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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
Spinal Stenosis

Abnormal narrowing of the spinal canal, causing compression of the spinal cord and/or spinal nerve roots.

causes of stenosis
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
Classification

3 categories of spinal stenosis according to pathogenesis:

  • Central Canal Stenosis
  • Lateral Recess Stenosis
  • Foraminal Stenosis
central canal 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
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
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
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
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
Management
  • Conservative

Analgesics

NSAIDs

Weight loss

Physical therapy

  • Surgical

Decompression with or without fusion

osteopathic considerations
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
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.
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