Spinal Stenosis and Radiculopathy: A Case Report Nicole … · Spinal Stenosis and Radiculopathy: A Case Report Nicole Miller, SDPT Graphics Concept A 2 68 Year Old Female with Spinal

12/30/2009

1

Spinal Stenosis and

Radiculopathy:

A Case Report

Nicole Miller, SDPT

Graphics Concept A

2

68 Year Old Female withSpinal Stenosis and Radiculopathy: A Case Report

Nicole Miller, SDPT

Graphics Concept B

12/30/2009

2

3

68 year old female withSpinal Stenosis & Radiculopathy:

A Case Report by

Nicole Miller, SDPT

Graphics Concept C

Spinal Stenosiswith Radiculopathy

Nicole Miller, SDPT

A case report:68 y/o female

Graphics Concept D – entire presentation

12/30/2009

3

5

Estelle Norton, PhDEstelle Norton, PhDEstelle Norton, PhDEstelle Norton, PhD

� History professor at CSU

� Single story ranch house

� Married 45 years

� Active lifestyle

- Walks

- Plays golf

6

Reasons for seeking PTReasons for seeking PTReasons for seeking PTReasons for seeking PT

� Recent fall, landing on tailbone

� Severe low back / leg pain since

� Pain walking and standing

� Unable to play golf

� Difficulty sleeping

12/30/2009

4

Current Ability to Participate � Unable to walk

more than 200ft

w/o severe pain

� Difficulty working

unable to teach

standing for entire

class

� Difficulty with

standing ADL’s

� Unable to golf

8

Patient HistoryPatient HistoryPatient HistoryPatient History

Comorbid

Degenerative joint disease

at L4, L5, S1

Moderately overweight

Premorbid

Intermittent back pain

since laminectomy (L5/S1)

20 years ago

12/30/2009

5

9

Disabilities and/or Disabilities and/or Disabilities and/or Disabilities and/or Functional LimitationsFunctional LimitationsFunctional LimitationsFunctional Limitations

Difficulty with:

� ADL’s that require standing

>20 min.

� Walking distances

� Sleeping

� Teaching (standing)

� Golf

10

ImpairmentsImpairmentsImpairmentsImpairments

� Severe low back pain

� Radiating pain into R LE,

impaired sensation, muscle strength, reflexes

� Decreased lumbar extension

� Joint stiffness at L1-L4,

+ mobility & symptom reproduction at L5

� Palpation on R paraspinals L3-S1,

increased tone and pain

12/30/2009

6

11

Spinal StenosisSpinal StenosisSpinal StenosisSpinal Stenosis

Primary• rare

• congenital spinal canal narrowing

Secondary• most common form

• adults in 5th-7th decades

• results from degenerative changes, infection, trauma or spinal surgeries

Atlas 2006, Sheehan 2001

12

Lumbar Spinal StenosisLumbar Spinal StenosisLumbar Spinal StenosisLumbar Spinal Stenosis


Lower back pain

Symptoms

12/30/2009

7

13



Walking & ADL’s limited due to severe pain

Symptoms

14



neurogenicclaudicationin one or both LEs

Symptoms

• increases with

walking/standing

• decreases with

sitting

• causes pain,

numbness and/or

weakness

12/30/2009

8

15

AnatomyAnatomyAnatomyAnatomy

Drake 2005, Haig 2002

16


� Zyga-pophysial joint

� Ligamenta flava

� Inter-vertebral discs

Drake 2005, Haig 2002

12/30/2009

9

17


Paraspinals

- iliocostalis

- longissimus

- multifidus

Haig 2002

18

PathologyPathologyPathologyPathology

� Central canal or

intervertebral foraminal

narrowing

� Causes:

- Intrinsic shape of the canal � congenitally short pedicles

� Degenerative process: � narrowing of vertebral spaces

� movement of one anatomic

segment on another

Atlas 2006, Sheehan 2001, Dutton 2004

12/30/2009

10

19

PathologyPathologyPathologyPathology

� Hypertrophy of tissues and joints

- Ligamenum flavum

- Facet joints (Zygapophysial joints)

� Intervertebral discs

� Paraspinal denervation

- Cause changes in spine biomechanics:

lumbar instability or impaired movement

Atlas 2006, Spivak 1998, Drake 2005,

Leinonen 2003, Haig 2002

20

RadiculopathyRadiculopathyRadiculopathyRadiculopathy

Symptoms

- lumbar spine: radiating pain into

buttocks and LEs

Etiology

- irritation of the nerve root

- caused by compression or

inflammation

- local ischemia of lumbar nerve

roots due to decreased blood flow

Atlas 2006, Sheehan 2001, Spivak 1998, Leinonen 2003

12/30/2009

11

21

HistologyHistologyHistologyHistology

Hypertrophy of the ligamentum flavumThickening and/or calcification of the ligamentum flavum centrally and at the insertion to the superior facet

Facet (zygapophysial joint) hypertrophyJoint can become inflamed & increase sizeFormation of osteophytes

Sheehan 2001, Spivak 1998, Drake 2005, Goodman 2003

22

HistologyHistologyHistologyHistology

Intervertebral discs

– Aging process: disc becomes desiccated as hydrated Type II collagen and proteoglycans are replaced with fibrous tissue, this causes collapse of disc which leads to herniation

Denervation of paraspinal muscles

– Impairment of neural imput, sensory and motor, to muscle tissue

Sheehan 2001, Drake 2005, Haig 2002

12/30/2009

12

23

Tissue Healing or Continued DeclineTissue Healing or Continued DeclineTissue Healing or Continued DeclineTissue Healing or Continued Decline

� Degenerative process

will continue

� Treatment interventions

and patient education

will help manage

symptoms and pain but

will not change

underlying pathological

process

Atlas 2006, Sheehan 2001,

Goodman 2003

24

Medical ManagementMedical ManagementMedical ManagementMedical Management

� Diagnosis w/ radiographs, CT, MRI

� NSAIDs and prescription pain meds

� Injections- corticosteroids, anesthetics or opioids

� Last resort: surgery- lumbar decompression/laminectomy/spinal fusion

Atlas 2006, Sheehan 2001, Spivak 1998, Simotas 2000, Simotas 2001, Lin 2005, Fritz 1997, Kim 1999, Bodack 2001

12/30/2009

13

Examination: Tests & MeasuresExamination: Tests & MeasuresExamination: Tests & MeasuresExamination: Tests & Measures

� AROM: Lumbar flexion, extension, sidebending and rotation

� Neurological exam: LE reflexes and sensation

� MMT: LE muscles and abdominals

� Joint mobility: Lumbar vertebrae

� Palpation of paraspinals

� Pain scales (0-10)

� Postural Assessment

� Special tests

- Straight leg raise, Thomas test, prone knee bend, SI test, slump test

26

Important Exam FindingsImportant Exam FindingsImportant Exam FindingsImportant Exam Findings

� Neurological exam

� Straight leg raise

� Thomas test

� Manual Muscle Testing

12/30/2009

14

27

Straight Leg Raise (SLR)Straight Leg Raise (SLR)Straight Leg Raise (SLR)Straight Leg Raise (SLR)

� For disc herniation and/or increased neural tension

� Reliability:

- substantial (kappa 0.6-0.8) interrater agreement (Vroomen, 2000)

� Validity, sensitivity and specificity

- patients with posterior pelvic pain form pregnancy (Mens, 2001)

active SLR a suitable diagnostic instrument

- Sensitivity: 0.87

- Specificity: 0.94

Additional Tests & MeasuresAdditional Tests & MeasuresAdditional Tests & MeasuresAdditional Tests & Measures

� Evaluation of hip and knee

� MMT of gluteus maximus

� Pain and functional limitation surveys

- baseline assessment

� Neurogenic claudication vs. vascular claudication

Sheehan 2001, Simotas 2001, Bodack 2001

12/30/2009

15

29

Connection:Connection:Connection:Connection:Disability / Functional Limitations Disability / Functional Limitations Disability / Functional Limitations Disability / Functional Limitations to Impairmentsto Impairmentsto Impairmentsto Impairments

� Unable to stand >20min

� Walking >200ft

� Limited at work

� Difficulty with ADLs

� Unable to sleep in preferred position

� Unable to play golf

Graphics Concept A

30

Connection:Connection:Connection:Connection:Disability &Functional Limitations of Impairments

Unable to stand

>20min

Walking >200ft

Limited at work

Difficulty with ADLs

Unable to sleep

comfortably

Unable to play golf

Graphics Concept B1

12/30/2009

16

31

Connection:Connection:Connection:Connection:Disability &Functional Limitations of Impairments

Unable to stand

>20min

Walking >200ft

Limited at work

Difficulty with ADLs

Unable to sleep

comfortably

Unable to play golf

Unable to stand

>20min

Graphics Concept B2

32

Connection: Connection: Connection: Connection: Pathology to ImpairmentsPathology to ImpairmentsPathology to ImpairmentsPathology to ImpairmentsLumbar Spinal Stenosis

Primary:

- severe low back pain when standing or

walking

- joint stiffness at L1-L4, joint mobility at L5

Secondary:

- decreased lumbar extension, R sidebending,

R rotation

- decrease in activities & general conditioning

12/30/2009

17

33

Connection:Connection:Connection:Connection:Pathology to ImpairmentsPathology to ImpairmentsPathology to ImpairmentsPathology to ImpairmentsRadiculopathy

Primary:

- radiating pain and paresthesias into R LE

- decreased sensation, muscle strength &

reflexes

Secondary:

- general deconditioning

- decreased lumbar ROM

34

Medical PrognosisMedical PrognosisMedical PrognosisMedical Prognosisis Pooris Pooris Pooris Poor

– Symptoms relieved with interventions such as

PT, injections and/or surgery

� Varies with age, comorbidities and activity

� Prognosis can be based on baseline functional

and pain measurement outcomes

� Condition is progressive with DJD

Atlas 2006, Sheehan 2001, Goodman 2003, Fritz 1997

12/30/2009

18

35

PT DiagnosisPT DiagnosisPT DiagnosisPT Diagnosis

Patient presents with a decreased ability to walk, perform ADLs and participate in

activities due to severe low back pain and radiating pain in the right lower extremity

consistent with spinal stenosis with radiculopathy at the levels of L4-S1

36

PT Practice Pattern 4FPT Practice Pattern 4FPT Practice Pattern 4FPT Practice Pattern 4F

APTA’s Guide to Physical Therapist Practice, 2nd Ed.

Impaired Joint Mobility, Motor Function,

Muscle Performance, Range of Motion,

and Reflex Integrity Associated

with Spinal Disorders

Range of visits: 8-24

over the course of 1-6 months

12/30/2009

19

37

PT PrognosisPT PrognosisPT PrognosisPT Prognosis

� Complete absence of pain

is not expected outcome- pain management is obtainable

� Walking tolerance should improve, if PT focuses on

improving patient’s lumbar extension range of motion

- mobilize upper lumbar and thoracic spine

- stretch hip flexors

Atlas 2006, Goodman 2003

38

PT InterventionsPT InterventionsPT InterventionsPT Interventions

� Patient Education

- improve posture and movement

patterns

� Pain Management

� Therapeutic exercises

- exercises with lumbar flexion or

unweighting

� Stretching / Strengthening exercises

- improve stability of trunk and hip

12/30/2009

20

39

ExercisesExercisesExercisesExercises

40

Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?

Documents

Spinal Stenosis and Radiculopathy: A Case Report Nicole … · Spinal Stenosis and Radiculopathy: A Case Report Nicole Miller, SDPT Graphics Concept A 2 68 Year Old Female with Spinal