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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. 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