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Objectives
• Outline subjective and objective findings used to identify
lumbar spinal stenosis
Physical Therapy Management of Lumbar
Spinal Stenosis
• Compare and contrast surgical vs conservative
management of lumbar spinal stenosis
• Create an evidence based physical therapy plan of care
for the management of lumbar spinal stenosis
Darren Calley, PT, DScPT, OCS
Adam Squires, PT, DPT
Anthony Thompson, PT, DPT
• Practice utilizing clinical reasoning to make decisions for
a patient case with lumbar spinal stenosis
March 25, 2017
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Common Beliefs About
Lumbar Spine Stenosis (LSS)
Background of LSS
LSS is “buttock or lower extremity pain that may occur with or
without low back pain and that is associated with diminished
space available for the neural and vascular elements in the
lumbar spine” (Zhang, 2014)
1. LSS requires surgery
2. Diagnosis is made from imaging
3. Prognosis is poor
Prevalence: affects more than 200,000 people in US (Lurie, BMJ
2016)
4. Disease will always be progressive
Most common reason for spinal surgery in those older than 65
• 47% of people aged 60-69 years have mild to moderate
stenosis
• Up to 19.7% have severe stenosis
5. Always avoid extension activities for LSS
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Where does LSS fit in low back pain
classification?
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Physical Therapy LBP Classification
(Delitto, JOSPT, 2012)
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Lumbar Treatment Based Classification
Pain Classifications
• Classification of patients with LBP into subgroups improves outcomes
Erhard, et al, 1994; Delitto et al, 1995; Fritz & George, 2000; Brennan et al, 2006; Fritz et al, 2003, 2007, Flynn
2002, Childs 2004
Classification
Manipulation
Stabilization
Specific exercise
Extension
Flexion
Lateral shift
Traction
1. Nociceptive
2. Neuropathic (radicular and peripheral sensitization)
Classification Criteria
3. Central Sensitization
No symptom distal to knee
Recent onset of symptoms (<16 d)
Low FABQ (<19)
Hypomobility of lumbar spine
Hip internal ROM >35
Where does the Lumbar Spinal Stenosis patient fit in?
Younger age (<40 yr)
Greater general flexibility
Aberrant movements during flexion or ext
+ prone instability test
Symptoms distal to buttock, Symptoms centralize w/extension, peripheralize w/flexion, directional
preference for extension
Older age >50, Directional preference for flexion, Image evidence of lumbar spinal stenosis
Frontal plane deviation, directional preference for lateral translation
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Signs & symptoms of nerve root compression
No movements centralize symptoms
SINSS Clinical Reasoning
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Risk Factors for Developing LSS
Severity (mild <-> high): degree of pain, impact on function
• Age >50
Irritability (mild <-> high): amount of activity to exacerbate the
symptoms, degree of exacerbation, time to subside
• Hyperlordotic curve in lumbar spine
Nature: specific PT diagnosis related to specific movement or
tissue dysfunction, pathological considerations.
• Spondylolithesis
Stage (acute <-> chronic): chronicity, recurrent, episodic
• Obesity
Stability (Stable <-> unstable): relationship/response to
aggravating factors, rate or progression of change in the
condition over time
• Female gender
• Scoliosis
• Smoking
• Physical strenuous work
• Low socioeconomic status
(Barakatt, J Man Manip Ther, 2009)
(Thome, DAI 2008)
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Comorbidities with LSS
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Differential Diagnosis of LSS
LSS often occurs with other conditions:
• Hip osteoarthritis
• Depression
• Myofascial pain
• Fibromyalgia
(Thome, DAI 2008)
(Fritz, Pain Med 2016)
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CPR for LSS
CPR for LSS
6 most important factors in diagnosis of LSS
1. Leg pain while walking
2. Flex forward while walking to relieve symptoms
3. Sit down or bend forward to relieve symptoms
4. Normal foot pulses
5. Relief with rest
6. Lower extremity weakness
(Sandella, PMR 2013)
(Backstrom,Man Ther 2011)
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Pathoanatomy of LSS
Pathoanatomy of LSS
Spinal changes
Disc degeneration of segment leads to disc
protrusion with ventral narrowing of canal
• Facet joint hypertrophy
• Loss of intervertebral
height
Reduced intervertebral disc height leads to
narrowing of lateral recess and intervertbral
foramen
• Disc bulging
Bone structures respond to subclinical
instability of segment with osseous changes
(facet hypertrophy, osteophytes, fibrotic
hypertrophy of ligamentum flavum)
• Osetophyte formation
• Hypertrophy of
ligamentum flavum
If stability is not created with osseous changes
instability may result in spondylolisthesis/
failure of the posterior ligamentous structures
• Scar tissue/ bony
proliferation (after
surgery/trauma)
(Katz, NEJM 2008)
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Patient Case
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Patient Case
• 61 year old male
Past medical history significant for:
• Moderate chronic obstructive pulmonary
disorder
• Diabetes Mellitus type 2
• Chronic kidney disease
• Hypertension
• One month of bilateral leg pain: lateral hips,
anterior and lateral thighs, and feet that was
getting progressively worse
• Worst when walking, especially uphill and on
stairs
• Less pain when walking slowly or leaning
forward (e.g. shopping cart)
• No pain at rest
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Patient Case
Patient Case
Imaging:
• Radiologist read as: “Small posterior disc
bulges L3-L4 through L5-S1 without
significant spinal canal narrowing. Prominent
epidural fat moderately effaces the thecal
sac at L5-S1. Moderate bilateral L3-L4 and
L4-L5 and mild left L5-S1 neural foraminal
narrowing. Slight retrolisthesis L3-L4 and
slight anterolisthesis L5-S1. Mild
degenerative facet changes.”
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Imaging Associated with LSS
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Imaging Associated with LSS
X-ray
• Lateral, flexion, extension images
• Rule out gross fractures, scoliosis, spondylolithesis
CT
• Best for looking at bony structures (facet joints)
• Used when MRI is contraindicated
• MRI
• Gold standard
• Allows for visualization of soft tissue (disc, ligaments) and
neural elements
• Good psychometrics for diagnosing LSS
• Sensitivity: 87-96%
• Specificity: 68-75%
Myelogram
• Visualizes bony detail and nerve-root compression
CT
X-ray
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How do I know if the pathoantomy seen
on my MRI is the source of my back pain?
Imaging Associated with LSS
Cardinal features of LSS on imaging-CT/MRI (Katz, NEJM 2008)
• Reduction in CSA of central canal
• Reduction in CSA of neural foramina
• Redundancy and hypertrophy of facet joints (often with
accompanying osteophytes)
• 21% of people with anatomic defined stenosis are
asymptomatic (Lurie, BMJ 2016)
• >20% of persons older than 60 yo have + imaging for
LSS with no functional symptoms (Katz, NEJM 2008)
• > 30% of asymptomatic subjects had canal narrowing
consistent with LSS (Weisel, SPINE 1984)
Imaging Parameters
• CSA values
• Normal: >120 mm2
• Mild stenosis: 100-120 mm2
• Moderate stenosis: 8-100 mm2
• Severe stenosis: <80 mm2
• AP diameter
• Severe stenosis: <10 mm
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Patient Case Update
Patient Case Update
Key exam findings:
• Pain at its worst: 8/10
• Patient Specific Functional Scale:
• Stairs: 2/10
• Walking uphill: 3/10
• Increased lumbar lordosis in standing
• Limited lumbar active range of motion
Key exam findings:
• Hypomobile to posterior-anterior and
rotational lumbar joint assessment
• Thomas test: positive bilaterally
• Bike test: positive
• Impaired core strength
• Hip abduction: 4/5 bilaterally
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LSS Clinical Findings
Patient SINSS
Subjective symptoms
Severity: Moderate
• Buttock/LE symptoms (with/without LBP)
Irritability: Moderate
• Most often proximal to knee joint
• Cramping/burning sensations
Nature: Neuropathic and Nociceptive
• Muscle weakness
• Reduced ability to stand/walk
Stage: Sub-acute
• Relief with sitting
Stability: Worsening
• Morning stiffness
• Positive shopping cart sign
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LSS Clinical Findings
LSS Clinical Findings
Supine
Standing
• Reduced hip range of motion
• Anterior pelvic tilt
• Normal skin texture/temperature
• Excessive lordosis
• Reduced symptoms with single/double knee to
chest
Gait
• Wide based ambulation
• Positive Thomas test
• Forward flexed posture
Prone
Sitting
• Tenderness to lumbar spine
• Reduced lordosis
• Paraspinal tension
• Forward head/shoulders
• Hyper-lordotic
• Reduced spinal mobility (lumbar and thoracic)
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Prognostic Factors for Developing
Chronic LBP
LSS Functional Examination
Treadmill test
• Symptoms below the knee
• 2-stage test (flat ground and incline 15 degrees)
• High pain intensity & disability
Bike test
• Patient rides upright until symptoms appear
• Elevated fear & catastrophizing
• Patient then rides in a flexed position
• Lower Self-efficacy
• If symptoms resolve = neurogenic
• Being non-employed
• If symptoms continue= vascular
• Passive coping style
• Distress/Depression
(Delitto, 2012, JOSPT; Grotle 2010, Pain; Turner 2008, Spine; Pincus 2008, Arth Rheum)
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Prognosis for LSS
PT Interventions
Prospective study with 8 year follow-up (Lurie, Spine 2015)
• 52% of non-operatively treated patients in
randomized cohort had undergone surgery 8
years
• Observational cohort of same study (nonrandomized but met inclusion criteria) resulted in
27% undergoing surgery after 8 years.
Interventions for LSS should include the following
• Therapeutic exercise
• Patient education
• Aerobic training
• Manual therapy
If conservative treatment fails after 3-6 months, surgery
may be needed (Kovacs, Spine 2011)
• Activity modification
Depression is a risk factor for less improvement in
quality of life following non-operative treatment (Lubelski J
• Modalities?
Neurosug Spine, 2015)
• Gait aids?
* Interventions should be based on the needs and comfort of the patient
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Spine Exercise Components
Acute LSS – What should I do?
Aerobic Exercise
• Remind tissues that it will be “OK”
• No more than 2 days relative rest
Directional
Preference
Strength
• Heat or ice as needed
• Go about your normal activities as
much as possible
Flexibility
• Walking is excellent
Neural Mobility
• Range of motion exercises – motion
is lotion
• Manual Therapy may be helpful
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Lumbar Extension – Good for LSS??
Lumbar Flexion – Good for Stenosis
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Flexibility Exercises
Lumbar Stabilization
Hip Flexors
Gluteals/Low Back
Thoracic Flexion
Thoracic Extension
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Manual Therapy Interventions
Bottom Line…
Movement > Specific Exercise
(Backstrom, Man Ther 2011)
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Education Interventions
•
•
•
Education Interventions
“Clinicians should not utilize patient education and
counseling strategies that either directly or indirectly
increase the perceived threat or fear associated
with low back pain…” (Delitto, JOSPT 2012)
Focus on positive prognosis, active recovery
strategies, and needing to improve function despite
pain
“Encourage patient to identify activities/situations
that increase symptoms and problem solve with
therapist to determine appropriate movement
strategies to reduce symptoms” (Backstrom, Man Ther 2011)
Topics to include in patient education
• Natural course of LSS
• Interventions that will be used
during therapy
• Purpose of home exercise program
• Self-management strategies
• Pain science information
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Patient Case
Patient Case
Interventions
• Manual Therapy
• Grade 3 and 4 anterior hip mobilizations
• Contract-relax stretching of hip flexors
• Grade 3 rotational lumbar mobilizations
• Home exercise program
• Hip mobility
• Core stabilizer strengthening
• Hip stabilizer strengthening
Outcomes
• Patient Specific Functional Scale
• Walking uphill: 8
• Stairs: 7
• Able to walk 3 miles without pain
• Rated pain as 1/10 at its worst
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Is surgery the most effective intervention
for LSS?
Medical approaches for low back pain
LSS is a prevalent condition among individuals over
age 60 and a condition for which there is debate about
best practice management including surgical and nonsurgical treatment recommendations.
1. Watchful waiting
2. Physical therapy
3. Drugs/injections
4. Surgery
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Conservative vs Surgical Interventions
Systematic review of non-operative treatment
Conservative vs Surgical Interventions
(Ammendolia,
Spine 2012)
• No high or mid level evidence to support
conservative treatment
• Very low level evidence that multimodal conservative
treatment is less effective than surgery
SPORT study
• Convergence of
pain, physical
function, and ODI
score in randomized
group
• Consistent
superiority of surgery
in observational
group
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Conservative vs Surgical Interventions
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Conservative vs Surgical Interventions
Matched pairs study (Herno, BJNeurosurg 1996)
• 54 pairs of surgical vs non-surgical patients
• Found no statistical difference in outcomes of
disability and functional status
Systematic Review (Kovacs, Spine 2011)
• Included studies with a total of 918 patients
• Found an advantage of surgery at 3 months to 4
years
• Differences lessened after this
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Conservative vs Surgical Interventions
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Conservative vs Surgical Management
Prospective study with 10 year follow-up (Amundsen, Spine 2000)
• 50% of conservative group achieved pain relief
• 80% of surgical group achieved pain relief
• No statistical difference in distance walked before
claudication symptoms between groups
Systematic Review comparing surgery and land based
treatment (Jarrett, BMC MSK Dis 2012)
• Exercise group improved 16-29% from baseline
• Surgical group improved 38-67% from baseline
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What to expect after LSS Surgery
Review of 64 surgical cohort studies. Pooled estimates
for individuals undergoing LSS surgery dropped in pain
from 63.4 to 33.1at 3 months and 19.2 at 5 years.
Disability dropped from 36.9 to 16.3 at 3 months and
12.4 at 5 years.
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Is There a Better LSS Surgery?
MILD Procedure for LSS
Systematic review of 12 studies of minimally invasive
vs open laminectomy for LSS showed improved
satisfaction (84% vs 75%) less blood loss, and shorter
hospital stay (2.1 days) for the minimally invasive
group.
Minimally Invasive Lumbar Decompression (MILD)
procedure is an image guided minimally invasive
procedure for treatment of degenerative central canal
LSS through percutaneous decompression of the
hypertrophic ligamentum flavum.
•
•
•
•
Outpatient procedure
Takes ~1 hour less expensive
1-2 spinal levels
Mixed efficacy
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LSS Decision
Making
Algorithm
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Take Home Messages
1. LSS is a clinical diagnosis corroborated by advanced
imaging.
Thank You
2. Degenerative findings and stenosis found on
imaging are common and may be non-specific.
3. In the absence of progressive neurologic symptoms,
management of LSS should begin conservatively.
4. Education, exercise, manual therapy should be
included with LSS conservative treatment.
5. Many adults with LSS can remain stable or improve
over time.
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References
References
• Ammendolia, C., Stuber, K., de Bruin, L. K., Furlan, A. D., Kennedy, C. A., Rampersaud,
Y. R., . . . Pennick, V. (2012). Nonoperative treatment of lumbar spinal stenosis with
neurogenic claudication: a systematic review. Spine (Phila Pa 1976), 37(10), E609-616.
doi:10.1097/BRS.0b013e318240d57d
• Lubelski, D., Thompson, N. R., Bansal, S., Mroz, T. E., Mazanec, D. J., Benzel, E. C., &
Khalaf, T. (2015). Depression as a predictor of worse quality of life outcomes following
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