SPINAL CANAL STENOSIS for physiotherapist.pptx

lumbar spine, Spinal canal stenosis, degenerative condition in the spinal canal,cause radiating pain and numbness to the buttock, thigh, or leg particularly during walking or standing ,anatomic and pathologic condition ,with spinal narrowing develop symptoms.
This is a best way for BPT students to understand the lumbar spinal canal stenosis and in it PT management of LSS describe in easy way .

1. LUMBAR SpinAL canal stenosis Dr. Nidhi Agarwal PHD,MPT ASSISTANT PROFESSOR DEPT. OF PHYSIOTHERAPY

2. Introduction Lumbar spinal stenosis (LSS) is a degenerative condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal. can cause radiating pain and numbness to the buttock, thigh, or leg particularly during walking or standing for a long time. The pain reduces usually when a patient is in resting, sits down, or bends forward. is related to aging, affecting mostly individuals over the age of 60 years. Not all patients with spinal narrowing develop symptoms, so the term "spinal stenosis" refers to the symptoms of pain and not to the narrowing itself and a diagnosis of spinal stenosis is only made once symptoms are present.

3. Lumbar spinal stenosis Lumbar spinal stenosis refers to an anatomic and pathologic condition that includes the narrowing of the lower spinal canal (central stenosis) or one or more lumbar vertebral foramina (foraminal/lateral stenosis).

4. Etilogy Some people are born with a small spinal canal. This is called "congenital stenosis”. However, spinal canal narrowing is most often due to age-related changes that take place over time. This condition is called "acquired spinal stenosis.“ Spinal stenosis is most common in people over 50 years of age. Acquired forms of LSS are further classified as degenerative,  spondylolisthetic , iatrogenic (postsurgical), posttraumatic, or combined.

5. Lumbar spinal stenosis can be caused by: Degenerative  spondylosis Degenerative  spondylolisthesis ankylosing spondylitis   Osteoarthritis Inflammatory spondyloarthritis Bulging of the disc Thickening of the vertebral ligament Tumour Infection Various metabolic bone disorders that cause bone growth, such as  Paget's disease

6. Clinical Presentation pain exacerbated by prolonged ambulation, standing, and with lumbar extension, and is relieved by forward flexion and rest  Neurogenic claudication  pain or discomfort that radiates to the buttock, thigh and lower leg after walking for a certain distance functional disability and decreased walking capacity. Shopping Cart sign Low back pain, numbness, and tingling 

7. SHOPING CART SIGN

8. Central stenosis: narrowing of the spinal canal - Lateral recess stenosis: narrowing of the lateral recess (area underneath the facet joints) - Foraminal stenosis: narrowing of the intervertebral foramen

9. Neurogenic claudication Neurogenic claudication refers to leg symptoms encompassing the buttock, groin and anterior thigh, as well as radiation down the posterior part of the leg to the feet. In addition to pain, leg symptoms can include fatigue, heaviness, weakness and/or paraesthesia . Patients with LSS also can report nocturnal leg cramps and neurogenic bladder symptoms. Symptoms can be unilateral or more commonly bilateral and symmetrical.

10. A key feature of neurogenic claudication is its relationship to the patient’s posture where lumbar extension increases and flexion decreases pain. Symptoms progressively worsen when standing or walking and are relieved by sitting.

11. Differential diagnosis Spinal cord primary or secondary tumour Peripheral neuropathy Osteoarthritis  of hips or knees Osteoporotic/ lumbar compression fracture Myofascial pain Rheumatoid arthritis Nonspecific low back pain Infection Radiculopathy

12. Lumbar  degenerative disk disease Lumbar facet arthropathy Lumbar spondylosis,  spondylolysis ,  spondylolisthesis  and  spondylodiscitis Mechanical low back pain Cauda equina syndrome  = red flag Peripheral vascular disease  (vascular claudication)

13. Diagnosis The therapist checks for pain or symptoms when the patient hyper-extends the spine (bends backwards), and checks for normal neurologic function (for instance, sensation, muscle strength, and  reflexes ) in the arms and legs. X-ray:- A degenerative process (disc degeneration, osteophytes, facet hypertrophy). It is also helpful in the evaluation of the alignment, loss of disc height and osteophyte formation.

14. MRI (Magnetic Resonance Imaging):- is used for determining the degree of stenosis and the thickness of Ligamentum Flavum. MRI is very sensitive to degeneration and is used for the evaluation of lateral recess stenosis. Sagittal T2-images focus on the foramen vertebrale and are used to diagnose central stenosis. A lack of fat around the root indicates foraminal stenosis. MRI (magnetic resonance imaging)  is the preferred method for visualizing soft tissues and nerve compression, while  CT (computed tomography) scans  show bony structures better. Electrodiagnostic tests:   Nerve conduction studies and electromyography (EMG) can help identify the location and extent of nerve damage Ultrasound (US)  Myelography

15. Examination Patients with stenosis often have lumbar, paraspinal, or gluteal tenderness, which is usually related to underlying degenerative changes, muscle spasms, and poor posture. The neurologic examination:- straight leg-raise test . Bicycle Stress Test :- During this test the patient first pedals on a cycle ergometer in upright position with preservation of neutral lumbar lordosis. The distance the patient has pedaled in a certain amount of time is recorded. The patient has to pedal a second time in a slumped position with lumbar delordosing . The distance the patient has pedaled in the same time is recorded again. Two-Stage Treadmill Test:-

16. The researchers have created a division in degrees on the basis of the occurrence of symptoms and their severity: - Grade 1 = patients who were able to walk symptom-free - Grade 2 = patients who were able to complete the test with some neurologic symptoms - Grade 3 = patients who were able to walk 5 – 15 minutes - Grade 4 = patients who were able to walk less than 5 minutes   The Trendelenburg test Romberg test ,  

17. Treatment Treatment options focus on managing symptoms and improving function, starting with non-surgical methods.  Non-Surgical: Medication :  Nonsteroidal anti-inflammatory drugs (NSAIDs) and other pain relievers can reduce pain and swelling. Physio Therapy:   Exercises to strengthen core muscles, improve flexibility and balance, and education on good posture and body mechanics. Corticosteroid Injections:   Injections into the epidural space around the nerves can provide short-term pain relief by reducing inflammation. Lifestyle Adjustments:  Maintaining a healthy weight and regular exercise can help manage symptoms .

18. Medical Management Treatment plans must be individualized based on each specific patient's presentation. Spinal stenosis rarely leads to progressive neurological injury. Therefor non-operative modalities should be attempted first. Medication:- Steroid Injections Non-steroidal Anti-Inflammatory Medications

19. Surgical Management laminotomy/laminoplasty. Laminectomy  Spinal Fusion Surgery may be an option if non-surgical treatments are ineffective and the pain significantly limits daily activities. Laminectomy:  The most common procedure, which involves removing the lamina (the back part of the vertebra), bone spurs, and thickened ligaments to create more space for the nerves. Spinal Fusion:  May be performed along with decompression if there is spinal instability.

20. Physiotherapy management

21. Bed rest Flexion-based exercise programs  -Lumbar flexion exercises are done to reduce the lumbar lordosis. This is the most comfortable position for the patient because the symptoms reduce in combination with a decrease of the epidural pressure in the lumbar spinal canal.  -Single and double leg knees to chest in supine position. This position should be held maintained for 30 seconds. In the single leg exercise the patient should alternate the legs. Double knee is a progressive exercise.  -This exercise program should have a stepwise logistic regression during the first 6 weeks.  -Treadmill walking is the final step in this program. Manual therapy Lumbar isometric and stretching exercises Static and dynamic postural exercises  Individualized muscle strengthening  In the over 70 age bracket a graded rehabilitation approach focusing on improving ambulation showed significant pain reduction. See the reference for comprehensive outline of rehabilitation exercises. Endurance exercises 

22. Stabilization of abdominal and back muscles to avoid excessive lumbar extension  Postural and ergonomic advice  Falls prevention intervention in seniors with LSS. Seniors with chronic low back pain have a significantly higher risk of falls Aerobic fitness  Cycling exercises Home exercises Education (Back school) and counselling  An aquatic walking and jogging program has a beneficial effect on muscle function tests, the BERG balance scale and the fall efficacy scale. The ankle range of motion also increased. This program still has to be investigated Corsets may help to maintain a posture of slight lumbar flexion to avoid atrophy of paraspinal muscles but it should be worn only for a limited number of hours per day. It also promotes back extension. A lumbar corset is significantly better than no corset for pain and walking capacities .

23. Single knee to chest Double knee to chest Lumbar rotation chest Thoracic extension self mobilisation Lower lumbar abdominal strengthening Hip abduction strengthening exercise

24. Iliopsoas self stretch Rectus femoris self stretch

25. MANUAL THERAPY Manual therapy is  a hands-on treatment method used by various healthcare professionals, including physical therapists, to treat musculoskeletal pain and disability It involves skilled hand movements to manipulate muscles and joints, with the goal of improving range of motion, increasing tissue extensibility, reducing pain, and improving overall function.  Techniques include soft tissue massage, joint mobilization (passive movement), and joint manipulation (a high-velocity, low-amplitude thrust)

26. Soft tissue techniques:   Manual actions like massage, muscle energy techniques, or myofascial release to work on muscles, tendons, and ligaments.  Joint mobilization:   Passive, slow-speed movement of a joint to restore normal motion and reduce pain.  Joint manipulation:   A faster, high-velocity, low-amplitude thrust applied to a joint, which may be accompanied by a "pop" or "click" sound.  Traction:   Applying manual force to distract a body part, such as the neck.  Common techniques

27. Joint Manipulation Traction Refrences from google

28. Refrences from google

29. BENEFITS OF MANNUAL THERAPY IN LSS Improves mobility:   Increases the range of motion in joints and the flexibility of soft tissues.   Reduces pain:   Modulates pain by influencing the nervous system and reducing inflammation.  Enhances function:   Improves muscle function and movement patterns.  Reduces swelling:   Helps decrease soft tissue swelling and restriction.  Provides psychological benefits:   The hands-on approach can also provide psychological benefits

30. A Neural Mobilization Treatment Strategy for Patients with Neurogenic Claudication Related to Degenerative Lumbar Spinal Stenosis (LSS): A Prospective Case Series https://l.facebook.com/l.php?u=https%3A%2F%2Fclinmedjournals.org%2Farticles%2Fijsem%2Finternational-journal-of-sports-and-exercise-medicine-ijsem-7-191.php%3Fjid%3Dijsem&h=AT2Ty95qnpdUUfXnSzsTlSBO5sUbIUSZHoqcCS2M01XvXVL-4_dWNQWNMsy24wdedSlaPmLLIeksoxwhEemp5LaXci909mQ8KcxjKKvtO5ptMPiy0JWUU53OUKnN84DNMNbWd4lhLuwG7SWI-4CRDQ3WZSm8AZio&__tn__=-UK-R&c[0]=AT02gytsx9T_QBQwxmq5Qp3TQT2W0CJGfIbU3xWTGbuStvvNDH7wFM4MYyMJR_FFaE0j9-2OqO39fN-jh4BGkS8OULEInZjESot8PuyaHIWa19YXDOlekek3uD_np9S0hBkstUPyIMNyAtM0aybW3ennfEatuGXgjf-guhl7mOgKl7AV1ALvx2FOlMk0X7o REFRENCE