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Extension – occurs when standing
Flexion – Occurs when sitting or bending forward
Anatomy of the SpineUnderstanding your spine: Helpful Terms
STENOSIS
• Narrowing of the spinal canal or neuroforamina
• causing a symptomatic compression of the neural element.
PATHOPHYSIOLOGY
• “Three-joint Complex”– a large tripod with the
disc as the front support and two facet joints as the back supports
– Any alteration in one of these joints can lead to damage to the others
• Vertebrae provide support for your head and body
• Discs act as “shock absorbers”• Vertebra protects spinal cord• Nerves have space and are not
pinched
• As we age, ligaments and bone can thicken
• Narrowing is called “stenosis”• Narrowing impinges on nerves in
spinal canal and nerve roots exiting to the legs
• Result - pain & numbness in back and legs
Nerve Root
Spinal Canal
Vertebra
“Trapped” Nerve Root
Bone (Facet Joint)
Ligament Flavum
Healthy Stenotic
Intervertebral Disc
PREVALENCE
• Most common indication for spinal surgery in patients over 60 y.o.
• 400,000 Americans are estimated to have spinal stenosis
PHYSICAL FINDINGSPhysical Finding Literature
Review
• Limited lumbar extension 66-100%• Muscle weakness 18-52%• Sensory deficit 32-58%
• Katz JN, et al: Diagnosis of lumbar spinal stenosis. Rheum. Dis. Clin. North Am. 20:471-483, 1994
NEUROGENIC CLAUDICATION
• Cardinal symptom of lumbar stenosis• Progressive pain and/or paresthesia in the
back, buttock, thigh and calves brought on by walking or standing, and relieved by sitting or lying down with hip flexion
DIFFERENTIAL DIAGNOSIS
• Vascular claudication• Osteoarthritis of hip or knee• Lumbar disc protrusion• Intraspinal tumor• Unrecognized neurologic disease• Peripheral neuropathy
REST
• Short term activity modification for acute pain
• Long term activity modification is not recommended
Lack of activity may lead to: • Obesity• General physical deterioration• Depression/other psychological problems• Worsening of co-morbidities
Treatment of Degenerative Lumbar Spinal Stenosis, Agency for Health and Quality 2004
Disease Burden of LSS
PHYSICAL THERAPY
• Avoid extension exercises acutely
• William Flexion Exercises
• Water aerobics• Strengthening of weak
muscle groups
EPIDURAL STEROID
• Commonly prescribed• 50% short-term efficacy• Not as selective• May not require
fluroscope
SPINAL INJECTION
• Most effective for acute pain• May not be indicated in cases of acute
denervation or progressive motor loss
DECOMPRESSION OF LATERAL RECESS
• Undercutting the ventral aspect of the facet joints and the associated ligamentum flavum.
• Medial facetectomy if necessary
• The traversing nerve root underneath the facet joint must be visualized
FUSION
• Sagittal instability• Scoliosis• Iatrogenic pars defect• Greater than 50%
facet joint resection