LUMBER CANAL STENOSIS ppt (5)

PRESENTADED BY-
Debanjan Mondal.
MPT,BPT,CMT,ERGONOMIST

Lumbar canal stenosis is a cauda equina compression
in which the lateral or anteroposterior diameter of the spine canal is
narrow with or without change in cross-sectional area. It is defined as
Narrowing of spinal canal ,nerve root canal or vertebral foramina
Lumbar canal stenosis is common cause of back pain.

CLASSIFICATION OF SPINAL CANAL
STENOSIS-
 GENERALISED/LOCALISED
 SEGMENTAL
a) Central
b) Lateral
c) Foraminal
d) Farout
 ANATOMICAL
a) Cervical –seen
b) Thoracic –rare
c) Lumbar – most common

PATHOLOGICAL(ARNOLD’S 1976)
1) CONGENITAL STENOSIS- eq. Achondroplasia
2) ACQUIRED STENOSIS - 1) Degenerative
2) Combined congenital
and degenerative
3) Spondylolisthetic
4) Spondylitic
5) Post traumatic
 MISCELLANEOUS
- Paget disease
- Fluorosis
- Kyphosis
- Scoliosis
- Fracture spine
- Diffuse idiopathic skeletal hyperost-
-osis syndrome

 IATROGENIC CAUSES –
eq- Hypertrophy of posterior bone graft.
- Incomplete treatment of stenotic
condition.
CLINICAL FEATURE –
 Low Back pain.
 Pain, paraesthesia and cramping of lower
extremities .
 cauda equina claudication is common symptom.
 Pain exacerbated by standing and walking.
 Parasthesia, hypoesthesia and heaviness in lower limb.
 Pain radiates to buttocks and lower extremities.
 Pain releaved by forward flexion.
 Pain relieved by sitting or lying down and increase by
standing or walking.

CAUDA EQUINA CLAUDICATION ISCHAEMIC CLAUDICATION
-Pain in the buttocks and lower extrem - Pain in legs appears on walking
Ities after walking.
- Relieved by sitting forward for 20 min. - Appears and disappear fast
-Hypoaesthesia, parasthesia precipitate - No neurological deficit
by walking uphills and cycling
-Pulses are felt - Absent pulses
- No trophic changes - Trophic changes in foot and toes

INVESTIGATION –
Radiograph – Reduce interpedicle distance.
- Anteroposterior or transverse diameter of affected
vertebral absolute midsaggital diameter of canal is
decreased.
- Hypertrophy and sclerosis of the facet joint.
- Reduced interlaminar space and short, stout spinous
process.
- Normal diameter
Anteroposterior = 15mm
Transverse = 20mm
Myelographic finding- Narrowing of the dural sac at the level of
facet joints and indentation of the dural
tube due to disc prolapsed.

MRI and CT SCAN-
Helps to diagnose lateral recess stenosis,
facet hypertrophy, mid sagittal distance etc.
Lumbar canal
stenosis
Magnetic resonance imaging (MRI
scans in a 75-year-old man. minimal
degenerative changes at the L1-L2
level.

Note the stenosis at L4-
L5 (arrow). severe lumbar canal stenosis at the
L4-L5 level due to (1) disc
degeneration, (2) facet hypertrophy,
and (3) ligamentum flavum
hypertrophy.

Physical examination –
- Reduced spinal mobility.
- Extension is more usually limited than
flexion.
- Lumbar, paraspinal and gluteal tenderness.
- Hip, and knee slightly flexed and trunk
stooped forward.
- Hamstring tightness is often present.
- Neurologic examination typically normal
or reveals only such a mild weakness, sensory
changes and difficulty in walking.

Special test –
1) Stoop test-
 Ask patient to walk --- pain develop--- continue to walk---
---- patient assumes a stooped posture--- symptom disappear—
---- the pain decreases by forward bending because the canal
length increase by 2.2 mm.
2) Lumbar extension test –(Katz et al)
 Ask the standing patient to hyperextend the lumbar spine for
30 to 60 second. A positive test is reproduction of the
buttock or leg pain.

Different diagnosis –
 Back pain
 Malignancy
 infection
 Vascular claudication
 Peripheral neuropathy
 Hip disease

Treatment –
Conerservative-
 NSAIDS(non steroidal anti-inflammatory drug) and analgesics.
 Epidural injection
 lumbar corset should be used.
 Calcitonin has also be used in patient with intermittent claudication.
Physiotherapy treatment –
 Improve strength, endurance and tone of abdominal muscle.
 Back ergonomics avoiding extension attitude are taught.
 Lumbar corset should be used provide back support.
 Emphasis on flexion exercise and generalized flexion attitude
avoiding extension.

 Gentle passive manipulation technique.
 Lumbar traction to releave spasm.
 Walking on inclined treadmill. Harness supported treadmill ambulation.
 Strong isometric exercise for abdomen.
 Single Knee to chest exercise.
 Spinal flexion exercise.
 Hamstring stretching performed by extending the knee with hip flexed 90*.
 Hip flexor stretching is performed by maintains posterior pelvic tilt while in
a half kneeling posture.
 Mini squats for general lower extremity strengthing exercises.

Surgical treatment-
 Surgical treatment is indicated in patient with moderate or
marked compression of the nerve root or severe cauda equina
syndrome.
 The aim of surgery is to decompress the cord.
For central canal stenosis
 LAMINECTOMY - Decompression laminectomy is useful. It is mostly
done in central canal stenosis.
 DISCECTOMY - Discetomy and osteotomy of inferior articular
process helps to remove the hypertrophic element.

For lateral canal stenosis
 LAMINECTOMY
 DISC EXCISION
 PARTIAL MEDIAL FACETECTOMY
 FORAMINOTOMY
 Spinal fusion to stabilise the lumbar spine is usually not
required as instability is less commonly seen in lumbar canal
stenosis.
 The neurogenic claudication respond poorly to the conservative
treatment but respond well to surgical decompression.

A patient with constitutional stenosis at L3-L4
and L4-L5. Figure 5a – T1-weighted MRI showing
narrowing of the thecal sac at L3 to L5 and
constriction of the sac at L3-L4. The third and
fourth lumbar discs protrude posteriorly.

figure 5b – MRI showing
transverse narrowing of
the spina canal causing
compression of the
nervous structures
Figure 5c – AP radiograph after
bilateral laminectomy at the
stenotic levels.

CT of a patient with severe
degenerative stenosis at L4-L5 level.
The central portion of the spinal
canal and the nerve-root canals are
narrowed by degenerative changes
of both superior and inferior
articular processes
AP radiograph
after total laminectomy
and undercutting
facetectomy at L4-L5.

A patient with marked spinal canal
stenosis at L2-L3 and severe root-
canal stenosis at L3-L4 and L4-L5,
who had total laminectomy at L2-
L3 and laminotomy at L3-L4 on the
left and L4-L5 on the right. Figure
7a – Preoperative MRI.
Preoperative
myelogram
Postoperative
radiograph.

A patient with mild degenerative spondylolisthesis of L4 and nerve-root
canal stenosis at the L4-L5 levels in whom a bilateral laminotomy (c) was
carried out.

patient with degenerative spondylolisthesis
of L4 and L5 causing a complete
myelographic block at L4-L5 (a) who had
total laminectomy at L3 to L5
intertransverse process
fusion at L4-S1.

Total laminectomy and bilateral intertransverse
process fusion with internal fixation (compact
CD system) for degenerative spondylolisthesis
of L4 and spinal canal stenosis at L4-L5 level

Radiographs showing regrowth of the posterior
vertebral arch after central laminectomy at
L3 to L5 immediately after surgery

A patient who had a combined spinal canal stenosis at L1 to L5.
Preoperative MRI showed compression of the nervous structures at the
first four
lumbar levels (a and b), but compression at L1-L2 was considered
relatively mild. Bilateral laminotomy was performed at L2-L3 to L4-L5 (c).
One year after surgery radicular symptoms recurred.

A NON SURGICAL TREATMENT APPROACH FOR PATIENT
WITH LUMBAR STENOSIS
JULIE M FRITZ
RICHARD E ERHARD
MICHELLE VIGNOVIC

Case description-
The two patient selected for this case report had
pathology and clinical presentation consistent with a diagnosis of lumbar spinal
stenosis.
PATIENT 1 PATIENT 2
AGE 58 76
GENDER female male
HEIGHT 152 cm 190 cm
WEIGHT 55 99
MED./H/S 9 yr. after kidney transplant. Left knee osteoarthritis
2 yr. after left tibial plateau # Hypertension
Non-insulin dependent diabe-
-tes mellitus.
Hypertension.
MEDICA. Immunosuppressive medication Altace
prednisone, Tylenol, codeine

PAST H/S 10 ys. History of low back pain 25 ys. History of low back pain
and 6 month history of right and a 7 months history of left
leg pain exacerbated by walk anterior leg pain exacerbated by
-ing. Onset of the lower extr walking.
-emity symptom was gradual.
No spinal trauma was report No spinal trauma was reported
DIAGNOSTIC Right facet OA at L3-4, L4-5, Mild central stenosis at L2-3.
IMAGING L5-S1. Severe central stenosis at L3-4,
Degenerative disc disease at L4-5.
L3-4, L5-S1. Right lateral stenosis at L4-5.
Mild central stenosis at L2-3.
Moderate central stenosis at
L3-4, L4-5.
Central disk herniations at
L3-4, L5-S1.

Inter physical therapy evaluation-
 Visual analog pain scale (0-10)
 Modified oswestry low back pain questionnaire
(10 areas of daily living and expresses the degree of disability as a
percentage)
 The Roland-Morris disability questionnaire
(It contain 24 items selected from the 136 item sickness impact profile
and reports a score from 0 – 24, with a score of reflecting the greatest
limitation.)
 Physical examination
 Neurological examination (Lower extremity reflexes, sensation, and
manual muscle testing and assessment of SLR)

 Assessment of bony land mark
 Active spinal range of motion
Treadmill walking
(Patient ambulate on a level treadmill and a treadmill with a 15*
incline. The patient were asked ambulate to walk at a comfortable
pace without handrails. The walking time till until the symptom of
low back pain or lower extremity pain increased over the level
recorded before the test began, and the maximal walking time limited
by either fatigue or symptoms were recorded. Patient walk maximum
of 15 min.)
Outcome measure-
1) VAS
2) Modified oswestry low back pain questionnaire
3) Roland- Morris disability evaluation
4) Two stage treadmill test

Finding of initial physical therapy evaluation-
Patient 1- Had a leg length discrepancy, with a long right leg. Peripherali-
zation of symptoms with lumbar extension. Patient had a positive
findings on neurological assessment in the form of reflex, sensory,
and motor changes as well as positive SLR test. The result of the
two stage treadmill test showed a longer walking time on the incli-
ned treadmill, an earlier onset of symptoms on the level treadmill
and a longer recovery after level treadmill.
Patient 2 - Peripheralization of symptoms with lumbar extension. The
two stage treadmill test result as earlier onset of symptoms
and a longer recovery time with level treadmill ambulation
than with inclined treadmill ambulation.
Treatment plan-
Both patients received physical therapy for LSS over 6 week
period and a 4 weeks follow- up.

Patient 1-
- Seen eight visit. The treatmentment approach had two
compnent s; 1) an exercise program of and 2)a program of
harness supported treadmill.
- He received at a 1.27 cm(0.5-in) heel lift in the left shoe to correct
a leg length discrepancy of 1.27cm.
- Spinal flexion increases the spinal canal dimensions. Flexion exer
cise may help to decrease symptoms.
- Exercise – Spinal flexion exercise including posterior pelvic tilts,
quadruped spinal flexion, single- knee-to –chest
exercise, hamstring muscle stretching,mini squats for
general lower extremity strengthening, hip flexor
stretching. Lower extremity strengthening exercise focus
ing on gluteus medius muscle.
- Harness supported treadmill- Harness supported treadmill ambula
tion In which a vertical traction force can be applied to
reduce the compressive loading on the spine and allow
for pain free gait training. Sufficient traction was applied
to completely relieve the patient’s symptoms of low
back and lower extremity pain during ambulation.

Patient 2-
- Seen eleven visit. The treatment has approach had two
component ; 1) An exercise program and 2) A program
of harness- supported treadmill.
- Exercise - Quadruped spinal flexion, hamstring stretching,
mini squad for general lower-extremity strengthing
SLR in flexion,extension,abduction and adduction
and terminal knee extension exercise. Hip flexor
stretching.
- Harness supported treadmill-Harness supported treadmill
in which a vertical traction force can be applied
to reduce the compressive loading on the spine
and allow for pain free gait training. Sufficient tra-
ction was applied to completely relieve the patient’s
symptoms of low back and lower extremity pain
during ambulation. He was tolerated treadmill exer-
cise better than 1.

Treatment outcome-
As the completion of 6 weeks of treatment , the patient
impairments were reassessed and the self report measu-
re and the two stage treadmill test were repeated
Patient 1- Improvement in lumbar range of motion.
- Improvement in neurological status.
- Sensation as well as improved.
- Improvement in SLR test.
- Improvement in muscle force production particularly in
gluteus medius muscle.
Patient 2- Improvement in lumbar range of motion.
- Improvement in muscle force production particularly in
quadriceps femoris muscle.
Patient 1 & Patient 2 –Both patients were found improvement in self
report out come measure.
1) VAS
2) Modified oswestry low back pain questionnaire.
3) Roland- Morris disability evaluation.
4) Two stage treadmill test.

 Both patients were able to ambulate the full 15 minutes during the 6 weeks
reassessment.
 Both patients were instructed to continue their home exercise program daily
after discharge form physical therapy .
 Both patients perform at least 15 to 20 minutes of symptom free walking
daily ,If symptom occurred the patient were instructed to stop walking and
sit until the symptoms diminished.
 Both patients returned for follow-up assessment 4 weeks after discharge
form physical therapy.
 The self report measure and the two stage treadmill test were readministered
 The result indicate indicated that the improvements in limitations and disab-
ility noted at the conclusion of physical therapy were maintained over a 4
weeks period following discharge.
 Both patients reported doing their home exercise programs, and neither pat-
ient reported using any pain medication following discharge.

MEASURE PATIENT 1 PATIENT 2
initial eval. After 6 weeks 4 wk. fo. initial eval after 6 wk 4 wk.
VAS 6/10 1/10 1/10 5/10 0/10 0/10
Modified low
Back pain osw 48 16 12 53 0 0
Estry question
naire
Rolandmorris
Disability que 17 2 3 19 1 1
stionnaire

Measure inclined treadmill level treadmill
initial eval. after 6 wk. 4 wk. foll.up initial eva. After 6 wk. 4 wk. f
Walking 1.5 2.5 2.5 1.5 2.5 2.5
Speed(mph
Time to in
Crease in 2 no increase no increase 1 no increase no incr
Symptoms noted noted noted ease
(min.) noted
Max. walki
-ng time 5 15 15 5 15 15
(min.)
Symptoms Lt. anterior none noted none notedLt. Anterior none noted none
Of comple leg pain leg pain noted
Tion
Recovery 4 not not assess 5 not assess-not as-
Time(min.) assessed -ed -ed sesed

LUMBER CANAL STENOSIS ppt (5)

In this document