Spinal canal stenosis

Spinal canal stenosis

1. Spinal canal stenosis ASHISH KUMAR SHARMA BPT 4 TH YEAR NOIDA INTERNATIONAL UNIVERSITY

2. SPINAL CANAL The  spinal canal  is the cavity within the vertebral column which contains the spinal cord with its associated nerve roots and vessels. The spinal canal becomes progressively narrower from its superior opening at the foramen magnum to its inferior opening at the sacral hiatus. The spinal canal fills with cerebrospinal fluid .The canal originates at the base of the skull and ends the sacrum.

3. The spinal cord descends through the canal nerve root emerge from holes to each sides of the canal and at the end of the spinal cord nerves branch out forming a horse like tail. Boundaries an terior: vertebral bodies, intervertebral discs, posterior longitudinal ligament posterior: ligamentum flavum lining the laminae lateral: vertebral pedicles

4. STENOSIS Stenosis is a narrowing or constriction of the diameter of a body passage or orifice Example. Spinal canal stenosis Aortic stenosis Pyloric stenosis

5. SPINAL STENOSIS Spinal stenosis is a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine. Spinal stenosis occurs most often in the lower back and the neck. Some people with spinal stenosis may not have symptoms. Others may experience pain, tingling, numbness and muscle weakness. Symptoms can worsen over time.

6. CONTINUE Spinal stenosis is most commonly caused by wear-and-tear changes in the spine related to osteoarthritis.  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. Some people are born with a small spinal canal. This is called "congenital stenosis”.

7. TYPES OF SPINAL STENOSIS The two main types of spinal stenosis are: Cervical stenosis .  In this condition, the narrowing occurs in the part of the spine in your neck. Lumbar stenosis .  In this condition, the narrowing occurs in the part of the spine in your lower back. It's the most common form of spinal stenosis.

8. CAUSES Spinal stenosis has many causes. Bone overgrowth/arthritic spurs :  Osteoarthritis is the wear and tear condition that breaks down cartilage in your joints including your spine. Cartilage is the protective covering of joints. As cartilage wears away, the bones begin to rub against each other.

9. CONTINUE Herniated disks:- The soft cushions that act as shock absorbers between your vertebrae tend to dry out with age. Cracks in a disk's exterior may allow some of the soft inner material to escape and press on the spinal cord or nerves. Thickened ligaments:-  The tough cords that help hold the bones of your spine together can become stiff and thickened over time. These thickened ligaments can bulge into the spinal canal

10. CONTINUE Spinal fractures and injuries:  Broken or dislocated bones and inflammation from damage occurring near the spine can narrow the canal space and/or put pressure on spinal nerves. Spinal cord cysts or tumors :  Growths within the spinal cord or between the spinal cord and vertebrae can narrow the space and put pressure on the spinal cord and its nerves. ,,,

11. LUMBAR CANAL STENOSIS 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. Is a Cauda Equina compression in which the lateral or anteroposterior diameter of the spinal canal is narrow with or without change in cross sectional area. It is defined as Narrowing of spinal canal nerve root canal or vertebral foramina.

12. CLINICAL FEATURES Low back pain Pain Cramping in lower extremities Pain exacerbated by standing and walking. Pain got decreased during sitting and by forward flexion. Cauda equina claudication is most common Loss of bladder or bowel control (in severe cases).

13. DIAGNOSIS Red flag  symptoms must be assessed. Radiography:- is usually the first step to identify 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. MRI (Magnetic Resonance Imaging) :- is used for determining the degree of stenosis and the thickness of Ligamentum Flavum.  A lack of fat around the root indicates stenosis. 

14. DIAGNOSIS…. Ultrasound (US)  Myelography :- It uses a contrast dye and X-rays or computed tomography (CT) to look for problems in the spinal canal. Problems can develop in the spinal cord, nerve roots, and other tissues. This test is also called myelography. Bone scan (shows where bone is breaking down or being formed).

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16. SPECIAL 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. If the patient can pedal further in slumped position than in upright position, lumbar spinal stenosis is indicated.

17. Upright position with lumbar lordosis Slumped posture with decreased lumbar lordosis

18. Two-Stage Treadmill Test This test is evaluated on a treadmill. When the patient walks on the flat (0°) treadmill their back is in an extended position. The walking distance in a certain amount of time is recorded. The patient walks on the treadmill a second time with an uphill slope, which means they walk in a flexed position. The walking distance in the same amount of time is recorded again. If the patient walks further on an uphill slope than on the flat treadmill, lumbar spinal stenosis is indicated.

19. Upright posture with no incline Flexed posture with incline

20. The Trendelenburg test Is used to observe for hip abductor weakness. Difficulty with walking on the toes suggests S1 root involvement. Difficulty with heel walking suggests L4 or L5 nerve dysfunction.

21. CROSSED STRAIGHT LEG RAISE TEST This test for examination of the lower back. Patient should prone lying position. The test is positive when the pain occur with less then 60 degree of hip flexion.

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23. Medical Management Conservative treatment  is the first-line treatment for this condition. Conservative treatment options include physical therapy, oral anti-inflammatory medications, and epidural steroid injections.

24. Medications Steroid Injections :-Injecting a corticosteroid into the space around the compression can help reduce the inflammation and relieve some of the pressure. Non-steroidal Anti-Inflammatory Medications:-   such as ibuprofen (Advil, Motrin), naproxen (Aleve), aspirin – or acetaminophen (Tylenol) can help relieve inflammation and provide pain relief from spinal stenosis.

25. SURGICAL TREATMENT LEMINECTOMY : - The most common type of surgery for this condition, laminectomy involves removing the lamina, which is a portion of the vertebra. Some ligaments and bone spurs may also be removed Laminotomy :- This procedure removes only a portion of the lamina, typically carving a hole just big enough to relieve the pressure in a particular spot. Laminoplasty:-   This procedure is performed only on the vertebrae in the neck (cervical spine). It opens up the space within the spinal canal by creating a hinge on the lamina. Metal hardware bridges the gap in the opened section of the spine. . 

26. PT .MANAGEMENT Pain Management By Electrotherapy Ultrasound Tens Hot Packs IFT

27. CONTINUE Bed rest Flexion-based exercise programs  Lumbar isometric and stretching exercises Static and dynamic postural exercises  Individualized muscle strengthening Endurance exercises Cycling exercises 

28. Spinal Mobility and Lumbar Flexion Exercises 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

29. SINGLE KNEE TO CHEST STRETCH While lying on your back, use your hands and gently draw up a knee towards your chest. Keep your other knee straight and lying on the ground. Repeat 5 Times Hold 15 Seconds Complete 1 set Perform 2 Times a Day.

30. DOUBLE KNEE TO CHEST STRETCH While lying on your back, hold your knees and gently pull them up towards your chest. Repeat 5 Times Hold 15 Seconds Complete 1 Set Perform 2 Times a Day

31. PIRIFORMIS STRETCH While lying on your back and leg crossed on top of your opposite knee. Hold your knee with your opposite hand and bring your knee up and over across your midline towards your opposite shoulder for a stretch felt in the buttock. Repeat 5 Times Hold 15 Seconds Complete 1 Set Perform 2 Times a Day

32. Lumbar rotation stretch

33. Posterior Pelvic Tilt Exercise Lie on the floor (or on a mat on the floor) with your knees bent and your feet flat on the floor.  Allow your back to maintain a natural curve, leaving space between your low back and the mat. Inhale. As you exhale, engage your abdominal muscles, allowing that action to tilt your tailbone upward and close the space between your low back and the mat or floor. You'll feel a gentle stretch of your low back. Do 5 to 10 reps.

34. SUPINE ACTIVE HAMSTRING STRETCH Grasp behind knee and keep leg at arms length. Extend leg up until a gentle stretch is found behind your knee. The opposite knee can be bent or straight at your therapists discretion. With this do ankle pumps . Repeat 10 Times Hold 15 Seconds Complete 1 Set. Perform 2 Times a Day

35. SEATED LUMBAR FLEXION Sit upright in a chair. Slowly bend forward until you feel tension in your back. Repeat exercise 2 in a daytimes. Hold position for 5 to 10seconds. Option: Perform with rotation to painful side

36. Cervical Stenosis Cervical stenosis is a narrowing of the cervical spinal canal. This narrowing of the spinal canal may result in compression of the spinal cord and/or the nerve roots and affect the function of the spinal cord or the nerve, which may cause symptoms associated with  cervical radiculopathy or cervical myelopathy . 

37. CERVICAL STENOSIS NORMAL CERVICAL VERTEBRAE

38. Pathophysiology The spinal cord can be directly compressed by osteophytic bones and ligamentous hypertrophy. Compression of local vascular structures can lead to ischemia of the spinal cord. A herniated disk can exert repeated local trauma to the spinal cord or nerve root during repetitive flexion and extension movements . 

39. Clinical Presentation Cervical stenosis does not necessarily cause symptoms, but if symptoms are present they will mainly be caused by associated  cervical radiculopathy or cervical myelopathy. C4-5 disk herniation can lead to deltoid weakness and shoulder paresthesia. Patients also can experience pain and paresthesia in the head, neck, and shoulder. C6-7 disk herniation is the most common, leading to a wrist drop and paresthesia in the 2 and three fingers. C5-6 disk herniation is the next common, resulting in weakness in forearm flexion and paresthesia in the thumb and radial forearm. In severe cases, bowel or bladder dysfunction (urinary urgency and incontinence) Problems with walking and balance

40. ETIOLOGY Overgrowth of bone. Wear and tear damage from osteoarthritis on your spinal bones can prompt the formation of bone spurs, which can grow into the spinal canal. Herniated disks. Thickened ligaments. Tumors. Spinal injuries.

41. DIFFRENTIAL DIAGNOSIS Diabetes  Ankylosing spondylitis) Peripheral neuropathy (paralysis) Peripheral vascular disease Single level lumbar disc herniation Spinal cord tumor Vascular insufficiency (atherosclerosis of the aorta and/or leg arteries)

42. CONTINUE CT can help differentiate calcified disks or bone osteophytes from “soft disks,” differentiate ossification of the posterior longitudinal ligament from a thickened posterior longitudinal ligament and detect bone fractures . MRI is the gold standard; it is able to show intrinsic cord abnormalities, the degree of spinal stenosis, and differentiate other conditions such as tumors, hematoma, or infection.  If a patient has a pacemaker and cannot obtain an MRI, a CT myelogram can be performed to identify the level and degree of stenosis .

43. Medical Management Initial treatment can include both conservative and nonsurgical methods. These methods include physical therapy such as stretching, strengthening, and aerobic fitness to improve and stabilize muscles and posture; anti-inflammatory and analgesic medications; and epidural steroid injections. Surgery is for only those who fail repeated nonoperative treatments .

44. PT.MANAGEMENT Stretching exercises: These exercises are aimed at restoring the flexibility of the muscles of the neck, trunk, arms and legs. Manual therapy: Cervical and thoracic joint manipulation to improve or maintain the range of motion. Heat therapy: to improve blood circulation to the muscles and other soft tissues. Cardiovascular exercises for arms and legs: This will improve blood circulation and enhance the patient's cardiovascular endurance and promote good physical conditioning. Aquatic exercises: to allow your body to exercise without pressure on the spine. Training of activity of daily living (ADL) and functional movements.

45. CONTINUE Aquatic exercises: to allow your body to exercise without pressure on the spine. Training of activity of daily living (ADL) and functional movements. Proper lifting, pushing, and pulling.

46. CHIN TUCKS Begin in either a standing or seated position. Align your chin so that it’s parallel to the floor. Place 2 fingers on your chin. Tuck your chin in, and pull your head back (help with your fingers). Hold this retracted position for 5 to 10 seconds. Aim for 10 repetitions of this exercise.

47. Fwd Neck Stretch Begin sitting in an upright position, shoulders slightly back, head looking straight ahead. It might be easiest to begin doing this in front of a mirror. While keeping your face and mouth relaxed, slowly glide your head straight back, as if you are trying to make a “double chin. Make sure not to open your mouth with this movement. While holding this position, slowly look down towards your chest with your entire head (help with arm). Hold this position for 10 seconds, then repeat it 10 times. Remember to keep the “tucked” position the entire time.

48. Median Nerve Slider This exercise will help to relieve tension on the nerves coming out of the neck as they travel down your arm.  Be careful, if this exercise causes any pain, stop doing it . Gently bend the hand back toward the forearm,  then extend the thumb out to the side . Using the opposite hand, apply gentle pressure on the thumb to stretch it. For each change of position, hold for 3–7 seconds. Release and repeat the whole exercise on the other hand.

49. Doorway Stretch This is a good stretch to help open up the chest area and upper back, to improve your posture. Position your elbows and hands in line with a door frame. Step through the door slowly, until you feel a stretch. Hold this end position for 20 to 30 seconds before returning to the starting position. Repeat this stretch 2-3 times.