164. Lumbar Spinal Stenosis

Join Kasey on the PT Snacks podcast as we delve into lumbar spinal stenosis, perfect for physical therapists and students eager to enhance their fundamentals. Understand the basics of stenosis, its impact on patients, and effective treatment approaches. Learn how to differentiate between types of stenosis, evaluate symptoms, and integrate conservative treatments with manual therapy and exercise for optimal patient outcomes. Stay informed on imaging techniques and when surgery might be necessary. Tune in for this bite-size segment and boost your practice skills!

00:00 Introduction to PT Snacks Podcast
00:48 Understanding Lumbar Spinal Stenosis
02:47 Symptoms and Causes of Lumbar Spinal Stenosis
07:57 Diagnosis and Imaging of Spinal Stenosis
10:45 Conservative Treatments for Spinal Stenosis
12:08 Surgical Options and Post-Op Care
12:49 Conclusion and Additional Resources

Transcript

0:31

Hey guys. Welcome to PT Snacks podcast. This is Kasey your host, and if you're tuning in for the very first time, first of all, welcome. But what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in bite-size segments of time. Now, today we're gonna talk about lumbar spinal stenosis, but before we do that, if you've listened to the show for at least three times and you feel like it's been really helpful, it would mean the world to me If you would just pause, leave a review, wherever you're listening, and then get right back to the show. So thank you also for those who've already done so, that really does make a difference to help reach other people and hopefully just help pour into their practice a little bit more. Now with that being said, let's cover what is spinal stenosis? What does it look like in our patients, and what do we do about it? Here's what stenosis is. Stenosis just means an abnormal narrowing of a passage in the body. So that's kind of broad, right? That's why I mean, specifically in this episode, we're covering lumbar spinal stenosis, which is where we're narrowing. We're talking about a narrowing of the spinal canal in the low back that can compress nerves and blood vessels, can causing back pain, leg pain, numbness, and limited walking tolerance. There's obviously different degrees to this, so. How much of stenosis someone has can affect how much of these symptoms are, it's not an all or none sort of thing. Oh, I have stenosis, I have all this leg pain, numbness, et cetera. However, we see a lot of times with these patients that. One. However, we know that this affects a lot of people and it is actually one of the top reasons for lumbar spine surgery is stenosis. So as physical therapists, we really need to have a good grip on what this is and how to evaluate to see if this is actually the case, because there's a poor correlation between imaging and clinical findings and then. What do we do for these patients? Do they need to go to surgery? Well, how do we know which ones go to surgery and what's, which don't? Or do they need to go to physical therapy? Well, what do we do in terms of exercise for these patients? A lot of times the goal is to reduce pain and improve walking and standard tolerance and increase function.'cause a lot of times they're having a lot of difficulty with extension based positions. So essentially, if we're talking about why lumbar spinal stenosis causes these symptoms in the first place, well for stenosis in the low back, the symptoms can happen from several problems happening at once. Causing pressure on the nerves and reduce blood flow to those nerves. Now if we're talking more so distinctly about nerve compression with age,'cause age is one of the most common risk factors for developing this. If we're talking about degenerative lumbar stenosis specifically. Several structures can thicken or enlarge. We can see dis bulges. We can see degeneration of the nucleus palis to where, that affects the disc height as itself. Uh, facet joints can become arthritic and overgrown. And the ligament and flavum, if you remember your anatomy, it's the ligament inside the canal can even thicken or ossify. So if we're visualizing the spinal cord, and I would definitely, this is a good one to know your anatomy for This can shrink the size of the spinal canal or the L, the nerve tunnels, foramina and add compression on the nose on those nerve roots. And the ka a equina, because remember the equina is ends around L one, L two in most people. So if there is compression, this can irritate the nerves, right? Most nerves like to have a little freedom of movement that can cause symptoms like burning, tingling, numbness, pens and needles in the buttocks and legs. Or it can cause motor signal, weak. It can impair motor signals cause heaviness or weakness in the legs. You might even see some ataxic gait wide base gait. And in severe cases, it can affect ballor bladder control as if the kata aquina is badly compressed. Um, this is a good indication that there is a lot of narrowing that's happening now because of the central canal. A lot of times the symptoms can be bilateral, whether in the buttocks or both legs, in a broad non DeRoma pattern. It doesn't always necessarily mean they always come on at the same time, though, it could switch between one side and the other. Right now, if it's more lateral or foraminal stenosis, the symptoms are gonna follow more of a specific nerve root, because if we're talking about a compression of a nerve root due to narrowing, we're talking about a radiculopathy, and that's gonna often be more one-sided. So see the difference between those central versus radi, central versus foraminal. Remember that the kata equina is made up of lower motor neuron symptoms. So something to keep in mind when you are assessing someone in your exam. Contrast that with neurogenic claudication, we can see the same narrowing also compress blood vessels around the nerves. And this can reduce arterial inflow and cause venous congestion so the nerves don't get enough oxygen during activity And. This is why with neurogenic claudication pain, numbness, burning, and fatigue in the legs and buttocks with walking or pulling, prolonged standing can happen and symptoms can worsen. The longer you stand or walk as the metabolic demand of the nerves rises. But blood flow is restricted. Symptoms typically improve with sitting or bending forward. So the common sign is the shopping cart sign. Because someone will use a shopping cart to lean forward and, and hold themselves up and still be able to walk forward because lumbar flexion slightly opens the canal and the foramina, which would ease the compression and vascular congestion. So in that scenario, we're talking about symptoms more so due from compression of the blood vessels that are around the nerves, not some, not just nerve compression from the narrowing itself. Now with someone in, they're walking into your clinic, they can have both leg and buttock symptoms and low back pain or both, or one or the other. So leg and buttock symptoms often can be from nerve root and vascular compromise. Genic claudication, radiculopathy, for example, low back pain can be from arthritic facet joints and degenerated discs. However, this is a gradual degenerative process, so symptoms tend to develop slowly and can fluctuate. Periods of time can be better or worse depending on. On the local environment of where those tissues are. Imaging severity and symptom severity do not always match very closely. So some people with a lot of narrowing on their imaging could have hardly any symptoms and vice versa. That's why imaging should always be combined with a clinical exam to make sure that things add up, because we know that imaging. Stenosis that's happening on imaging is very, very common. So the last thing that we want is to assume that someone's coming in with stenosis, not do a proper exam, and maybe their source of pain is from something else. But we didn't really line up our treatment very well from our exam'cause we did a poor exam. And then therefore that person maybe doesn't have successful physical therapy. That's lazy physical therapy. You need to confirm your diagnosis with something to the best of your abilities if it is in your power to do so. So definitely make sure that you're screening things out. Now as far as as how to identify it, there was a systematic review by De Shepherd at all where they essentially were able to find different clinical findings with. Sensitivity and specificity findings. So they found that with stenosis, right, it's worse with extension based positions. The most sensitive clinical finding they found is radiating leg pain. That's worse with standing. The next one they found was bilateral buttock or leg pain that resolves with sitting or bending forward and wide by skate is also sensitive and specific. A lower diagnostic value is a straight leg raise, which should make sense, which should make sense if you think about the position that you're putting a straight leg raise on in terms of imaging that's used. Usually it'll be an MRI as the gold standard, but they can use a CT with myography if an MRI is contraindicated for a similar diagnostic value, but downside is it's invasive and ionizing, so it also doesn't show intrinsic spinal pathology, so maybe not the best option. A plain CT is still good for viewing calcification and surgical planning if that's on the agenda. An X-ray is one of the only commonly used imaging that shows a patient axial loading. And the nice thing is you can see flexion extension to see if there's any dynamic instability. Um, but overall we know, again, poor correlation to imaging and clinical symptoms. Now, I will say in terms of conservative treatment and conservative, could be physical therapy, it could be modalities, it could be exercise, manual. A lot of research kind of clumps it all together. But essentially some of the more common interventions will be flexion based and trunks, trunk, hip strengthening, stretching, aerobic training, et cetera. Basically, the idea here is to put someone's body in an environment where we're not just irritating the tissue, whatever that tissue is, right? If it's nerve blood vessels around the nerve, et cetera. So that someone is actually having a positive reaction to the stress that we're applying to help build up their resiliency for what they need to be able to do. That's the idea here. That's why you need to understand what the process is that's going on as much as we know what's going on, right? So beyond that manual therapy. When combined with exercise, it can help to improve pain and disability. They've done a lot of body weight, supported treadmills, cycling, walking programs, All sorts of stuff. But essentially we know that exercise-based PT is better than no exercise and it can help improve pain and disability in the short term at least. Surgery can be very helpful, especially for those who have more severe stenosis and are symptomatic. So often they'll do some sort of surgical decompression. The people who do really well with surgery are people who have predominantly leg symptoms and not back. Non-smokers have nor normal BMI and people who don't have depression. The. Pt. Fun fact. There was a systematic review of RCTs in 2014. They found that active rehab six weeks to three months after surgery was more effective than standard care for long-term improvement in functional status, low back pain, and leg pain. So PT for the win there. The idea here, what you should have from this is what is stenosis? How do we differentiate between the different types of stenosis? What do we do about it? An extra bonus for you to think about is based on the patient in front of you. If you're trying PT first, let's say it's not an obvious do surgery first. At what point do you ask yourself, is physical therapy the right place for this patient? So something to think about now. That's it for today, guys. But if you have any questions, this obviously could be a lot more, but again, for the sake of this show, we're just, I want you to be able to be exposed and then do the follow-up work, do the research. This is just a launchpad, right? But. Again, if you have any questions, feel free to reach out at Pt Snacks podcast@gmail.com. I am, I have an Instagram now, PT Snacks, so you're always welcome to shoot me dms. We also have a newsletter and I'm gonna be sharing things that I am using to help me learn better'cause a lot of the strategies that we learned in PT school. We don't have time to implement in real life. We need to be able to be more concise with our time so we have time to do other things that are on our commitments. That are commitments, right? So feel free to follow along so that you can, if you wanna be a part of the journey, and just also get updates on what episode episodes are coming out. One note med Bridge is actually offering listeners over a hundred dollars off their year subscription, which basically gives you access to thousands of online CEU courses, webinars. They even have like an exercise program you can use with your patients. So if that's something that interests you, definitely use the promo Code PT Snacks podcast in the show notes below, or you can just use the link below and they will be able to help you get sorted from there. But beyond that, that's it. Hope you guys have a great rest of your day.