Spinal Stenosis

Document the baseline deficit before you touch the back - Record motor strength by myotome, sensory distribution, gait, and bowel and bladder function. About 43% of these patients already have weakness, and the neurologic exam is otherwise typically normal, so anything you find after a block needs a pre-anesthetic comparator in the chart.

Know the findings that mean cauda equina - New bowel or bladder dysfunction, saddle anesthesia, or bilateral lower extremity weakness points to cauda equina or conus medullaris syndrome and makes the case urgent. Everything else in lumbar stenosis is elective surgery done to improve function rather than to prevent neurologic deterioration.

Neuraxial is possible, but the anatomy fights you - Preexisting neurologic disease is a relative contraindication to spinal anesthesia, and osteophytes, facet hypertrophy, and spondylolisthesis obliterate the midline landmarks you would normally palpate. Nerve root injury and cauda equina syndrome are recognized complications of subarachnoid block, so weigh the technique against a general anesthetic instead of defaulting to it in a canal that is already narrow.

Position for a canal that opens in flexion - Flexion widens the canal and relieves symptoms; extension narrows it and reproduces the pain, which is why these patients tolerate walking uphill better than downhill. Flex the spine for neuraxial placement and keep the lumbar spine out of extension on the table. Ask the awake patient which position they can hold before you induce.

Prone laminectomy is a positioning case - Brachial plexus injury and cervical spine injury are the classic prone morbidities. Keep C5 in line with the occiput so the neck is neither over-flexed nor over-extended, pad head, shoulders, arms, breasts, and genitals, check the eyes for undue pressure every 15 minutes, keep the eyes above the heart with roughly 10 degrees of reverse Trendelenburg, and palpate the radial pulse once the arms are positioned.

Cervical stenosis changes the airway plan - Cervical narrowing can progress to myelopathy, showing up as hand clumsiness and gait disturbance. Limit neck extension during laryngoscopy and reach for the video laryngoscope rather than a direct view bought with an extended neck.

Ask about the analgesic history - Conservative care runs 3 to 6 months before surgery is offered and consists of physical therapy, oral anti-inflammatories, and epidural steroid injections. Get the actual drug list and doses, note where and how recently steroid was injected near your planned interspace, and plan a multimodal postoperative regimen for a patient who is already analgesic-experienced.

Set the postoperative neurologic expectation - Decompression is done to improve function, not to prevent deterioration, so an unchanged deficit in PACU is not a failed operation. A new or progressing deficit is the finding that needs the surgeon back at the bedside.

Spinal stenosis is narrowing of the central canal, the lateral recess, or the neural foramen, compressing the cord in the cervical spine and the cauda equina and exiting nerve roots in the lumbar spine. Most of it is degenerative: posterior disc protrusion, vertebral osteophytes, facet hypertrophy, and ligamentum flavum hypertrophy, sometimes with a degenerative spondylolisthesis that translates one vertebra forward on the next, most often L4 on L5. Symptoms come from mechanical compression plus nerve root ischemia. The signature is neurogenic claudication: bilateral but asymmetric leg pain worsened by standing, walking, and lumbar extension, and relieved by sitting or forward flexion, because flexion widens the canal. Cervical stenosis can progress to myelopathy. Lumbar stenosis is the leading reason patients over 65 come to spine surgery, so you meet these patients both for decompression and incidentally.