Degenerative Central Canal Stenosis

Question 1

Pathophysiology

Answer 1

affects central canal
typically degenerative - degradation of vertebral body into the central canal, causing the space to reduce
ageing spine
slow and long term process
symptom production mainly ischaemic - caused by reduced blood supply to the neural tissue
NEUROGENIC CLAUDICATION - onset of pain with activity/position due to reduced blood supply to the nerve
degree of narrowing doesn’t equal degree of pain

Question 2

Subjective History

Answer 2

60+
insidious and chronic onset
likely to have back pain also
Leg pain main problem
- bilateral symptoms
- asymmetrical - pain distribution differs between each leg
- describe pain/discomfort - not typical neuro descriptions
- pulling/tension pain
- unsteady/weakness
if have severe bowel/bladder symptoms - need to refer on
buttock pain common

Question 3

Aggravating/Easing

Answer 3

Aggravated by Extension

• sustained lumbar extension positions
• progressive onset of pain with extension activities
• walking and standing
• declining function over time

Eased by Flexion

• sitting
• leaning forwards
• adopt a flexed position during gait
• bike riding is fine
• standing is not relieving

Question 4

Physical Examination

Answer 4

Imaging very important - informs treatment 
patient likely to have adpative flatback posture - don't want to move them into extension 
wide based gait 
short stride 
slow gait 
poor balance 
active movements not interesting 
PAIVM and PPIVM not indicated 
poor control of extension load 
lack of hip extension ROM 
lack of thoracic extension ROM 
LL weakness 
NDT varies 
neural palpation difficult to determine - no good side to compare it to 
neural integrity varies 
more likely to have positive neural testing post activity 
post walking weakness

Question 5

Could it be PVD?

Answer 5

PVD pain is mainly in your calves
buttock pain uncommon 
no back pain 
no pain in standing 
standing relieves pain post walking 
bike pain brings on pain 
legs look less healthy 
pulse abnormalities

Question 6

Pyschological Function

Answer 6

pathology not as important as they might think
need to give good explanation of what is going on
point out their individual functional contributors
emphasise the importance of exercise
lots of pain free people have a stenosis
explain the treatment plan
will take time
likely lifelong exercise regime

Question 7

General Function

Answer 7

general fitness program - cycling

lifestyle issues - particularly smoking and obesity

Question 8

Tissue Sensitivity

Answer 8

surgery will be able to change the stenosis - if conservative management fails
medications
movement may influence ischaemia

Question 9

Local Function

Answer 9

UNLOAD THE NERVE 
Promote movement into central canal opening positions 
- be aware of any osteoporotic risks 
- movement into flexion 
- HEP 
- stretches
- manual therapy 
- consider if there is any unilateral bias to the presentation 

Control neural compression load 
- minimise central canal closing 
FIND IT - independent flexion 
CONTROL IT - control the extension load 
LOAD IT - age appropriate extension program

Question 10

Remote Function

Answer 10

Improve central canal closing away from the lumbar spine

• movement of the hip and thoracic spine into extension
• improve the capacity of the hip and thoracic muscles to work into extension

Improve remote neurodynamics

• unload tension remotely
• improve sliding remotely