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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


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

  • 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


Case Presentation


Case Presentation


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