Spine- Thoracolumbar VII- Stenosis thru Anomalies Flashcards
What is stenosis?
Narrowing around and compression of neurological structures
What is the MOST common diagnosis of for spinal surgery in adults??
Stenosis in adults over 60 years of age
What population is stenosis most common in?
- typically over 65 years of age
Why can younger people get stenosis?
Spondylolisthesis
What percentage of asymptomatic individuals have canal narrowing on imaging?
30%
Is compression from outside in unilateral or bilateral?
Unilateral> bilateral and central
What is compression from outside in due to?
- age-related disc and joint changes MOST commonly
- instability - older or younger individuals
- enfolding of ligamentum flavum (likely need sx)
What causes compression from inside out?
- sheath around nerve is fibrotic due to persistent inflammation
- increased blood supply to nerve with activity, particularly walking, causes nerve to enlarge
- Fibrotic nerve wont expand, compression results from inside out
Compression from inside out is the same result as __________ but a different mechanism
Narrowing
What structures are involved with ischemic compression and venous congestion?
- spinal nerve
- radicular arteries supply spinal nerve
What is the spinal nerve for segment L3,4?
L4
What is the spinal nerve for segment L4,5?
L4 and L5
What is the spinal nerve for L5,S1?
L5-S2
What are the symptoms of lateral stenosis?
- Unilateral LE > LBP with segmental paresthesias and gripping type pain due to ischemia
What decreased LE>LBP with stenosis?
FB/sitting/AM
What increases LE> LBP with stenosis?
Standing/walking and possibly coughing/sneezing if acute
Are symptoms worse with level walking or an incline with stanosis?
Level walking
What are signs we will find in our observation with lateral stenosis?
- slouched
- possible scoliosis
What will we find with ROM with lateral stenosis?
-Flexion/ Contralateral side bend decreased LE and LBP but may demonstrate limited motion due to NOT being able to open lateral foramen
- Extension/ipsilateral SB increased LE and LBP and may also demonstrate limited motion due to contact with spinal nerve
- rotation inconsistently produces symptoms
What will we find with neuro testing with lateral stenosis?
likely positive for radiculopathy
What will we find with stress tests with lateral stenosis?
Possible positive PA pressure/torsion when sustained
What will we find with accessory motion with lateral stenosis?
- hypomobility
Where will hypomobility in accessory motion testing be?
- in adjacent joints, lower thoracic, upper lumbar, and/or LE especially HIP
- In lumbar flexion and contralateral SB to open lateral foramen
What will be impaired with lateral stenosis? (muscle type)
impaired local muscle stabilization
What special tests can we do for lateral stenosis?
- stability tests
- LE discrepancies
- balance deficits
- Cooks CPR
What are we looking for with stability tests with lateral stenosis?
Possible excessive shearing
What type of LE discrepancies are we looking for with lateral stenosis?
- leg length discrepancy
- impaired mechanics
- etc.
What can we see with balance deficits with lateral stenosis?
- wide based gait
What are cooks CPR special tests?
- bilateral symptoms
- LE pain over LBP
- standing/walking pain
- pain relief with sitting
- over 48 years of age
Whats the criteria for cooks special test?
4/5 LR+ = 4.6
1/5 LR- = .19
Will compression or distraction be positive for lateral stenosis?
- compression positive
- distraction negative and possibly relieving
** only with sustained hold
Why does no lymphatic veins in PNS or CNS impact stenosis?
- body cant pull swelling off as efficiently, can lead to extended inflammatory phase
What can central stenosis possibly indicate?
- possibly spinal cord if above L1/2, if lower can be cauda equina, which is multiple spinal nerves, which leads to LMN S&S
Why can the hip especially be hypomobile with lateral stenosis?
if it doesnt extend, body will compensate with lumbar extension which can make lateral stenosis worse
How can we differentiate neural vs vascular cases of stenosis?
- Ankle brachial index test for possible peripheraial arterial disease (PAD)
- bicycle test
What does the ankle brachial index test?
- ratio of tibial and brachial arteries
- normal is .9-1.3
- .41-.9 is mild to moderate
- less than or equal to .4 is severe
What is the bicycle test? what does it look for?
- cycling upright in slight extension then bending to lean on handlebars for three minutes each
- if stenosis, pain with decrease with bent position, if it does not PAD is indicated
Why can a larger lateral spur be problematic with stenosis?
- one large lateral spur could affect multiple spinal nerves because they are positioned more vertical compared to cervical spine where it would take multiple levels of spurring
Why is there no change with SB or Rotation with central stenosis?
these movements dont change the size of the central foramen
What are the classic S&S of cauda equina syndrome?
- incontinence (bowel and bladder dysfunction, LMN S&S)
- Saddle paresthesias
What is the PT rx directed at?
Foraminal opening
What can we educate the patient about regarding stenosis?
- pt education of foramen and good prognosis
What else beside pt education can we do to direct foraminal opening for patients with stenosis?
- directional preference into flexion
- intermittent traction may be helpful with radiculopathy, esp if no centralization
- manual therapy
- neural mobilizations if gliding restrictions
What sub group is manipulation most effective for?
Stenosis with LBP
What areas can we do manual therapy / manipulation on with stenosis?
- lower thoracic
- lumbar manipulation MOST effective with exercise
- evidence of support for addition of hip joint manipulation
When is lumbar manipulation for stenosis MOST effective?
When combined with exercise
What kinds of MET can we do for stenosis to open the foramen?
Aerobic
* unweighted walking
* cycling as effective as un-weighted walking
* primary influence may be on circulation improvements
Balance training
local muscle stabilization
When can we start balance training with stenosis patients?
- ONLY as able to be upright without symptoms
- this position causes symptoms, start with seated balance training
Which is better? Corsets or no corsets for stabilization?
Corsets better than no corsets
Why can corsets be helpful for stenosis?
Increases vertical seperation, can create a small amount of space and relieve compression
What are surgery indications with stenosis?
- presence of constant and/or worsening symptoms
- failure to obtain relief with 3-6 months of non-surgical treatments
Is there a BEST surgery for stenosis?
inconclusive best surgery
Which surgeries are considered effective for stenosis?
Spinal decompression of laminectomy and/or partial discectomy with or without fusion
What is better with surgery for stenosis? Not better?
- Benefit with pain/disability but walking distance NOT better
Is the outcome different with surgery vs PT if just stenosis?
Outcome can be like comprehensive PT if just stenosis
What is the improvement with surgery for stenosis with spondylolythesis?
Substantially greater pain relief and improvement in function vs. PT at 4 years
What is spondylolysis?
Bony defect or fracture in pars interarticularis unilaterlly or bilaterally
What is the etiology of spondylolysis?
- excessive and repetitive extension, particularly when combined with rotation
- congenital (could be aymptomatic)
- direct trauma
What is the prevelance of spondylolysis?
- highest in adolescent athletes
- biological males over females
Why does spondylolysis affect adolescent athletes?
- as we grow vertically the bone density drops, takes time to fill in bone properly to meet demand
What are risk factors for spondylolysis?
- MOST common: athletics
- low vitamin D in ~75% of cases
- Genetics/ Bony morphology
- excessive lordosis (loads bone more)
What are the structures most commonly involved with spondylolysis?
MOST at L5, S1
- secondarily at L4,5
What are S&S of spondylolysis?
- like a worse case of instability S&S
- possible fracture S&S
- conditions leading to low vitamin D
What is spondylolisthesis?
Anterior vertebral segment slippage
How many types of spondylolisthesis?
5, 2 most common
What are the two most common types of spondylolisthesis?
- isthmic or adolescent with spondylolysis
- degenerative
What is the MOST common type of spondylolisthesis?
Isthmic or adolescent with spondylolysis
What causes adolescent spondylolisthesis?
- age group with MOST rapid slipping
- mechanism of action: repetitive or traumatic extension
What is degenerative spondylolisthesis due to?
- due to age-related disc changes and occurs after the 5th decade
- NO fracture
What are the degrees of slippage with spondyloisthesis?
- grade 1 = 0-25%
- grade II = 26-50%
- grade III = 51-75%
- grade IV = 76-100%
What are S&S of spondylolisthesis?
- like worse case of instability
- possible lateral or central stenosis S&S with slippage
- NO correlation with slippage and degree of symptoms
Can a grade I spondyloisthesis have more symptoms than a grade III?
YES
What is PT rx for spondylolysis and spondylolisthesis?
- like a worse case of hypermobility/instability
What is the MET outcomes with spondylolysis and spondylolisthesis?
better outcomes with 10 weeks of local muscle training vs traditional therex alone out to 1.5 years
What is the prognosis for spondylolysis and spondylolisthesis?
- healing greater in unilateral lesion vs bilateral lesion
> 84% of young adults improved after 1 year with up to 25% slippage
92% of adolescents returned to sport within 6 months
How can such a large percentage of young adults improve after 1 year?
- better with early intervention and unilateral lesion
- not dependent on lesion healing
Why does LBP return in around half of the cases of spondylolysis and spondylolisthesis?
- stress fracture doesnt heal, so improved symptoms get aggitated later on and comes back
When is surgery indicated with spondylolisthesis?
Confirmed imaging without conservative benefits
What are surgical outcomes for spondylolisthesis?
- 83% excellent to good outcomes with modified scott technique vs others (fusion)
What is there strong evidence of with acute IDD and extension?
short term benefit with LE symptoms and centralization occurs
What is the benefit of extension with persistent IDD?
- short term benefit
What is extension directional preference NOT superior to with persistent IDD?
- NOT superior vs stabilization exercises
- NOT superior vs combined manual therapy and non-stabilization exercise
- NO difference in pain and function vs no intervention at all
Just because a disc change is noted, is it causing the symptoms?
NO, not in up to 2/3 of cases
What can reduced circulation cause within the muscle?
- may cause up to 300 mm Hg of pressure within the muscle
What percentage of a muscle contraction with reduce circulation?
- a 30% max voluntary contraction of the muscle will reduce circulation
What percentage of a muscle contraction will nearly eliminate circulation?
A 70% MVC of the muscle
Why is proper posture and regular change of positions helpful for circulation?
Allows proper blood flow
What does a flexed and depressed posture do to the diaphragm?
Compresses diaphragm
- actively overworked and insufficient with persistent LBP
- thoracic extensors and accessory respiratory muscles overwork to compensate
What does a decreased anti-gravity reflex of muscles lead to?
Local muscle inhibition
What muscle is smaller in those with persistent neck pain?
Transversus abdominus
What happens to the load on the lumbar region with every anterior inch of FHP?
Load doubles
What is the PT rx for sitting FHP and msk issues?
- posture/ergonomic
- education: sit tall and be supported by chair
- Diaphragmatic breathing to minimize accessory respiratory muscles
- MT/MET in thoracolumbar regions to improve mobility
- MET to improve local muscle functions in thoracolumbar regions
What fusions are anomalies?
- Congenital and autolytic
What are the types of congenital fusions?
- lumbarization (6 lumbar vertebra, S1 doesnt fuse with sacrum)
- Sacralization ( 4 lumbar vertebra, L5 fuses with sacrum, 1 less vertebra)
What are the autolytic fusions due to?
- due to age-related joint disease
- spurring bridges and fuses joints
