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Journal of Craniovertebral Junction and Spine
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EDITORIAL
Year : 2011  |  Volume : 2  |  Issue : 2  |  Page : 55-56  

'Only fixation' as rationale treatment for spinal canal stenosis


Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, Maharashtra, India

Date of Web Publication24-Aug-2012

Correspondence Address:
Atul Goel
Department of Neurosurgery, King Edward VII Memorial Hospital, Parel, Mumbai- 400 0012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-8237.100049

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How to cite this article:
Goel A. 'Only fixation' as rationale treatment for spinal canal stenosis. J Craniovert Jun Spine 2011;2:55-6

How to cite this URL:
Goel A. 'Only fixation' as rationale treatment for spinal canal stenosis. J Craniovert Jun Spine [serial online] 2011 [cited 2019 Jul 17];2:55-6. Available from: http://www.jcvjs.com/text.asp?2011/2/2/55/100049

Spinal canal stenosis is common and a disabling clinical condition. Spinal lumbar and cervical canal stenosis is frequently associated with'age-related' degenerative changes. The pathogenesis has been well described in the literature, the general consensus for over a century being focused on degeneration of the intervertebral disc. The most accepted view of pathogenesis is that it is related to a cascade of processes that start with degeneration of the disc due to its dehydration or herniation. Osteophyte formation and ligamentous hypertrophy are implicated to be either primary phenomenon or related to the degeneration of the disc and reduction of the disc height. It has been generally accepted that following this primary event, there occurs reduction of disc space height, bulge of the posterior annulus/posterior longitudinal ligament, overriding of the facets and/or infolding of the ligamentum flavum that ultimately lead to stenosis of the spinal canal and intervertebral neural foramina. Although the issue of instability in lumbar and cervical canal stenosis has been discussed on several occasions, its role as the primary factor in the pathogenesis has not been appropriately addressed. The prominent visualization of the disc space by the conventional imaging using plain radiographs and of spinal canal and cord by computer based imaging has probably been the factor that limits the observation of activities of the rather obscure corner of facets.

On the basis of our experience and observations, we speculated that instability of the spinal segment is related to muscle weakness that has a profound impact on the pathogenesis of entire spectrum of spondylosis or degeneration of spine. [1],[2],[3],[4] The term'degenerative stenosis' can be more aptly referred to as'degenerative instability'. The symptoms of lumbar canal stenosis are related to posture and often increase on extension and on prolonged standing or walking. The classical symptom of claudication pain appears on walking for a distance. The claudication distance progressively reduces as the extent of degeneration increases. Similarly, the symptoms in cervical canal stenosis occur on prolonged standing or activity and pain in the nape of the neck is a prominent symptom. Considering that the symptoms occur only after physical activity, and only in late stages at rest, it appears that the canal is not inherently stenosed, but the physical activity or posture initiates a phenomenon that leads to symptoms of stenosis. After a period of rest or on altering the posture, the canal stenosis is reversed. It is apparent that weakness of the muscles of the back leads to their fatigue and subsequent incompetence may lead to facetal override or telescoping. We discussed earlier the relevance of instability secondary to age-related, disuse-related or abuse -related weakness of the muscles of the back of the spine. [1],[2],[3],[4] The muscles that extend the spine and assist in the standing human position throughout the human life are prone to fatigue or to weakness. Overriding of the facets as a result of the muscle weakness forms the basis of pathogenesis of degeneration of the spine and of spinal canal stenosis.

Facetal over-riding has generally been considered to be a secondary phenomenon to the primary disc degeneration and not much importance has been given to this anatomical and physiological phenomenon. The radiological effect on the spinal canal size on axial loading has been discussed. Reduction of the inter-facetal joint space, osteophyte formation adjacent to the facets, facetal overriding or listhesis, and similar such facet related radiological features can suggest degeneration in this region and can suggest presence of instability. Reduction of the articular cavity space and subsequent facetal overriding or telescoping and consequent ligamental laxity and buckling might occur on activity. It appears that the phenomenon of lumbar and cervical canal stenosis is'dynamic' in nature and local spinal instability plays a major role in its genesis. Standing human posture, ageing muscles, heavy body weight and sedentary life style may have contributory effects on pathogenesis of spinal canal stenosis. It does appear that the muscles have a role in keeping the spinal segments apart. Physiotherapy and traction over the back and neck have been successfully used for decades in the management of spinal degeneration.

With age, each vertebral component telescope or come closer to each other resulting in the reduction in the overall height of the spinal column. The initial effect of the weakness of the muscles of the back is relayed on the facets and results in reduction in the inter-facetal articular space. Reduction in the inter-facetal space simulates the phenomenon of reduction in the space of the knee joint that ultimately results in arthritis of the knee joint. In our earlier publication, we stressed the importance of distraction of the facets as treatment for spinal stenosis and showed the reversal of entire range of pathogenetic effects of spinal degeneration. [3],[4] We showed that following distraction of the facets, the intervertebral ligaments that are buckled get stretched into normalcy and clearly suggest that the ligaments are not hypertrophic but are only buckled. The interlaminar and intervertebral body height increases. The process results in increase in the foraminal height and spinal canal dimension. The disc space height increase results in restoration of its water content. Following distraction of the facets, all the secondary phenomenon reverse, effectively increasing the canal size and reversing the effects of spinal degeneration and spinal canal stenosis.

As the stenosis occurs on activity, it clearly suggests that vertical instability is the primary factor that results in spinal canal stenosis. It suggests that spinal elements come closer to each other on activity. Considering the fact that instability is the primary factor in the generation of lumbar and cervical canal stenosis, it is apparent that stabilization can form the cornerstone of its treatment without the need for any kind of bone or ligamentous decompression. We recently fixed the affected spinal segments using trans-articular screws, without physically distracting the facets, or removal of any part of the bone or ligament. The fixation of the facets was done in a prone position that obliterated the lumbar lordosis, widened the inter-facet distance and resulted in flexion of the lumbar spine. For cervical spine, fixation was done in neck flexion position. Our successful outcome suggests that stabilization of the spinal segment has a role in the treatment of lumbar and cervical canal stenosis. Fixation of the affected components of the spine results in avoidance of excessive strain on weak muscles and stretches the ligaments and restores the foraminal and spinal canal height. Stabilization of the facets might assist in alleviation of dynamic events that are associated with lumbar canal stenosis. Fixation of the involved motion segment assists in eliminating subtle movements that could probably be the cause of pain in the segment and can result in reversal of processes that ultimately result in spinal canal stenosis.

Vertical instability and telescoping, listhesis or overriding of the facets on physical activity seems to be the defining phenomenon in pathogenesis of spinal canal stenosis. It does appear that fixation of the spine in flexed spinal position without any bony decompression can form a rational form of treatment of'degenerative' spinal canal stenosis.

 
   References Top

1.Goel A. Facet distraction spacers for treatment of degenerative disease of the spine: Rationale and an alternative hypothesis of spinal degeneration. J Craniovertebr Junction Spine 2010;1:65-6.  Back to cited text no. 1
[PUBMED]    
2.Goel A. Facet distraction-arthrodesis technique: Can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2011;2:1-2.  Back to cited text no. 2
[PUBMED]    
3.Goel A, Shah A. Facetal distraction as treatment for single and multilevel cervical spondylotic radiculopathy and myelopathy: A preliminary report. J Neurosurg Spine 2011;14:689-96.  Back to cited text no. 3
[PUBMED]    
4.Goel A, Shah A, Jadhav M, Nama S. Distraction of facets with intra articular spacers as treatment for lumbar canal stenosis: Report on a preliminary experience with 21 cases. J Neurosurg Spine 2011.  Back to cited text no. 4
    



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