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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 5 th 8 th 2013 nottingham conference centre united kingdom www nspine co uk

September 5th – 8th 2013

Nottingham Conference Centre, United Kingdom

www.nspine.co.uk


Osteopathic management of patients with spinal stenosis

Osteopathic Management of Patients with Spinal Stenosis


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.


Case presentation

Case Presentation


Case presentation1

Case Presentation


Case presentation2

Case Presentation


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