Lumbar Spinal Stenosis

Lumbar Spinal Stenosis

Lumbar Spinal Stenosis pathology Spinal Stenosis is a narrowing of the spinal canal with encroachment on the neural structures by surrounding bone and soft tissue.[1,2]
Prevalence The prevalence of acquired, so-called “degenerative” lumbar stenosis has been suggested as ranging from 1.7 to 13.1%[7,8,11]
Pain location Lumbar spine, buttocks, legs[1,2]
Pain sensation / Symptoms Spinal Stenosis is a narrowing of the spinal canal with encroachment on the neural structures by surrounding bone and soft tissue. Patients typically present with radicular leg pain or with neurogenic claudication (pain in the buttocks or legs on walking or standing that resolves with sitting down or lumbar flexion). Spinal stenosis is the most common reason for lumbar spine surgery in adults over the age of 65 years.[1,2]

Indications for surgery appear to vary widely, and rates of procedures vary by at least a factor of 5 across geographic areas.[3,4]

Radiographic evidence of stenosis is frequently asymptomatic; thus, careful clinical correlation between symptoms and imaging is critical.[5,6]

Pathology Verbiest measured the mid-sagittal diameter of the lumbar canal at operation and proposed two major types of stenosis [10]: absolute stenosis, with diameter 10 mm or less; and relative stenosis with diameters ranging from 10 to 12 mm.

In a CT study, the same author suggested that midsagittal lumbar canal diameters less than 10 mm represent absolute stenosis and diameters less than 13 mm represent relative stenosis [12].

Ulrich and colleagues suggested that the antero-posterior diameter of the spinal canal (measured on axial plain CT) less than 11.5 mm is small [9].

In another CT study, Lee and colleagues [13] reported that the sagittal diameter of the lumbar spinal canal is never smaller than 10 mm in a normal spine.

Literature 1. Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ. Lumbar spinal fusion: a cohort study of complications, reoperations, and resource use in the Medicare population. Spine. 1993;18:1463–70.[PubMed]

2. Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine. 2005;30:1441–5. [PubMed]

3. Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992−2003. Spine. 2006;31:2707–14. [PMC free article] [PubMed]

4. Weinstein J, Birkmeyer J. The Dartmouth atlas of musculoskeletal health care. American Hospital Association Press; Chicago: 2000. [Atlas link .PDF]

5. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am.1990;72:403–8. [PubMed]

6. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331:69–73.[PubMed]

7. De Villiers PD, Booysen EL. Fibrous spinal stenosis. A report on 850 myelograms with a water-soluble contrast medium. Clin Orthop Relat Res. 1976:140-144. [PubMed]

8. Roberson GH, Llewellyn HJ, Taveras JM. The narrow lumbar spinal canal syndrome. Radiology.1973;107:89-97. [PubMed]

9. Ullrich CG, Binet EF, Sanecki MG, Kieffer SA. Quantitative assessment of the lumbar spinal canal by computed tomography. Radiology. 1980;134:137-143. [PubMed]

10. Verbiest H. Pathomorphologic aspects of developmental lumbar stenosis. Orthop Clin North Am.1975;6:177-196. [PubMed]

11. Fanuele JC, Birkmeyer NJ, Abdu WA, Tosteson TD, Weinstein JN. The impact of spinal problems on the health status of patients: have we underestimated the effect? Spine. 2000;25:1509-1514. [PubMed]

12. Verbiest H. The significance and principles of computerized axial tomography in idiopathic developmental stenosis of the bony lumbar vertebral canal. Spine. 1979;4:369-378. [PubMed]

13. Lee BC, Kazam E, Newman AD. Computed tomography of the spine and spinal cord. Radiology.1978;128:95–102. [PubMed]

 

Diagnosis Physical Examination findings Tests / Cluster Treatment plan
Lumbar stenosis Provocation in extension Gait analysis Start training lumbar spine towards flexion
  Reduction in flexion

 

Strength testing

 

Optimize hip extension

 

  Neurological signs

below the knee (3D)

Sensibility testing

 

Optimize posture to reduce lumbar lordosis
  Claudicatio IM

 

Reflex testing

 

Be alerted for thoracic spine compensation strategy’s
  Test of Naffzinger Training local stabilizers
  Test of Kemp

 

Examples of mobilizations:

Start training lumbar spine towards flexion (do the stretching exercises in the beginning of the video)

Optimize hip extension: iliopsoas stretching technique

Posted in Uncategorized