patient
slip
is unlikely.
the
pars
interarticularis
Whether
stabilisation
with spondylolytic
Furthermore,
the
lateral
and
division
of the spine
spondylolisthesis
decompression
does
of any
is done
depends
progression
of
not
influence
stability
of the segment.
We are of the opinion
that, if there is no indication
for fusion
of the spondylolisthesis
itself, then, in the older patient,
stabilisation
is not necessary.
also be remembered
that these
patients
may present
the syndrome
of spinal
stenosis
absence
of any
latrogenic
spinal
patient
with
pseudarthrosis.
new
bone
into
two
dowel
The progression
along
of surgery.
the severity
a tight
fusion,
is done,
neurological
canal
spinal
then
and
in whom
symptoms
VOL.
50 B,
NO.
new
and
3,
the
front
of the
may result
in very severe
stenosis
is not recognised
progression
no
spinal
AUGUST
stenosis
grafts
illustrates,
of the stenosis
may
or
it
in both
Iaminae.
be
may
cases
This
new
This raises
a further
possibility.
of any compression
of the cauda
probable
complication
the progression
of root
their
signs.
stenosis-latrogenic
the
formation
at the time
determines
and
overt
of the
spinal
stenosis
may
cause
1968
such
as a disc
herniation
produced
develop
suggested
bone
at
in
operation,
association
that it was
formation
was
as the
with
a
caused
by
confirmed
The capacity
of the spinal
canal
equina,
and the smallest
intrusion
root compression.
and a conventional
result.
of spinal
fusion
would
undoubtedly
compression
in some patients
who
signs.
the
because
It must
in the
If, at the
posterior
As
be very
have had
is found
spinal
rare,
such
to explain
time of laminectomy
interlaminar
fusion
stenosis
is rare,
this
but it would
explain
a fusion
carried
out,
the
progression
of
61 8
r. SCHATZKER
The
with
authors
have
spondylolisthesis
spinal
stenosis.
developmental
could
give rise
“
narrowing
entity.
trauma
“
“
spinal
stenosis,
in the pars
form
“
spondylosis
authors
spinal
interarticularis,
appears
to be the
stenosis
associated
and
iatrogenic
with
most
common.
Teng
as a cause of cauda
equina
compression,
but
to the conclusion
that
their
cases
represent
with degenerative
compression,
then
Achondroplasia
(Brish,
Lerner
spinal
“
a defect
developmental
stenosis
equina
G. F. PENNAL
developmental
without
described
leads
the
spinal
cauda
“
of the
the
(1963)
article
to
with
and
Of these,
and Papatheodorou
a review
of their
encountered
1966) and
dealt
with
AND
changes
of ageing.
If spondylosis
alone
this should
be a much
more
frequently
(Epstein
et a!. 1962),
Paget’s
disease
and
Braham
1964)
are much
rarer
(Hartman
forms
of
and Dohn
structural
canal.
SUMMARY
I.
The
narrowing
syndrome
of the
of spinal
lumbar
stenosis
spinal
is due
to compression
of the cauda
equina
from
structural
canal.
2. Patients
with
this
syndrome
present
symptoms
of cauda
equina
claudication
or of
unremitting
bizarre
back pain and sciatica.
3. The compression
of the cauda
equina
is always
posterior
and postero-lateral
and is caused
by narrowing
of the lateral
recesses
and of the dorso-ventral
diameter
of the spinal
canal.
4. The diagnosis
can be made
only by myelography.
The only form of successful
relief of
the nerve
root
compression
in spinal
stenosis
The authors
would like to thank Dr F. P. Dewar
colleagues
for contribution
of cases to this series.
the Toronto
General
Hospital
and the Department
for their help in the preparation
of the illustrations.
The major
portion
the F. N. G. Starr
of this investigation
Memorial
is adequate
lateral
and
longitudinal
decompression.
and Dr I. Macnab
for their interest
and counsel;
also their
We also wish to thank the Department
of Photography
of
of Art as Applied
to Medicine
of the University
of Toronto
was supported
by the
Mary
and
Wallace
Duncan
Fellowship
and
Scholarship.
REFERENCES
J. N., and LOGUE,
V. (1961):
Intermittent
Claudication
of the Cauda
Equina.
An Unusual
Syndrome
Resulting
from Central
Protrusion
of a Lumbar
Intervertebral
Disc.
Lancet,
i, 1081.
BRISH,
A., LERNER,
M. A., and BRAHAM,
J. (1964):
Intermittent
Claudication
from Compression
of Cauda
Equina
by a Narrowed
Spinal Canal.
Journal
of Neurosurgery,
21, 207.
EPSTEIN,
J. A., EPSTEIN,
B. S., and LAVINE,
L. (1962):
Nerve Root Compression
Associated
with Narrowing
of
the Lumbar
Spinal
Canal.
Journal
of Neurology,
Neurosurgery
and Psychiatry,
25, 165.
HARTMAN,
J. T., and DOHN,
D. F. (1966): Paget’s Disease
ofthe
Spine with Cord or Nerve-Root
Compression.
Journal
of Boize and Joint
Surgery,
48-A,
I 079.
MACNAB,
I. (1950):
Spondylolisthesis
with an Intact
Neural
Arch-The
So-called
Pseudo-spondylolisthesis.
Journal
of Bone and Joint
Surgery,
32-B, 325.
MIXTER,
W. J., and BARR, J. S. (1934): Rupture
ofthe
Intervertebral
Disc with Involvement
ofthe Spinal Canal.
The New England Journal ofMedicine,
21 1, 210.
NEWMAN,
P. H. (1963): The Etiology
of Spondylolisthesis.
Journal
ofBone
and Joint
Surgery,
45-B,
39.
SCHLESINGER,
E. B., and TAVERAS,
J. M. (1953): Factors
in the Production
of “Cauda
Equina”
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