Case 9 Lumbar canal stenosis

Figure 9.1: MRI of the patient axial T2 and sagittal T2.

Clinical presentation

• A 68-year-old male patient with diabetes and hypertension presented with right sciatica affecting the L4 and L5 nerve distribution for the past 2.5 years.
• has experienced calf muscle claudication for one year.

• Q1: What is the pathophysiology of neurogenic claudication?
• The pathophysiology of neurogenic claudication includes the following factors:

1. Direct compression on the nerve roots from osteophytes or hypertrophy of the ligamentum flavum, especially if superimposed on congenital spinal canal stenosis.

2. Ischemia and venous congestion due to compression of segmental vessels and epidural veins.

3. Repeated local trauma from repetitive movements.

• Q2: Given the patient’s diabetes and advanced age, is there concern for other diseases that may manifest as claudication, considering the risk factors of diabetes and old age?
• Given the patient’s diabetes and advanced age, there is concern that the claudication might also indicate another disease, such as peripheral arterial disease (PAD), commonly associated with these risk factors. This condition often presents with claudication, characterized by pain and cramping in the legs due to reduced blood flow. Assessment of peripheral vascularity should include observing trophic changes in the lower limbs, checking pulsations, and conducting duplex ultrasound and angiography to evaluate the vascularity of the lower limbs.

• Q3: What are the minimally invasive operations that can be performed for lumbar canal stenosis?
• It includes the following:

1. Bilateral laminoforaminotomy.

2. Unilateral laminoforaminotomy and contralateral decompression from the same side.

3. X-Stop implant.

4. Epidural steroid injection and radiofrequency.

Figure 9.2: X-stop.