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December 27, 1995, Vol 274, No. 24 >
ARTICLE | December 27, 1995

A 50-Year-Old Woman With Disabling Spinal Stenosis FREE

Steven R. Garfin, MD
[+] Author Affiliations

Dr Garfin is Professor of Orthopedic Surgery, University of California, San Diego.

This conference took place at the Orthopedic Grand Rounds of the Beth Israel Hospital, Boston, Mass, on July 26, 1995.

Reprint requests to Division of General Medicine and Primary Care, Beth Israel Hospital, 330 Brookline Ave, LY339, Boston, MA 02215 (Ms Walzer).


JAMA. 1995;274(24):1949-1954. doi:10.1001/jama.1995.03530240059042
Text Size: A A A
Published online
Article
References

Dr Delbanco:  Miss W is a 50-year-old woman who has a long history of low back pain. Divorced, she lives in an apartment by herself and works as a medical technician in a community-based doctor's office. She is insured through a large not-for-profit managed care organization.At 4 years of age, Miss W fell off a horse, but she did not have subsequent problems until 18 years of age when she experienced low back pain. Since then, she has had intermittent pain and multiple therapeutic recommendations from chiropractors, orthopedists, and a neurosurgeon in addition to her primary care doctor. At times, she has been on prolonged periods of bed rest and has had to miss work. Approximately 8 years ago, Miss W developed symptoms of fibromyalgia with generalized pain focused on her knees, bunions, elbows, wrists, shoulders, and pelvic region. She has been treated with multiple nonsteroidal anti-inflammatory agents (NSAIDs),

REFERENCES

1 +
Garfin SR, Herkowitz HN, Mirkovic S, Booth RE.  Nonoperative and operative treatment.  In: Rothman RH, Simeone FA, eds. The Spine . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1992;:857-875.
2 +
Johnsson KE, Rosen I, Uden A.  A natural course of lumbar spinal stenosis. Clin Orthop . 1992;;279:82-86.
3 +
Kirkaldy-Willis WH, Wedge JH, Yong-Hing K, O'Reilly J.  Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine . 1978;;3:319-328.
4 +
Garfin S, Rydevik B, Lind B, Massie J.  Spinal nerve root compression. Spine . 1995;;20:1810-1820.
5 +
Rydevik B, Brown M, Lundborg G.  Pathoanatomy and pathophysiology of nerve compression. Spine . 1984;;9:7-15.
6 +
Olmarker K, Rydevik B, Hansson T, et al.  Compression-induced changes of the nutritional supply to the porcine cauda equina. J Spinal Dis . 1990;;3:25-29.
7 +
Rydevik B, Holm S, Brown M, et al.  Diffusion from the cerebral spinal fluid as a nutritional pathway for spinal nerve roots. Acta Physiol Scand . 1990;; 138:247-248.
8 +
Garfin SR, Herkowitz HN.  Disc disease, does it exist?  In: Weinstein J, Wiesel S, eds. The Lumbar Spine . Philadelphia, Pa: WB Saunders Co; 1990;.
9 +
Schonstrom N, Bollender N, Spengler D.  The pathomorphology of spinal stenosis as seen on CT scans of the lumber spine. Spine . 1985;;10:806-811.
10 +
Cohen MS, Wall EJ, Brown A, Rydevik B, Garfin SR.  Cauda equina anatomy, II: extrathecal nerve roots and dorsal root ganglia. Spine . 1990;;15: 1248-1251.
11 +
Wall EJ, Cohen MS, Massie JB, Rydevik B, Garfin SR.  Cauda equina anatomy, I: intrathecal nerve root organization. Spine . 1990;;15:1244-1247.
12 +
Lipson S.  Clinical diagnosis of spinal stenosis. Semin Spine Surg . 1989;;1: 143-144.
13 +
Spengler DM.  Degenerative stenosis of the lumbar spine. J Bone Joint Surg Am . 1987;;69:305-309.
14 +
Deyo RA, Ciol MA, Cherkan DC, et al.  Lumbar spinal fusion: a cohort study of complications, re-operations, and research use in the medicare population. Spine . 1993;;18:1463-1470.
15 +
Yuan HA, Garfin SR, Dickman CA, Mardjetko SM.  A historical cohort study of pedicle screw fixation in thoracic, lumbar, sacral spine fusion. Spine . 1994;;19( (suppl) ):2279S-2296S.
16 +
Mardjetko SM, Connolly PJ, Shott S.  Degenerative lumbar spondylolisthesis: meta-analysis of literature 1970-1993. Spine . 1994;;19( (suppl) ):2256S-2265S.
17 +
Bennett RM.  Fibromyalgia and the facts: sense or non-sense. Controversies Clin Rheum . 1993;;19:45-59.
18 +
Block SR.  Fibromyalgia and the rheumatisms: common sense and sensibility. Controversies Clin Rheum . 1993;;19:61-77.
19 +
Deyo RA.  Fads in the treatment of low back pain. N Engl J Med . 1991;; 325:1039-1940.
20 +
Deyo RA, Diehl AK, Rosenthal M.  How many days of bed rest for acute low back pain? a randomized clinical trial. N Engl J Med . 1986;;315:1064-1070.
21 +
Frymoyer JW.  Back pain in sciatica. N Engl J Med . 1988;;318:291-300.
22 +
Mayer TG, Mooney V, Gatchel RJ. Contemporary Conservative Care for Painful Spinal Disorders . Philadelphia, Pa: Lea & Febiger; 1991;.
23 +
Max MB, Lynch SA, Muir J, Sholf SE, Smoller B, Dubner R.  Effects of desipramine, amitryptyline, and fluoxetine on pain and diabetic neuropathy. N Engl J Med . 1992;;326:1250-1256.
24 +
Spitzer WO, Leblanc FE, Dupuis M, et al.  Scientific approach to the assessment and management of activity related spinal disorders: a monograph on clinicians' report of the Quebec Task Force on Spinal Disorders. Spine . 1987;;12( (suppl) ):1-59.
25 +
Mayer TG.  Spine functional restoration.  In: Rothman RH, Simeone FA, eds. The Spine . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1992;:1929-1944.
26 +
Gregg R.  Chronic pain management and lumbar stenosis. Semin Spine Surg . 1994;;6:156-161.
27 +
Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH.  Spinal manipulation for low back pain. Ann Intern Med . 1992;;117:590-598.
28 +
Meade TW, Dyer S, Browne W, Townsend J, Frank AO.  Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. BMJ . 1990;;300:1431-1437.
29 +
Meade TW, Dyer S, Browne W, Frank AO.  Randomized comparision of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. BMJ . 1995;;311:349-351.
30 +
Hadler NM, Curtis P, Gillings DB, Stinnett S.  A benefit of spinal manipulation as adjunctive therapy for acute low back pain: a stratified controlled trial. Spine . 1987;;12:702-706.
31 +
Weinstein J.  Neurogenic and non-neurogenic pain and inflammatory mediators. Orthop Clin North Am . 1991;;22:235-247.
32 +
Weinstein JN.  Anatomy and neurophysiologic mechanisms of spinal pain.  In: Frymoyer JW, ed. The Adult Spine . New York, NY: Raven Press; 1991;: 29-46.
33 +
Korkala O, Grondblad M, Liesi P, Karaharju E.  Immunohistochemical demonstration of nociceptors in the ligamentous structures of the spine. Spine . 1985;;10:156-157.
34 +
Kantrowitz F, Robinson DR, McGuire MDB.  Corticosteroids inhibit prostaglandin production by rheumatoid synovia. Nature . 1975;;258:737-739.
35 +
Claman HN.  Corticosteroid and lymphoid cells. N Engl J Med . 1972;;287: 388-397.
36 +
Rinehart JJ, Balcerzak SP, Sagone AL, LoBuglio AF.  Effects of corticosteroids on human monocyte function. J Clin Invest . 1974;;56:1337-1343.
37 +
Schreiber AD, Parsons J, McDermott P, Cooper RA.  Effects of corticosteroids on the human monocyte IgG and complement receptors. J Clin Invest . 1975;;56:1189-1197.
38 +
Bogduk N, Christophidis N, Cherry D, et al. Epidural Steroids in the Management of Back Pain and Sciatica of Spinal Origin: Report of the Working Party on Epidural Use of Steroids in the Management of Back Pain . Canberra, Australia: National Health and Medical Research Council; 1993;.
39 +
Dilke TFW, Burry HC, Grahame R.  Extradural corticosteroid injection in the management of lumbar nerve root compression. BMJ . 1973;;2:635-637.
40 +
Cuckler JM, Bernini PA, Wiesel SW, Booth RE, Rothman RH, Pickens GT.  The use of epidural steroid in the treatment of radicular pain. J Bone Joint Surg Am . 1985;;67:63-66.
41 +
Rapp SE, Haselkorn JK, Elam K, Deyo RA, Ciol MA.  Epidural steroid injection in the treatment of low back pain: a meta-analysis. Anesthesiology . 1994;;81:923.
42 +
Kana SM, Wiesel SW.  Conservative therapy for spinal stenosis. Semin Spine Surg . 1994;;6:109-115.
43 +
Katz JN, Lipson SJ, Larson MG, et al.  The outcome of decompressive laminectomy for degenerative lumbar stenosis. J Bone Joint Surg Am . 1991;; 73:809-816.
44 +
Herkowitz HN, Kurz LT.  Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am . 1991;;73:802-808.
45 +
Johnsson KE, Johnell I, Udena A, et al.  Pre-operative and post-operative instability in lumbar spinal stenosis. Spine . 1989;;14:591-593.
46 +
Herron LD, Mangelsdorf C.  Lumbar spinal stenosis: results of surgical treatment. J Spinal Dis . 1991;;4:26-33.
47 +
Lehmann TR, Spratt KF, Tozzi JE, et al.  Long term follow-up of lower lumbar fusion patients. Spine . 1987;;12:97-104.
48 +
Van Horn JR, Bohnen LJ.  The development of discopathy in lumbar disc adjacent to a lumbar anterior interbody spondylosis: a retrospective match pair study with a post-operative follow-up of 16 years. Acta Orthop Belg . 1992;;58: 280-286.
49 +
Penta M, Sandhu A, Fraser RD.  Magnetic resonance imaging assessment of disc degeneration 10 years after anterior lumbar interbody fusion. Spine . 1995;;20:743-747.
50 +
Caputy A, Luessenhop A.  Long-term evaluation of decompressive surgery for degenerative lumbar stenosis. J Neurosurg . 1992;;77:669-676.
51 +
Sanderson PL, Wood PL.  Surgery for spinal stenosis in old people. J Bone Joint Surg Br . 1993;;75:393-397.
52 +
Silvers HR, Lewis PJ, Asch HL.  Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg . 1993;;78:695-701.
53 +
Tuite GF, Stern JD, Doran SE, et al.  Outcome after laminectomy for lumbar spinal stenosis, part 1: clinical correlations. J Neurosurg . 1994;;81:699-706.
54 +
Bigos SJ. Acute Low Back Pain in Adults . Rockville, Md: Agency for Health Care Policy and Research; December 1994;.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Garfin SR, Herkowitz HN, Mirkovic S, Booth RE.  Nonoperative and operative treatment.  In: Rothman RH, Simeone FA, eds. The Spine . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1992;:857-875.
2 +
Johnsson KE, Rosen I, Uden A.  A natural course of lumbar spinal stenosis. Clin Orthop . 1992;;279:82-86.
3 +
Kirkaldy-Willis WH, Wedge JH, Yong-Hing K, O'Reilly J.  Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine . 1978;;3:319-328.
4 +
Garfin S, Rydevik B, Lind B, Massie J.  Spinal nerve root compression. Spine . 1995;;20:1810-1820.
5 +
Rydevik B, Brown M, Lundborg G.  Pathoanatomy and pathophysiology of nerve compression. Spine . 1984;;9:7-15.
6 +
Olmarker K, Rydevik B, Hansson T, et al.  Compression-induced changes of the nutritional supply to the porcine cauda equina. J Spinal Dis . 1990;;3:25-29.
7 +
Rydevik B, Holm S, Brown M, et al.  Diffusion from the cerebral spinal fluid as a nutritional pathway for spinal nerve roots. Acta Physiol Scand . 1990;; 138:247-248.
8 +
Garfin SR, Herkowitz HN.  Disc disease, does it exist?  In: Weinstein J, Wiesel S, eds. The Lumbar Spine . Philadelphia, Pa: WB Saunders Co; 1990;.
9 +
Schonstrom N, Bollender N, Spengler D.  The pathomorphology of spinal stenosis as seen on CT scans of the lumber spine. Spine . 1985;;10:806-811.
10 +
Cohen MS, Wall EJ, Brown A, Rydevik B, Garfin SR.  Cauda equina anatomy, II: extrathecal nerve roots and dorsal root ganglia. Spine . 1990;;15: 1248-1251.
11 +
Wall EJ, Cohen MS, Massie JB, Rydevik B, Garfin SR.  Cauda equina anatomy, I: intrathecal nerve root organization. Spine . 1990;;15:1244-1247.
12 +
Lipson S.  Clinical diagnosis of spinal stenosis. Semin Spine Surg . 1989;;1: 143-144.
13 +
Spengler DM.  Degenerative stenosis of the lumbar spine. J Bone Joint Surg Am . 1987;;69:305-309.
14 +
Deyo RA, Ciol MA, Cherkan DC, et al.  Lumbar spinal fusion: a cohort study of complications, re-operations, and research use in the medicare population. Spine . 1993;;18:1463-1470.
15 +
Yuan HA, Garfin SR, Dickman CA, Mardjetko SM.  A historical cohort study of pedicle screw fixation in thoracic, lumbar, sacral spine fusion. Spine . 1994;;19( (suppl) ):2279S-2296S.
16 +
Mardjetko SM, Connolly PJ, Shott S.  Degenerative lumbar spondylolisthesis: meta-analysis of literature 1970-1993. Spine . 1994;;19( (suppl) ):2256S-2265S.
17 +
Bennett RM.  Fibromyalgia and the facts: sense or non-sense. Controversies Clin Rheum . 1993;;19:45-59.
18 +
Block SR.  Fibromyalgia and the rheumatisms: common sense and sensibility. Controversies Clin Rheum . 1993;;19:61-77.
19 +
Deyo RA.  Fads in the treatment of low back pain. N Engl J Med . 1991;; 325:1039-1940.
20 +
Deyo RA, Diehl AK, Rosenthal M.  How many days of bed rest for acute low back pain? a randomized clinical trial. N Engl J Med . 1986;;315:1064-1070.
21 +
Frymoyer JW.  Back pain in sciatica. N Engl J Med . 1988;;318:291-300.
22 +
Mayer TG, Mooney V, Gatchel RJ. Contemporary Conservative Care for Painful Spinal Disorders . Philadelphia, Pa: Lea & Febiger; 1991;.
23 +
Max MB, Lynch SA, Muir J, Sholf SE, Smoller B, Dubner R.  Effects of desipramine, amitryptyline, and fluoxetine on pain and diabetic neuropathy. N Engl J Med . 1992;;326:1250-1256.
24 +
Spitzer WO, Leblanc FE, Dupuis M, et al.  Scientific approach to the assessment and management of activity related spinal disorders: a monograph on clinicians' report of the Quebec Task Force on Spinal Disorders. Spine . 1987;;12( (suppl) ):1-59.
25 +
Mayer TG.  Spine functional restoration.  In: Rothman RH, Simeone FA, eds. The Spine . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1992;:1929-1944.
26 +
Gregg R.  Chronic pain management and lumbar stenosis. Semin Spine Surg . 1994;;6:156-161.
27 +
Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH.  Spinal manipulation for low back pain. Ann Intern Med . 1992;;117:590-598.
28 +
Meade TW, Dyer S, Browne W, Townsend J, Frank AO.  Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. BMJ . 1990;;300:1431-1437.
29 +
Meade TW, Dyer S, Browne W, Frank AO.  Randomized comparision of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. BMJ . 1995;;311:349-351.
30 +
Hadler NM, Curtis P, Gillings DB, Stinnett S.  A benefit of spinal manipulation as adjunctive therapy for acute low back pain: a stratified controlled trial. Spine . 1987;;12:702-706.
31 +
Weinstein J.  Neurogenic and non-neurogenic pain and inflammatory mediators. Orthop Clin North Am . 1991;;22:235-247.
32 +
Weinstein JN.  Anatomy and neurophysiologic mechanisms of spinal pain.  In: Frymoyer JW, ed. The Adult Spine . New York, NY: Raven Press; 1991;: 29-46.
33 +
Korkala O, Grondblad M, Liesi P, Karaharju E.  Immunohistochemical demonstration of nociceptors in the ligamentous structures of the spine. Spine . 1985;;10:156-157.
34 +
Kantrowitz F, Robinson DR, McGuire MDB.  Corticosteroids inhibit prostaglandin production by rheumatoid synovia. Nature . 1975;;258:737-739.
35 +
Claman HN.  Corticosteroid and lymphoid cells. N Engl J Med . 1972;;287: 388-397.
36 +
Rinehart JJ, Balcerzak SP, Sagone AL, LoBuglio AF.  Effects of corticosteroids on human monocyte function. J Clin Invest . 1974;;56:1337-1343.
37 +
Schreiber AD, Parsons J, McDermott P, Cooper RA.  Effects of corticosteroids on the human monocyte IgG and complement receptors. J Clin Invest . 1975;;56:1189-1197.
38 +
Bogduk N, Christophidis N, Cherry D, et al. Epidural Steroids in the Management of Back Pain and Sciatica of Spinal Origin: Report of the Working Party on Epidural Use of Steroids in the Management of Back Pain . Canberra, Australia: National Health and Medical Research Council; 1993;.
39 +
Dilke TFW, Burry HC, Grahame R.  Extradural corticosteroid injection in the management of lumbar nerve root compression. BMJ . 1973;;2:635-637.
40 +
Cuckler JM, Bernini PA, Wiesel SW, Booth RE, Rothman RH, Pickens GT.  The use of epidural steroid in the treatment of radicular pain. J Bone Joint Surg Am . 1985;;67:63-66.
41 +
Rapp SE, Haselkorn JK, Elam K, Deyo RA, Ciol MA.  Epidural steroid injection in the treatment of low back pain: a meta-analysis. Anesthesiology . 1994;;81:923.
42 +
Kana SM, Wiesel SW.  Conservative therapy for spinal stenosis. Semin Spine Surg . 1994;;6:109-115.
43 +
Katz JN, Lipson SJ, Larson MG, et al.  The outcome of decompressive laminectomy for degenerative lumbar stenosis. J Bone Joint Surg Am . 1991;; 73:809-816.
44 +
Herkowitz HN, Kurz LT.  Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am . 1991;;73:802-808.
45 +
Johnsson KE, Johnell I, Udena A, et al.  Pre-operative and post-operative instability in lumbar spinal stenosis. Spine . 1989;;14:591-593.
46 +
Herron LD, Mangelsdorf C.  Lumbar spinal stenosis: results of surgical treatment. J Spinal Dis . 1991;;4:26-33.
47 +
Lehmann TR, Spratt KF, Tozzi JE, et al.  Long term follow-up of lower lumbar fusion patients. Spine . 1987;;12:97-104.
48 +
Van Horn JR, Bohnen LJ.  The development of discopathy in lumbar disc adjacent to a lumbar anterior interbody spondylosis: a retrospective match pair study with a post-operative follow-up of 16 years. Acta Orthop Belg . 1992;;58: 280-286.
49 +
Penta M, Sandhu A, Fraser RD.  Magnetic resonance imaging assessment of disc degeneration 10 years after anterior lumbar interbody fusion. Spine . 1995;;20:743-747.
50 +
Caputy A, Luessenhop A.  Long-term evaluation of decompressive surgery for degenerative lumbar stenosis. J Neurosurg . 1992;;77:669-676.
51 +
Sanderson PL, Wood PL.  Surgery for spinal stenosis in old people. J Bone Joint Surg Br . 1993;;75:393-397.
52 +
Silvers HR, Lewis PJ, Asch HL.  Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg . 1993;;78:695-701.
53 +
Tuite GF, Stern JD, Doran SE, et al.  Outcome after laminectomy for lumbar spinal stenosis, part 1: clinical correlations. J Neurosurg . 1994;;81:699-706.
54 +
Bigos SJ. Acute Low Back Pain in Adults . Rockville, Md: Agency for Health Care Policy and Research; December 1994;.

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