DIAGNOSTIC AND THERAPEUTIC DIFFICULTIES IN PATIENTS WITH ASSOCIATED CERVICAL AND LUMBAR STENOSIS

Abstract

Purpose of the study: Missing a cervical stenosis in patients with lumbar canal stenosis can lead to an inadequate surgical strategy and delay in treatment of overt cord compression.

Material and methods: Among 100 patients with lumbar canal stenosis, we identified patients with symptoms related to cervical stenosis. These four patients had to undergo surgical decompression of the cervical and lumbar spine to achieve full symptom relief. Careful analysis of the clinical expression is essential to identify cervical stenosis with few or no signs. Presence of gait disorders related to balance disorders, widening of the balance polygone, or use of a crutch, are suggestive of an associated lesion. MRI facilitates diagnosis of cervical compression. EMG and somesthetic evoked potentials are the gold standard examinations to confirm clinical and radiographic suspicion.

Results: Gait disorders, other than simple claudication and/or radiculalgia warranted MRI and electric explorations in these patients. In these four patients, compression of the posterior cord explained well the gait disorders via a deep sensorial mechanism.

Discussion: MRI evidence of cervical osteoarthritis is not sufficient to confirm the origin of the patient’s complaints. There must be a perfect correlation with the electrical results, particularly evoked potentials associated with MRI to confirm the organic origin of disorders resulting from cervical stenosis. Positive diagnosis of such an association requires a specific treatment algorithm as was used in three of our four patients. In the fourth case, the lumbar compression appeared to predominate over the cervical compression leading to decompression of the lumbar canal followed later by decompression of the cervical canal. Between the two procedures, the patient’s status had considerably declined. This strategy which had appeared adequate was thus found to be quite inadequate and even dangerous.

Conclusion: Presence of gait disorders other than simple claudication or single-level or multiple-level radiculalgia in patients with lumbar canal stenosis should lead to search for an associated cervical stenosis. The perfect correlation between the radiographic and electrical findings is indispensable to establish certain diagnosis. The cervical stenosis should be treated before the lumbar stenosis.