Spinal Stenosis

Contents

What is Spinal Stenosis?

It is a narrowing of the spinal canal

Types

Lumbar spinal stenosis (LSS) is a narrowing of the spinal canal in the lower back. LSS can be divided in etiology ( primary and secondary stenosis) and anatomy (central, lateral and foraminal stenosis).

Primary stenosis is a cognital condition. Secondary stenosis can have several possible causes. In most of the cases it is a chronic degeneration or other causes can be rheumatoid arthritis , spine trauma, bone tumors, calcification of the Ligamentum Flavum[1]. Anatomic classification can be applied differentiating between  centrally (central stenosis), the nerve root canal (far lateral recess stenosis), or narrowing of the intervertebral (IV) foramen (foraminal stenosis). One single or combination of anatomic variation(s) can occur. [2]

Central stenosis can be caused by degeneration of the vertebral disc. This can lead to  narrowing of spinal canal arround the cauda equina. Lateral stenosis can be related to the lateral recess ( entrance zone and midzone ) [3] [4]or the foramina ( exit zone ). Foraminal stenosis is related to a narrowing of the spinal foramina [4]. It can be the result of a reduced height of the intervertebral space. Foraminal stenosis is also related with age-related degenerative disease of the lumbar discs and/or lumbar facet joints; this increases bone deposition (i.e. osteophytes) due to abnormal redistribution of load bearing in the lumbar spine.  Thickening of the joint capsule, osteoarthritis of the facet joints, and cyst formation can also narrow the spinal canal or IV foramen[5]

Entrance zone is located medial to the processus articulatio superior. The causes of stenosis in this area can be osteophytes, herniated nucleus pulposus, short pedicle and facet joint morfphology. The mid zone is located from the medial to lateral pedicle. The causes of stenosis in this area can be osteophytes. Exitzone is located around the foramina. The causes of stenosis in this area van be hypertrophy, luxation of the facet joint, osteophytes[4] 

Lateral and Foraminal Stenosis can lead to compression of the nerve roots leaving the spinal canal.[6] The L4-L5 are the most frequent affect with LSS, followed by L3-L4 , L5-S1 and L1-L2[1]. Spinal stenosis can cause compression of the nerve roots of blood vessels, wich can be related to the painful symptoms of lumbar spinal stenosis [7]

Cervical spinal stenosis is a narrowing of the spinal canal in the cervical region ( C1-C7). It compresses the nerve roots where they leave the spinal cord.[6] The symptoms of cervical spinosis are head-neck-shoulder pain caused by the degeneration of the disc and instability[8]. This form of spinal stenosis is more dangerous than Lumbal spinal stenosis. [6]

Clinical Presentation

• Patients usually >65 years old
• Symptoms in back and leg
• Pain with standing
• Pain with walking
• Neurogenic claudication (pain and/or parethesias, and/or cramping to one or both legs)

• Observable decreased lumbar lordosis

• Lengthened hip extensor muscles (gluteus maximus and hamstrings)
• No pain when sitting
• Pain worsens with lumbar extension

• Pain improves with lumbar flexion[5]


Physical Diagnostic Procedures

Bicycle Stress Test
• Patient pedals in an upright position preserving lumbar lordosis on an upright cycle ergometer. Distance pedaled is recorded.
• Patient than pedals in a slumped position (i.e. flexed position). Distance pedaled is recorded.
• Positive Test: If patient pedals further in slumped position compared to upright position, LSS is indicated.

Upright position                            

Upright posture with lumbar lordosis                                              Slumped posture with decreased lumbar lordosis


Two-Stage Treadmill Test
• Patient walks on treadmill with 0% grade (i.e. extended position). Distance walked is recorded.
• Patient then walks on treadmill with an uphill slope (i.e. flexed position). Distance walked is recorded.
• Positive Test: If patient walks further on an uphill slope, LSS is indicated[9].

                                                                 

Upright posture with no incline                                                                            Flexed posture with incline

Outcome Measures

  • Oswestry Disability Index
  • Fear-Avoidance Belief Questionnaire [7]
  • The Swiss Spinal Stenosis Questionnaire [7]
  • The Oxford spinal Stenosis Score [7]
  • Zurich Claudication Questionnaire [10]
  • The Maine-Seattle Back Questionnaire [10]

Management / Interventions

Need to individualize treatment plan based on patient presentation.

Manipulation to the spine

• Spinal Manipulation

Manipulation to pelvis and hip

Manual stretching
• Back and hip musculature

Muscle strengthening
• Gluteus medius: Hip abduction exercises
• Gluteus maximus: Functional squats, leg press, step-ups

Flexion exercises
• Single knee to chest
        Patient supine. Flex one knee to chest. Hold position for 30 seconds. Alternate legs.
        Progress to double knee to chest.
• Double knee to chest
        Patient supine. Flex both knees to chest. Hold position for 30 seconds.

Body weight supported treadmill ambulation

Address impairments in mobility, coordination, and strength.


  • Note:  Whitman et al. found that the combination of the interventions listed above had superior outcomes compared to a combination of flexion exercises, non-thermal ultrasound to the lumbar area, and regular treadmill walking in treating patients with spinal stenosis. There were improvements in disability, patient satisfaction, and in the Two-Stage Treadmill Test[9].

Resources

Recent Related Research (from Pubmed)

References

References will automatically be added here, see adding references tutorial.
  1. 1.0 1.1 Eberhard S, Harald P, Randolf K, Vieri F, Karl M. Einhäupl et al. Lumbar spinal stenosis: syndrome, diagnostics and treatment. Neurology 2009; 5:392-403.
  2. De Graaf I, Prak A, Bierma-Zeinstra S, Thoma S., Peul W., Koes B. Diagnosis of Lumbar Spinal Stenosis : A Systematic Review of the Accuracy of Diagnostic Tests. SPINE 2006; 31 (10) : 1168–1176.
  3. Sirvanci M., Bhatia M., Ganiyusufoglu K.A., Duran C., Tezer M., Ozturk C., et al. Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR Imaging. Eur Spine 2008; 1: 679–685.
  4. 4.0 4.1 4.2 Karantanas A.H., Zibis A.H., Papaliaga M., Georgiou E., Rousogiannis S. Dimensions of the lumbar spinal canal: variations and correlations with somatometric parameters using CT. Eur Radiol. 1998; 8 : 1581-1585.
  5. 5.0 5.1 Katz JN and Harris MB. Clinical Practice. Lumbar spinal stenosis. New England Journal of Medicine. 2008; 358(8): 818-825.
  6. 6.0 6.1 6.2 http://familydoctor.org/online/famdocen/home/common/brain/disorders/256.html
  7. 7.0 7.1 7.2 7.3 Pratt R. K., Fairbank J. C. T., Virr A. The Reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the Assessment of Patients With Lumbar Spinal Stenosis. SPINE 2002; 27(1): 84–91.
  8. University of Maryland – Medical Center http://www.umm.edu/spinecenter/education/cervical_spinal_stenosis.htm
  9. 9.0 9.1 Whitman JM, Flynn TW, Childs JD et al. A Comparison Between Two Physical Therapy Treatment Programs for Patients With Lumbar Spinal Stenosis. SPINE. 2006; 31(22): 2541-49.
  10. 10.0 10.1 Watters W.C., Baisden J., Gilbert T., Kreiner D. S., Resnick D., Bono C. et al.Clinical Guidelines. Degenerative Lumbar Spinal Stenosis. Burr Ridge (IL):NASS; 2007.
.
</div>

The Movement System

Learn about the movement system with Shirley Sarhmann & Mark Comerford in this month's members learn topic.

Become a member