Original research submitted as partial fulfillment of the requirements for the Masters in Medicine degree in Orthopaedic surgery at the University of Witwatersrand, Johannesburg, April 2014 / Objectives 1. Assessment of radiological parameters of spinal stenosis using Magnetic Resonance imaging. 2. Clinical assessment of patients with Oswestry disability index and Neurogenic claudication outcome score questionnaires. 3. To assess correlation between clinical assessment questionnaires’ scores and radiological parameters. Background. Spinal stenosis is a common presentation in the elderly and a reason for surgical intervention. Diagnostic criteria are still inconclusive. There is poor correlation between clinical and radiological findings. New observations have been described and whether they improve diagnostic criteria remains to be seen. Methods. 30 patients with spinal stenosis were included in the study. The 2 questionnaires were administered and Magnetic Resonance Imaging copies were obtained. Questionnaires and images were analyzed. Osirix programme was used to analyze the images and do the measurements. Data was entered onto an excel sheet and analyzed using Statistica software. Frequencies and correlations were done. Results. The age range was between 41 and 85.There were 22 females and 8 males. L4/L5 was the commonest level involved in 23 patients. Multilevel involvement was 23% and those patients had a higher morphological grade, which was statistically insignificant. The commonest morphological grade was C. Sedimentation was positive in 93% of the patients. The Oswestry disability Index and Neurogenic Claudication Outcome score were negatively correlated, which was statistically significant, p = 0.0004. There was no correlation between clinical and radiological features. Conclusion. Spinal stenosis remains a clinical dilemma. There is variability within the population and lack of correlation between clinical and radiologic features. Radiological features however correlate with each other, but do not help with optimizing patient care.

The incidence of lumbar spinal stenosis (LSS) is steadily rising, mostly because of a noticeably older age structure. In Sweden, LSS surgery has increased continuously over the years and is presently the most common argument to undergo spine surgery. The purpose of the surgery is to decompress the neural elements in the stenotic spinal canal. To avoid instability, there has been a tradition to do the decompression with a complementary fusion, especially if degenerative spondylolisthesis is present preoperatively. The overall aims of this thesis were to evaluate which method of surgery that generally can be considered to give sufficiently good clinical results with least cost to society and risk of complications and to determine whether there is a difference in outcome between smokers and non-smokers. The Swespine Register was used to collect data on clinical outcome after LSS surgery. In two of the studies, large cohorts were observed prospectively with follow-up after 2 years. Data were analysed in a multivariate model and logistic regression. In a randomised controlled trial (RCT, the Swedish Spinal Stenosis Study), 233 patients were randomised to either decompression with fusion or decompression alone and then followed for 2 years. The consequence of preoperative degenerative spondylolisthesis on the results was analysed and a health economic evaluation performed. The three-dimensional CT technique was used in a radiologic biomechanical pilot study to evaluate the stabilising role of the segmental midline structures in LSS with preoperative degenerative spondylolisthesis by comparing laminectomy with bilateral laminotomies. Smokers, in comparison with non-smokers, showed less improvement after surgery for LSS. Decompression with fusion did not lead to better results compared with decompression alone, no matter if degenerative spondylolisthesis was present preoperatively or not; nor was decompression with fusion found to be more cost-effective than decomression alone. The instability caused by a decompression proved to be minimal and removal of the midline structures by laminectomy did not result in increased instability compared with the preservation of these structures by bilateral laminotomies. In LSS surgery, decompression without fusion should generally be the treatment of choice, regardless of whether preoperative degenerative spondylolisthesis is present or not. Special efforts should be targeted towards smoking cessation prior to surgery.

Abstract Genetic factors have been implicated to play a role in both degenerative lumbar spinal stenosis (LSS) and intervertebral disc disease (IDD). Sequence variations in the genes coding for collagen IX and inflammatory mediators have been indicated as risk factors for IDD. Nine genes coding for intervertebral disc (IVD) collagens I, II, IX and XI and aggrecan (AGC1) were analyzed for sequence variations in 29 Finnish individuals with LSS. In addition, two polymorphisms in the vitamin D receptor gene and one in the matrix metalloproteinase-3 gene were studied. Study subjects were analyzed both clinically and radiologically. Results indicated an association between the COL11A2 IVS6-4 a to t polymorphism and LSS (p = 0.0016). Moreover, the t/t genotype was found more often in the patient group compared to controls (p = 0.0011). A novel splicing mutation, likely resulting in the synthesis of a truncated protein, was identified in COL9A2. Eight hundred four Chinese individuals were screened for the presence of the Trp2 and Trp3 alleles. The Trp2 allele was found in 20% of the individuals compared to the previously reported 5% in Finnish patients with IDD characterized by sciatica. The Trp2 allele was found to predispose to IVD degeneration and end plate herniations, increasing the risk by 2.4-fold from 40 to 49 years of age. In addition, the degeneration was worse in individuals with the Trp2 allele. The risk for annular tears was 4-fold greater in study subjects from 30 to 39 years of age who were Trp2 positive. Surprisingly, the Trp3 allele was absent even though it was found in about 9% of Finnish individuals. One hundred fifty-five Finnish individuals with IDD characterized by sciatica were analyzed for sequence variations in four genes coding for inflammatory mediators IL1A, IL1B, IL6, and TNFA. In addition, sixteen polymorphisms in inflammatory mediator genes were analyzed. The results identified an association between sciatica and the E5+15T>A polymorphism in IL6 (p = 0.007). A significant association was also seen in the IL6 haplotype analysis (-597 g>a, -572 g>c, -174 g>c and E5+15T>A). The association of the GGGA haplotype with the disease was highly significant (p = 0.0033).

Diss. (sammanfattning) Stockholm : Karol. inst., 2005. / Härtill 5 uppsatser.

This thesis presents a literature review of the diagnosis and treatment of lumbar spinal stenosis (LSS), including a brief description of the patient history and non-surgical options while focusing mainly on the current array of surgical techniques. LSS is defined as a narrowing of any part of the lumbar spinal canal. This narrowing places excessive pressure on both the spinal cord and peripheral nerves resulting in pain, numbness and weakness in the lower extremities. LSS has a large spectrum of potential treatment options since the disease itself has a wide range of severities. An extensive physical exam, using the appropriate clinical surveys, physical manipulations, and imaging studies, is of paramount importance in the successful diagnosis. Currently, conservative treatment, while an important first step in managing LSS, seems to be limited to a first line of defense, lasting only a short period of time. Physical therapy results appear to be beneficial for only six months to a year, and despite their increased usage in recent years, management through the use of non-steroidal anti-inflammatory drugs, opiates, and corticosteroid injections seem to provide very little benefit. Surgical treatment for LSS ultimately appears to be the most effective method in reducing pain and disability for the patient who fits the clinical and radiological findings indicative of LSS. Although current surgical options available are numerous, including different types of fusion, bone grafts, and innovative joint replacements, the most promising procedures appear to be minimally invasive lumbar disk replacement surgery and dynamic stabilization. These procedures offer the benefits of a minimally invasive surgical approach, while reducing stenosis though hardware that not only reduces pain but also allows patients to maintain spinal flexibility and natural functional motion.

Σκοπός: Πρόκειται για μια προοπτική μελέτη που αφορά στη χειρουργική θεραπεία ασθενών που έπασχαν από εκφυλιστική σπονδυλική στένωση της ΟΜΣΣ σε πολλαπλά επίπεδα (δύο ή περισσότερα). Αποσκοπεί στο να διερευνήσει εάν η συγκεκριμένη χειρουργική τεχνική βελτιώνει τα συμπτώματα των ασθενών και κατά πόσον αυτή η βελτίωση διατηρείται στο χρόνο. Υλικό-Μέθοδος: Σαράντα-ένας ασθενείς συμμετείχαν στην μελέτη, που έλαβε χώρα στην Ορθοπαιδική Κλινική του Πανεπιστημίου Πατρών, από το 1997 έως το 2004. Οι ασθενείς είχαν συμπληρώσει τουλάχιστον 1 έτος μετεγχειρητικής παρακολούθησης. Ο μ.ο. ηλικίας των ασθενών ήταν 61,02 +_ 9,62 έτη (κυμαινόμενη από 33 έως 79 έτη). Οι ασθενείς προεγχειρητικά υποβάλλονταν σε λεπτομερή ακτινολογικό και κλινικό έλεγχο. Ο ακτινολογικός έλεγχος περιελάμβανε απλές και δυναμικές ακτινογραφίες, αξονική τομογραφία (CT), μαγνητική τομογραφία (MRI) και/ή μυελογραφία με μυελο-CT. Ο κλινικός έλεγχος περιελάμβανε τη συμπλήρωση του ερωτηματολογίου της Oswestry Disability Index (ODI) και της Visual Analog Scale (VAS). Βάσει του προεγχειρητικού ελέγχου 23 ασθενείς έπασχαν από εκφυλιστική στένωση σε 2 σπονδυλικά επίπεδα (περιελάμβανε 3 σπονδύλους), σε 16 ασθενείς είχαν προσβληθεί 3 επίπεδα και 2 ασθενείς είχαν προσβληθεί 4 επίπεδα. Επιπλέον αναδείχθηκε ότι 12 ασθενείς έπασχαν από σκολίωση, 18 ασθενείς από σπονδυλολίσθηση 1ου βαθμού, ενώ 9 ασθενείς από τμηματική αστάθεια. Η κλινική εικόνα των ασθενών περιελάμβανε κυρίως άλγος στην οσφύ και στα κάτω άκρα και/ή νευρογενή διαλείπουσα χωλότητα. Επιπλέον 6 ασθενείς παρουσίαζαν σταδιακά επιδεινούμενη νευρολογική σημειολογία. Η χειρουργική τεχνική περιελάμβανε ευρεία οπίσθια αποσυμπίεση των οστικών και συνδεσμικών δομών. Περιελάμβανε αφαίρεση της ακανθώδους απόφυσης του σπονδυλικού πετάλου και του ωχρού συνδέσμου, ώστε να υπάρξει απελευθέρωση του σπονδυλικού καναλιού οπισθίως. Η αποσυμπίεση εκτείνονταν από το έξω όριο του ενός καναλιού των ριζών έως το έξω όριο του άλλου και αφορούσε όλα τα στενωτικά επίπεδα που εκ των προτέρων είχαν καθοριστεί μέσω, του προεγχειρητικού ελέγχου. Η σταθερότητα της Σ.Σ. επιτυγχανόταν με την τοποθέτηση διαυχενικού συστήματος σπονδυλοδεσίας, που εκτείνονταν ένα σπονδυλικό επίπεδο εκατέρωθεν των επιπέδων αποσυμπίεσης. Το τελικό στάδιο της τεχνικής περιελάμβανε τοποθέτηση μοσχευμάτων για την επίτευξη αρθρόδεσης, τα οποία τοποθετούνταν μεταξύ των εγκαρσίων αποφύσεων. Ο μέσος χειρουργικός χρόνος ήταν 228min (από 120min έως 420min). Η παρακολούθηση των ασθενών μετεγχειρητικά γίνονταν σε ετήσια βάση και περιελάμβανε τη συμπλήρωση της ODI και VAS όσον αφορά στο κλινικό σκέλος και απλές και δυναμικές ακτινογραφίες όσον αφορά στο ακτινολογικό σκέλος. Αποτελέσματα: Ο μέσος χρόνος παρακολούθησης των ασθενών ήταν 3,71 +_ 1,54 έτη (κυμαινόμενος από 1 έτος έως 6 έτη). Η συνολική ποιότητα ζωής των ασθενών, όπως εκτιμάται με την ODI, παρουσίασε στατιστικά σημαντική βελτίωση μετεγχειρητικά, που διατηρήθηκε για όλα τα έτη παρακολούθησης. Συγκεκριμένα από 61,06% προεγχειρητικά, βελτιώθηκε στο 16,30% το 4ο μετεγχειρητικό έτος. Στατιστικά σημαντική βελτίωση παρουσίασε και ο πόνος όπως εκτιμήθηκε με τη VAS. Συγκεκριμένα από 7,88 προεγχειρητικά, βελτιώθηκε σε 2,35 το 4ο μετεγχειρητικό έτος. Εκτιμώντας τις επιμέρους παραμέτρους της ODI, διαπιστώνεται πως η μεγαλύτερη βελτίωση επιτεύχθηκε στο άλγος, στην προσωπική φροντίδα, στην ικανότητα καθίσματος, στην ικανότητα ύπνου και στην ικανότητα για ταξίδι. Στις παραπάνω δραστηριότητες ποσοστό ασθενών μεγαλύτερο από 90% παρουσίαζε φυσιολογική ή σχεδόν φυσιολογική δραστηριότητα, με βαθμολογία ‘0’ ή ‘1’ το 4ο μετεγχειρητικό έτος στην 6βάθμια κλίμακα. Η ακτινολογική παρακολούθηση μετεγχειρητικά ανέδειξε αστάθεια σε παρακείμενο επίπεδο σε 2 ασθενείς (4,87%), θραύση μιας βίδας στον Ι1 σπόνδυλο σε 1 ασθενή (2,43%) και χαλάρωση μιας βίδας σε 1 ασθενή (2,43%). Όλοι οι ανωτέρω ασθενείς υποβλήθηκαν σε νέα επέμβαση. Η πιθανότητα συνεπώς για τους ασθενείς της μελέτης να μην υποβληθούν σε νέα επέμβαση λόγω μηχανικής αποτυχίας της αρχικής επέμβασης, ήταν 90,24%. Οι υπόλοιποι ασθενείς παρουσίασαν στον ακτινολογικό έλεγχο πλήρη πώρωση με συνεχή οστική γεφύρωση μεταξύ των εγκαρσίων αποφύσεων άμφω και σταθερότητα σε παρακείμενα επίπεδα. Τέλος οι 39 ασθενείς (95,12%) δήλωσαν ικανοποιημένοι με το αποτέλεσμα της επέμβασης και ότι θα την επαναλάμβαναν κάτω από τις ίδιες συνθήκες. Συμπέρασμα: Η ευρεία οπίσθια αποσυμπίεση συνοδευόμενη από οπισθοπλάγια σπονδυλοδεσία με χρήση υλικών, προσφέρει ικανοποιητικά και αναπαραγόμενα κλινικά και ακτινολογικά αποτελέσματα σε ασθενείς που υποφέρουν από πολυεπίπεδη σπονδυλική στένωση και αστάθεια (εκφυλιστική σκολίωση και/ή εκφυλιστική σπονδυλολίσθηση). Με την παραπάνω τεχνική αποφεύγεται η υποτροπή της στένωσης λόγω άναρχης οστικής αναδόμησης (bone regrowth). Όταν η τεχνική εφαρμόζεται σε προσεκτικά επιλεγμένους ασθενείς οδηγεί σε μικρό ποσοστό επιπλοκών, αποτελώντας μια αξιόπιστη λύση στο πρόβλημα της σημαντικής παθολογίας της σπονδυλικής στήλης. / Aim: This is a prospective study on the surgical treatment of patients who suffered from degenerative spinal stenosis of lumbar spine in multiple levels (2 or more). Our goal was to show if our technique improves substantially patient’s symptoms and if the improvement is long lasting. Patients and Method: Between 1997 and 2004, 41 patients were participated in this study, which took place at the Orthopaedic Department of Patras University Hospital. All patients had completed 1-year postoperative follow up. Mean age was 61 years (range 33 – 79 years). All patients underwent preoperatively detailed radiological and clinical evaluation. Radiological aproach included face, profile and dynamic x-rays, computer tomography (CT), magnetic resorance (MRI) and/or myelography with myelo-CT. Clinical evaluation was done using Oswestry Disability Index (ODI) and Visual Analog Scale (VAS). Twenty-three patients suffered from degenerative stenosis in 2 levels (included 3 vertebral bodies), in 16 patients were involved 3 levels and in 2 patients were involved 4 levels. Furthermore 12 patients suffered from concomitant scoliosis, 18 patients from concomitant spondylolisthesis (1st grade), 9 patients from segmental instability and 2 patients from scoliosis and spondylolisthesis. Patients’ symptoms were low back pain, sciatica and/or neurologic intermittent claudication. In 6 patients neurologic deterioration was observed. Surgical technique was wide posterior decompression. This included removal of spinous process, vertebral lamina and ligamentum flavum, and lead to fully posterior exposure of the spinal canal. Decompression was taken place in all the stenotic segments and was extended from one to another root canal in each segment. In order to achieve stability of the spine we used transpedicular screw fixation system, which extended one segment above and one below the decompressed area. Finally we used osseous graft and allograft between transverse processes. Mean surgical time was 228 (120-420) min. Patients’ follow up was done once per year and included the completion of ODI and VAS and face profile and dynamic x-rays for clinical and radiological assessment respectively. Results: Mean follow up was 3,7 (1-6) years. The quality of patients’ life, as is estimated with ODI, showed substantial improvement, which lasted all years. In specific from 61% preoperatively, improved to 16% the 4th postoperative year. Pain also presented statistical significant improvement, as is estimated with VAS. In specific from 7,9 preoperatively improved to 2,3 the 4th postoperative year. Evaluation of ODI’s parameters showed that the greater improvement was achieved in pain, personal care, sitting, sleeping and traveling. More than 90% of the patients had normal or nearly normal activity in these aforementioned parameters, the 4th postoperative year. Two patients had instability in an adjacent level (4,9%). Also one screw breakage in 1 patient (2,4%) and one screw loosening in another one (2,4%), both in S1 vertebral, was observed. These 4 patients underwent second surgical intervention due to instability. Finally there was possibility 90,2% for the patients not to underwent second operation due to mechanical failure. The rest of the patients presented with solid fusion, confluent osseous bridging between the transverse processes and stable adjacent vertebral levels. Conclusions: Wide posterior decompression combined with posterolateralinstrumented fusion, lead to satisfactory and reproducible clinical and radiological results to patients who suffer from degenerative lumbar spinal stenosis in multiple levels with concomitant instability (degenerative scoliosis and/or degenerative spondylolisthesis). The aforementioned technique avoids substantial bone regrowth and stenosis recurrence. Proper use in carefully selected patients has low complication rate, giving us a good and long-lasting result.

Orientador: João Batista de Miranda / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T07:18:16Z (GMT). No. of bitstreams: 1 Cavali_PauloTadeuMaia_D.pdf: 2639722 bytes, checksum: 55b4478f11151611236860d14a52b44f (MD5) Previous issue date: 2012 / Resumo: Existe uma grande variabilidade de resultados nos estudos prévios que analisam os parâmetros do alinhamento sagital (PAS) em indivíduos normais e em pacientes com doenças degenerativas da coluna lombar. A maioria desses estudos relacionam os PAS somente com o sintoma de dor lombar crônica, em grupos de pacientes com diferentes doenças degenerativas lombares, o que dificulta a aplicação clínica desses dados tanto na avaliação diagnóstica como na indicação terapêutica. O objetivo deste estudo caso-controle foi analisar as relações dos PAS com os diferentes sintomas entre um grupo de pacientes com diagnóstico de estenose lombar e um grupo controle e as mesmas relações entre os subgrupos de pacientes diferenciados por sintoma. Foram colhidos os dados da história, exame clínico, ressonância magnética e de exames radiográficos de 23 pacientes com estenose lombar (denominado grupo estenose) e de 17 indivíduos saudáveis (denominado grupo controle). Os PAS utilizados foram: cifose torácica (CT), lordose lombar (LL), eixo sagital vertical (C7-T1), listese anteroposterior (OAP), lordose lombo-pélvica total (LLT) e regional (LLR), eixo sagital em T1, T4 eT9 (ES1, ES4 e ES9 respectivamente), inclinação sagital T1-L5 (IST1-L5), "offset sagital" T1 e T9 (OST1 e OST9), "tilt pélvico" (TP), "slope sacral" (SS), morfologia pélvica (MP), ângulo sacro-femoral (ASF), distância sacro-femoral (DSF) e "overhang" (OVHG). Na Fase 1 do estudo, os dados do PAS foram correlacionados entre os indivíduos do grupo controle e grupo estenose e, na Fase 2, entre os subgrupos do grupo estenose diferenciados por sintomas como lombalgia, radiculopatia, claudicação neurogênica e dor, medida pela Escala Analógica de Dor (EAD). Na Fase 1, observou-se que os pacientes do Grupo Estenose (GE) como um todo tiveram menores valores de LLT (p = 0,006) e LLR em L1, L2 e L3 (p = 0,026) e os pacientes do GE com sintoma de radiculopatia, além dos dados acima, tiveram aumento do TP (p = 0,004), quando comparados ao Grupo Controle (GC). Na Fase 2, o Subgrupo Lombalgia obteve maiores valores de CT (p = 0,035) e LLR (p = 0,028) e uma diminuição do TP (p = 0,029), OST1 (p = 0,022), DSF (p = 0,014) e OVHG (p = 0,035) em relação aos outros pacientes do GE que não se queixavam de lombalgia e, no Subgrupo Radiculopatia, houve a diminuição da LLR (p < 0,047). Este estudo demonstra que há correlações significativas dos sintomas e dos PAS entre o GE e o GC e também entre os Subgrupos do GE diferenciados por sintomas. Estes dados indicam uma melhor interpretação clínica dos PAS, assim como podem sugerir a terapêutica mais adequada / Abstract: There is a great variation in the results of previous studies analyzing sagital alignment parameters (SAP) in normal individuals and in patients with degenerative diseases of the lumbar spine. Most studies associate SAP only with chronic lumbar pain, in groups of patients with different lumbar degenerative diseases, which makes it difficult to apply these data clinically both in diagnostic evaluation and in therapeutics. The objective of this prospective, diagnostic case-control study was to examine the relationship between sagittal balance parameters and different symptoms of spine disease in patients with lumbar canal stenosis (LCS) and controls and the same associations between subgroups of patients with different symptoms. We collected clinical history, clinical exam data from 23 patients with spinal stenosis and 17 healthy volunteers (controls). Magnetic resonance imaging (MRI) and x-rays allowed the measurement of sagittal axis parameters. The SAP analyzed were thoracic kyphosis, lumbar lordosis, sagittal axis, anterior-posterior listesis, total and regional lumbar-pelvic lordosis, sagittal axis in T1, T4 and T9, pelvic tilt, sacral slope, pelvic morphology, sacro-femoral angle, sacro-femoral distance and overhang. In the first phase of the study, SAP data were correlated between controls and patients, and in the second phase, the subgroups inside the group of patients with stenosis were compared for symptoms as lumbar pain, radiculopathy, neurogenic claudication and pain, measure by the visual analogue scale (VAS). In the first phase, it was observed that the stenosis patients presented lower values of total lumbopelvic lordosis (p = 0.006) and regional lordosis L1, L2 and L3 (p < 0.026). Those with stenosis and radiculopathy also had higher values of pelvic tilt (p = 0.004) and lower values for total lumbopelvic lordosis and regional lordosis in L1 and L2 (p < 0.05) than controls. All patients complaining of back pain had higher values of thoracic kyphosis (p = 0.035), regional lumbopelvic lordosis in L1 (p = 0.028), lower values for pelvic tilt (p = 0.029), sagittal T1 offset (p = 0.022), sacro-femoral distance (p = 0.014) and overhang (p = 0.035) compared to patients without the complaint. Patients with stenosis and radiculopathy were less prone to have regional lordosis in L2, L3 and L4 (p = 0.047, p = 0.047 and p = 0.023 respectively). In conclusion, this study shows that there are significant correlations between symptoms and sagittal axis parameters between patients with and without spinal canal stenosis and also in subgroups of the patients with stenosis with different complaints.These data indicate a better clinical interpretation of SAP, as well as suggest a better therapeutic approach / Doutorado / Cirurgia / Doutor em Cirurgia

No description available.

As doenças que provocam a estenose da coluna lombar têm contribuído para a piora da qualidade de vida, ocasionando dor e limitações funcionais em uma parcela considerável da população ativa. O tratamento cirúrgico da estenose geralmente é indicado quando ocorre déficit neurológico progressivo, resistente ao tratamento conservador e se a doença apresenta impacto na qualidade de vida do paciente. A carência de pesquisas nacionais já publicadas sobre o tema, principalmente aquelas com enfoque na avaliação subjetiva desses indivíduos nos motivou a realização deste estudo observacional e analítico, de delineamento transversal. O objetivo foi avaliar as expectativas e a associação da qualidade de vida relacionada à saúde (QVRS) com a presença de sintomas de ansiedade e depressão em pacientes que aguardavam o tratamento cirúrgico da Estenose do Canal Lombar. A amostra foi composta por pacientes com indicação cirúrgica de estenose lombar, atendidos entre agosto de 2011 e novembro de 2012, em um hospital geral público de ensino. Os dados foram coletados por entrevistas individuais e consulta aos prontuários dos participantes. As variáveis de interesse foram mensuradas por instrumentos específicos e previamente validados. A QVRS foi avaliada pelo Índice de Incapacidade de Oswestry e pelo SF-36. Os sintomas de ansiedade e depressão foram avaliados segundo as subescalas do Hospital Anxiety and Depression Scale (HADs). As expectativas frente ao tratamento cirúrgico da estenose foram investigadas por questões previamente usadas em estudos internacionais. Os dados foram analisados descritivamente, e o teste t de Student foi utilizado para amostras independentes e realizado para comparar as médias das variáveis de interesse, segundo a presença de sintomas de ansiedade ou depressão. O nível de significância adotado foi de 0,05. Participaram da investigação 38 pacientes, sendo 32 (84,2%) com diagnóstico de estenose lombar, três (7,9%) com espondiloartrose, dois (5,3%) com estenose lombar/listese e um (2,6%) apresentava diagnóstico de discopatia. O tempo médio de evolução da doença foi de 38,3 meses. A média de idade foi 60,4 anos, e 63,2% eram mulheres. Na avaliação da QVRS, pelo SF-36, os domínios mais comprometidos foram aqueles relacionados às atividades físicas como Aspectos físicos (M=4,61; D.P.=11,4) e Capacidade funcional (M=25,8; D.P.=11,4) e os mais bem avaliados foram Estado geral de saúde (M=73; D.P.=12,5) e Saúde mental (M=63,8; D.P.=17,2). A média do ODI obtida entre os participantes foi de 50,9%. A classificação dos participantes mostrou que 55,3% apresentavam incapacidade grave, 23,7%, incapacidade moderada e 21,1%, invalidez. Sintomas de ansiedade e de depressão estavam presentes, respectivamente, em 31,6% e 10,5%. Comparando os valores médios dos domínios do SF-36, segundo a presença ou não desses sintomas, em sete dos oito domínios, o grupo com sintomas apresentou médias menores do que o grupo sem sintomas, indicando pior QVRS. Entretanto, as diferenças entre os grupos foram estatisticamente significantes apenas para o domínio Estado geral de saúde, considerando a presença de ansiedade, e para o domínio Saúde mental quando os grupos foram comparados segundo a presença de sintomas de depressão. Na avaliação das expectativas, 47,4% dos participantes esperavam ficar \"Muito melhor\" com relação à dor nas pernas, capacidade de caminhar e independência das atividades diárias. Embora com limitações, o presente estudo, contribuiu para a prática clínica, uma vez que pode ampliar o conhecimento sobre os pacientes com estenose lombar. Diante da nossa prática clínica, consideramos que as expectativas referidas pelos pacientes frente ao tratamento cirúrgico nem sempre podem ser satisfeitas. Assim, os enfermeiros, entre outros profissionais que cuidam destes pacientes, precisam se responsabilizar por uma orientação mais clara e objetiva, voltada às reais possibilidades advindas da cirurgia para a melhora da qualidade de vida. A presença de sintomas de ansiedade e depressão também deve ser considerada como relevantes no pré-operatório destes indivíduos. / The diseases that cause stenosis of the lumbar spine have contributed to the worsen the quality of life and cause pain and functional limitations in a considerable portion of the working population. Surgical treatment of stenosis is usually indicated in case of progressive neurological deficit, resistance to conservative treatment and when the disease has an impact on quality of life of the patient. The lack of national researches already published on the subject, especially those focusing on the subjective evaluation of those individuals, motivated us to conduct this observational and analytical study, cross-sectional design. The objective was to evaluate the association of expectations and the Health-Related Quality of Life (HRQoL) with symptoms of anxiety and depression in patients awaiting surgical treatment of lumbar stenosis. The sample was consisted of patients with surgical indication for lumbar stenosis, treated between August 2011 and November 2012, in a hospital of public teaching. Data were collected through individual interviews and hospital records of participants. The variables of interest were measured by specific instruments, previously validated. HRQoL was assessed by the Oswestry Disability Index and the SF-36. Symptoms of anxiety and depression were assessed by the subscales of the Hospital Anxiety and Depression Scale (HADS). Expectations for the surgical treatment of stenosis were investigated by questions previously used in international studies. Data were analyzed descriptively and the Student t test for independent samples was performed to compare the means of the variables of interest, according to the presence of symptoms of anxiety or depression. The significance level was 0.05. 38 patients participated in the study, 32 (84.2%) with a diagnosis of lumbar stenosis, three (7.9%) espondiloarthrosis, two (5.3%) lumbar stenosis / listese and one (2.6%) had been diagnosed of discopathy. The duration of disease was on average 38, 3 months. The mean age was 60.4 years and 63.2% were women. In the assessment of HRQOL by SF-36, the amost affected areas were those related to physical activities like physical aspects (M = 4.61, SD = 11.4) and functional capacity (M = 25.8, SD = 11, 4) and areas with better evaluation were General health (M = 73, SD = 12.5) and Mental health (M = 63.8, SD = 17.2). The average of ODI obtained among participants was 50.9%. The classification of the participants showed that 55.3% had severe disability, 23.7% moderate disability and 21.1% invalidity. Symptoms of anxiety and depression were present, respectively, in 31.6% and 10.5%. Comparing the mean values of the SF-36 in the presence or absence of these symptoms, in seven of the eight domains, the group with symptoms showed lower average than the group without symptoms indicating worse HRQOL. However, the differences between the groups were statistically significant only for the domain general health, considering the presence of anxiety, and for the domain mental health when the groups were compared according to the symptoms of depression. In evaluating the expectations, 47.4% of respondents were expected to be \"much better\" about leg pain, walking ability and independence of activities daily. Even with limitations, this study has contributed to the clinical practice, since it can increase knowledge about patients with lumbar stenosis, we believe that the expectations reported by patients about surgical treatment can not be always satisfied. Thus, nurses, and other professionals who care for these patients need to take responsibility for clearer and objective guidance, oriented for the real possibilities arising from the surgery to improve the quality of life. The presence of symptoms of anxiety and depression should also be considered as relevant preoperatively these individuals.

Dor lombar é uma queixa comum especialmente entre os idosos. O termo estenose espinal é baseado no fato de que um espaço mínimo do canal vertebral é necessário para o funcionamento normal das estruturas nervosas e quando esse espaço torna-se estreito, resulta em sintomas como dor, dormência e fraqueza dos membros inferiores e claudicação neurogênica, que pioram com o esforço e melhoram com o repouso. Objetivos: Avaliar as alterações cinemáticas da marcha antes e após esforço físico em teste de esteira e correlacionar com a percepção de dor e com o grau de estenose do canal vertebral lombar obtido através do exame de ressonância nuclear magnética. Método: 14 pacientes com diagnóstico de estenose do canal vertebral lombar, com média de idade de 74,5 (9,8) anos e a área transversal média do canal vertebral foi de 43,86 (28,76) mm2. Para análise cinemática foram utilizados o sistema Vicon® MX 40 e o software Nexus® de reconstrução tridimensional das imagens. O exame constou de três fases: 1) Captura de seis ciclos de marcha após um período de descanso; 2) Caminhada em esteira durante um período máximo de 20 minutos; 3) Nova captura de outros 6 ciclos da marcha imediatamente após o esforço. A partir destes dados, as variáveis espaço temporais e angulares foram extraídas e analisadas individualmente e, em seguida, comparadas com a percepção da dor de cada paciente obtido pela escala visual analógica no inicio e ao final do exame e com a área transversal do canal vertebral medida em exames de ressonância nuclear magnética. Resultados: A maior parte das correlações se mostraram fracas e os resultados mais expressivos se referiram ao GDI onde notamos diminuição das medianas para ambos os membros com correlação negativa moderada com a percepção da dor pós-esforço, tanto para o membro esquerdo (r= -0,64, p=0,014) quanto para o direito (r= -0,53, p= 0,05), o que significa que existe uma diminuição significante da função geral dos membros inferiores conforme o sintoma da dor aumenta ( p= 0,002). Este fato pode ter reflexo na diminuição da cadência e da velocidade além dos tempos de apoio simples (significante para o membro esquerdo, p= 0,019) e balanço (significante para o membro direito, p= 0,013) como parte de uma estratégia de proteção contra a dor e o desequilíbrio. Conclusão: Há alteração da velocidade, cadência e dos tempos de apoio simples e duplo apoio para compensar a dor e a diminuição da função dos membros inferiores medida pelo GDI se correlaciona com o aumento da dor. Porém, as variáveis cinemáticas da marcha e a dor não tiveram correlação com tamanho da área transversal do canal vertebral / Back pain is a common complaint especially among older patients.The spinal stenosis term is based on the fact that a minimum space of the spinal canal is necessary for normal functioning of the nervous structures, and when this space becomes narrow, results in nerve compression symptoms such as pain, lower limbs numbness and weakness and neurogenic claudication, which increase with stress and decreases with rest. Objective: Evaluate kinematics changes of gait before and after physical effort in treadmill test, and correlate with the perception of pain and the lumbar stenosis degree obtained by nuclear magnetic resonance. Method: 14 subjects were evaluated with diagnostic of lumbar stenosis with a mean age of 74,5 (9,8) years and average size of the spinal canal was 43.86 (28.76) mm2. Were used for kinematic analysis Vicon ® MX 40 system and Nexus ® software for images three-dimensional reconstruction. The exam consisted of three phases: 1) Capture of six gait cycles after a rest period; 2) Walk on treadmill for a maximum of 20 minutes; 3) New capture of other 6 gait cycles immediately after the effort. From these data, temporal-spatial and angular variables were extracted and analyzed individually and compared to the pain perception obtained by visual analog scale at the beginning and the end of the exam and the cross-sectional area of the dural sac obtained from the nuclear magnetic resonance. Results: Most of the correlations were weak and the most significant results are reported to GDI when we observed decrease in medians for both lower limbs to moderate negative correlation when compared to pain perception after effort for both left (r = - 0.64, p= 0.014) and right limb (r= -0.53, p= 0.05), which means that there is a significant reduction in the global function of the lower limbs according the symptom of pain increases (p = 0.002). This fact may be reflected in decreased cadence and gait speed and also the times of single support (significant for the left limb, p= 0.019) and balance (significant for the right limb, p= 0.013) as a protection strategy against pain and imbalance. Conclusion: There is changing the speed, cadence and time of single and double support for compensation of pain and decreased function of the lower limbs measured by GDI correlates with increased pain. However, the kinematic variables of gait and pain did not correlate with the size of cross-sectional area of the spinal canal