Transcript 09. Osteopathic Management of Patients with Spinal Stenosis

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.
Case Presentation
Pt:
M, 53yrs
Presentation:
Axial low back pain & bilateral LEX pain, >3yrs. Unable
to walk more than 30-40yds before pain made him stop.
PMH:
Extensive physio, pain management, Gabapentin,
Pregabalin, Caudal epidural & bilateral L5 root block
(x2).
Diagnosis:
Degenerative L4/5 disc disease with foraminal stenosis.
Surgical plan: L4/5 decompression.
Osteopathic
Evaluation:
Restricted flexion left L5 & SIJ.
Restricted extension L1-4.
TTT given:
Articulation of Lsp & L/S junction.
Soft tissue stretching through hips and LEX.
Encouraged extension through Lsp.
Pre TTT ODI:
40%
Post TTT ODI:
8%
Able to walk >40 minutes and has returned to normal
activity levels.
Case Presentation
Pt:
F, 45yrs
Presentation:
Bilateral SI joint pain, with a history of axial
low back and leg pain.
PMH:
L4/5 decompression & microdiscectomy.
Assessment:
SI joint injections gave complete but very short
lived relief – diagnostic.
Osteopathic
Evaluation:
Restricted flexion & extension in the right SI
joint, left lower lumbar spine & right T/L
junction.
TTT given:
Articulation, soft tissue work and manipulation
to improve spinal mechanics.
Pre TTT ODI:
42%
Post TTT ODI: 16%
Case Presentation
Pt:
M, 42yrs
Presentation:
Chronic neck & low back pain (4-5yrs).
LBP radiating to right leg.
PMH:
Physio. Pain management (analgesia, Gabapentin).
Diagnosis:
Multi level disc degeneration in Csp & Lsp, with
foraminal stenosis at C6/7 & L4/5.
Osteopathic
Evaluation:
Flexion & extension restrictions at T9-SIJ & C1-T5
left.
TTT given:
Articulation of Csp, Tsp & Lsp. Mobilisation of hips
and stretching of LEX soft tissues.
Pre TTT ODI:
Pre TTT NDI:
60%
66%
Post TTT ODI:
Post TT NDI:
8%
11%
Patient resumed full employment.