Spinal Stenosis and Radiculopathy: A Case Report. Nicole Miller, SDPT. 68 Year Old Female with. A Case Report. Nicole Miller, SDPT 12/30/2009

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1 Spinal Stenosis and Radiculopathy: A Case Report Nicole Miller, SDPT Graphics Concept A 68 Year Old Female with Spinal Stenosis and Radiculopathy: A Case Report Nicole Miller, SDPT 2 Graphics Concept B 1

2 68 year old female with Spinal Stenosis & Radiculopathy: A Case Report by Nicole Miller, SDPT 3 Graphics Concept C Spinal Stenosis with Radiculopathy A case report: 68 y/o female Nicole Miller, SDPT Graphics Concept D entire presentation 2

3 Estelle Norton, PhD History professor at CSU Single story ranch house Married 45 years Active lifestyle - Walks - Plays golf 5 Reasons for seeking PT Recent fall, landing on tailbone Severe low back / leg pain since Pain walking and standing Unable to play golf Difficulty sleeping 6 3

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 Patient History Comorbid Degenerative joint disease at L4, L5, S1 Moderately overweight Premorbid Intermittent back pain since laminectomy (L5/S1) 20 years ago 8 4

5 Disabilities and/or Functional Limitations Difficulty with: ADL s that require standing >20 min. Walking distances Sleeping Teaching (standing) Golf 9 Impairments 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 10 5

6 Spinal Stenosis Primary rare congenital spinal canal narrowing Secondary most common form adults in 5 th -7 th decades results from degenerative changes, infection, trauma or spinal surgeries 11 Atlas 2006, Sheehan 2001 Lumbar Spinal Stenosis Symptoms Lower back pain 12 Atlas 2006, Sheehan

7 Lumbar Spinal Stenosis Symptoms Walking & ADL s limited due to severe pain 13 Atlas 2006, Sheehan 2001 Lumbar Spinal Stenosis Symptoms neurogenic claudication in one or both LEs increases with walking/standing decreases with sitting causes pain, numbness and/or weakness 14 Atlas 2006, Sheehan

8 Anatomy 15 Drake 2005, Haig 2002 Anatomy Zyga-pophysial joint Ligamenta flava Inter-vertebral discs 16 Drake 2005, Haig

9 Anatomy Paraspinals - iliocostalis - longissimus - multifidus 17 Haig 2002 Pathology 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 18 Atlas 2006, Sheehan 2001, Dutton

10 Pathology 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 19 Atlas 2006, Spivak 1998, Drake 2005, Leinonen 2003, Haig 2002 Radiculopathy 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 20 Atlas 2006, Sheehan 2001, Spivak 1998, Leinonen

11 Histology Facet (zygapophysial joint) hypertrophy Joint can become inflamed & increase size Formation of osteophytes Hypertrophy of the ligamentum flavum Thickening and/or calcification of the ligamentum flavum centrally and at the insertion to the superior facet 21 Sheehan 2001, Spivak 1998, Drake 2005, Goodman 2003 Histology 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 22 Sheehan 2001, Drake 2005, Haig

12 Tissue 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 23 Atlas 2006, Sheehan 2001, Goodman 2003 Medical Management Diagnosis w/ radiographs, CT, MRI NSAIDs and prescription pain meds Injections - corticosteroids, anesthetics or opioids Last resort: surgery - lumbar decompression/laminectomy/spinal fusion 24 Atlas 2006, Sheehan 2001, Spivak 1998, Simotas 2000, Simotas 2001, Lin 2005, Fritz 1997, Kim 1999, Bodack

13 Examination: 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 Important Exam Findings Neurological exam Straight leg raise Thomas test Manual Muscle Testing 26 13

14 Straight Leg Raise (SLR) For disc herniation and/or increased neural tension Reliability: - substantial (kappa ) interrater agreement (Vroomen, 2000) Validity, sensitivity and specificity - patients with posterior pelvic pain form pregnancy (Mens, 2001) active SLR a suitable diagnostic instrument - Sensitivity: Specificity: Additional 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

15 Connection: Disability / Functional Limitations to Impairments Unable to stand >20min Walking >200ft Limited at work Difficulty with ADLs Unable to sleep in preferred position Unable to play golf 29 Graphics Concept A Connection: Disability & Functional Limitations of Impairments Unable to stand >20min Walking >200ft Limited at work Difficulty with ADLs Unable to sleep comfortably 30 Unable to play golf Graphics Concept B1 15

16 Connection: Disability & Functional Limitations of Impairments Unable to stand >20min Walking >200ft Limited at work 31 Unable to stand >20min Unable to play golf Difficulty with ADLs Unable to sleep comfortably Graphics Concept B2 Connection: Pathology to Impairments Lumbar Spinal Stenosis Primary: - severe low back pain when standing or walking - joint stiffness at L1-L4, joint mobility at L5 32 Secondary: - decreased lumbar extension, R sidebending, R rotation - decrease in activities & general conditioning 16

17 Connection: Pathology to Impairments Radiculopathy Primary: - radiating pain and paresthesias into R LE - decreased sensation, muscle strength & reflexes Secondary: - general deconditioning - decreased lumbar ROM 33 Medical Prognosis is Poor Condition is progressive with DJD 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 34 Atlas 2006, Sheehan 2001, Goodman 2003, Fritz

18 PT 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 35 PT Practice Pattern 4F 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 36 APTA s Guide to Physical Therapist Practice, 2 nd Ed. 18

19 PT 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 37 Atlas 2006, Goodman PT 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 19

20 Exercises 39 Questions? 40 20