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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk. Osteopathic Management of Patients with Spinal Stenosis. Spinal Stenosis. Abnormal narrowing of the spinal canal, causing compression of the spinal cord and/or spinal nerve roots. Causes of Stenosis.
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September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk
Spinal Stenosis Abnormal narrowing of the spinal canal, causing compression of the spinal cord and/or spinal nerve roots.
Causes of Stenosis • Aging factors that may cause spaces in the spine to narrow: • Ligaments (ligamentum flavum) can thicken • Bony spurs • Intervertebral discs – bulge or herniate • Facet joints break down • Compression fractures – common in osteoporosis • Cysts on facet joints • Arthritis • Hereditary • Instability, e.g. Spondylolisthesis • Trauma
Classification 3 categories of spinal stenosis according to pathogenesis: • Central Canal Stenosis • Lateral Recess Stenosis • Foraminal Stenosis
Central Canal Stenosis • Mainly caused by: • hypertrophy of ligamentum flavum • facet joint osteophyte formation • degenerative spondylolisthesis • May lead to compression of cauda equina.
Lateral Recess Stenosis • Compression between medial aspect of a hypertrophic superior articular facet & posterior aspect of the vertebral body and disc. • Hypertrophy of ligamentum flavum &/or facet joint capsule, osteophyte or disc protrusion can exacerbate stenosis. • The traversing nerve root is compressed in the lateral recess (e.g. L5 nerve root in the L5/S1 lateral recess).
Foraminal Stenosis • Rare. • Mainly occurs in isthmic spondylolisthesis, where exiting nerve root is compressed in the distorted foramen (e.g. L5 nerve root in the L5/S1 lateral recess). • Also occurs in far lateral disc herniation where the exiting nerve root is compressed in the foramen.
Clinical Features • Symptoms are insidious, generally presenting in the over 50’s. • May be a long history of low back pain, but leg symptoms lead to presentation. • Central canal stenosis - Bilateral leg symptoms which are vague & often described as heaviness, soreness or weakness. - Claudication – presents as numbness, weakness or discomfort in legs: may come on with walking or prolonged standing & is relieved by sitting or rest. Patients can walk further if leaning on a shopping trolley or uphill. - CES if severe. • Lateral recess stenosis Unilateral radicular symptoms of leg pain with numbness, paraesthesia or burning in a dermatomal distribution.
Natural History • Course of spinal stenosis is chronic and benign. • *Johnsson, Rosen & Uden followed up on 32 stenosis patients after a mean 49 months without any treatment. Of the 32 patients, 15% improved, 70% stayed the same, & only 15% became worse. *Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop. 1992; 279: 82-86.
Management • Conservative Analgesics NSAIDs Weight loss Physical therapy • Surgical Decompression with or without fusion
Osteopathic Considerations • Patients that osteopathy can help are the ones that have no frank impingement of the spinal cord or nerves. • Often unilateral foraminal encroachment is from long standing postural adaptations. • Patients tend to present with reduced Lsp lordosis & a fixed flexed postural deformity - feel better when leaning forwards. ↓ Self-perpetuating cycle: adapted posture causes pain, then they flex to relieve the pain which causes worsening of the contractures. • Shortened gait – shortened gluteii, etc.
Treatment Strategy • Introduce extension through Lsp, T/L & hips – release off the psoas, hip flexors and anterior muscle groups to relieve the pressure on the back. Use long levers. • Work with soft tissue and rotational component of the spine to reduce the stress on spinal mechanics. • Address segmental restrictions – often see many consecutive change over points: 1 flexed restricted segment, then 1 extended restricted segment, etc – often in Tsp. • Improve global flexion and extension through Tsp/Lsp/Sacrum. • Fine to HVT as long as there is no frank impingement. • Tissues will revert to flexed/shortened state, therefore imperative to establish a good exercise regime to maintain lengthened muscles.
