WHAT IS STENOSIS? DO I NEED SURGERY OR CAN POSTURAL THERPAY HELP?

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1 WHAT IS STENOSIS? DO I NEED SURGERY OR CAN POSTURAL THERPAY HELP? Stenosis is a narrowing of the spinal canal. It usually occurs in the lower back (lumbar spine) or the neck (cervical spine) It occurs when the growth of bone or tissue reduces the size of the openings in the spinal bones. This narrowing squeezes and irritates the nerves that branch out from the spinal cord. It can be caused by: Thickened ligaments (like the ligamentum flavum) Herniated discs Arthritis and osteoarthritis Cysts and tumors Bone spurs (calcium deposits that occur due to friction) In many cases, these symptoms are caused by faulty structural alignment, dysfunctional joint positions, and muscular dysfunction. What are the symptoms? Back pain Nerve pain down one or both legs Butt Pain Numbness or tingling Loss of bladder control Stiffness in the legs or thighs With pure lumbar stenosis, often these symptoms get worse when one walks, stands straight or leans back. In many cases, the pain will decrease when sitting or leaning forward. This differs from disc herniation s which often feel better upon extension,

2 From the illustration below, you can see how the spinal canal narrows when someone is diagnosed with stenosis. This picture is of a lumbar stenosis in which a disc is herniated. This can often cause severe pain and postural deviations. Physical examination & diagnosis: Often a physical examination is performed when lumbar stenosis is suspected. The curvature of the spine should be assessed. One would like to see a proper S shaped curve with the pelvis in a level neutral position (not tipped forward or back). A slight lumbar curve and a slight thoracic curve should be present. As you can see from the pictures below, when dysfunction in the spine exists, it affects the whole spine as well as the pelvis. This is why there isn t a significant success rate when one chooses to just treat the lumbar spine alone. In diagnosing lumbar stenosis, the mobility and flexibility of the spine with any changes in symptoms during active flexion or extension should be recorded (particularly the presence of leg pain or numbness with extension of the spine).

3 The straight leg raise test, which is performed by sitting and raising one leg out while dorsiflexing the foot, is classically associated with pain and nerve compression if a disc is herniated or bulging. Most patients that experience a true positive straight leg raise, complain of sciatic like pain in the elevated leg at about degrees of elevation. This sign is usually absent in patients with pure lumbar stenosis. When experiencing pain with this test, it s often beneficial to stay away from exercises that involve hip flexion with knee extension. How is it treated? According to WebMD, you can most likely control mild to moderate symptoms of stenosis with pain medicines, corrective exercise, and physical therapy. Your doctor may also give you a spinal shot of corticosteroids, a medicine that reduces inflammation. Web MD also maintains, you may need surgery if your symptoms get worse or if they limit what you can do. In these cases, surgery to remove bone and tissue that are squeezing the spinal cord can help relieve leg pain and allow you to get back to normal activity. It s important to note, this may not help back pain as much. Surgery options Doctors most often recommend decompression surgery for lumbar stenosis. A laminectomy is typically performed (a surgery to remove the lamina which is the back part of the vertebra that covers your spinal canal). A laminectomy enlarges the spinal canal to relieve pressure on the spinal cord and nerves. Laminectomy

4 How can Postural Alignment Therapy & Corrective Exercise help? In the book Pain Free by Pete Egoscue, he states Pain isn t a structural problem. He left himself open for someone to say, what about stenosis which appears to be a structural defect. Egoscue maintains, there may be a structural component to stenosis, but this condition is also muscular. Stenosis is the result of friction due to musculoskeletal misalignment, the body reacts to this friction by forming calcium deposits to protect its vital components. This is similar to someone with flat feet developing a bunion to protect the structure of the foot. Obviously with lumbar stenosis, this solution is not ideal, as the calcium will interfere with the movement of the vertebrae, and given enough calcium, nerve impingement can occur which can be quite painful. Of course one can remove the lamina of the vertebrae and scrape away the calcium and this will most likely reduce nerve impingement, but as Pete Egoscue states, I have rarely seen a case of stenosis where this procedure was really necessary. If the lumbar, thoracic and cervical curves are restored to their functional positions, the spine will usually have enough room to operate functionally and the muscular system can be restored and trained to initiate proper movement patterns. Muscular dysfunction occurs as one loses their natural S shape curve to the spine (excessive lordosis or flat back syndrome). This is typically due to some form of pelvic dysfunction (anterior, posterior, rotation, or an illium disparity). When we assess the spine above the pelvis, as it s pulled from its neutral position, the upper back has to compensate usually creating kyphosis (an excessive rounding of the thoracic spine). This will pull the neck (cervical spine) from its neutral position. When we assess the how the dysfunctional pelvic position affects the joints below the pelvis, often we ll see a faulty position of the femurs and how they sit in the hip sockets. One may see knees that turn out often causing feet that are externally rotated. All these dysfunctional structural misalignments can lead to various symptoms, such as stenosis, as weak and compensating muscles allow the structure of the spine to be displaced and damaged. As you can see, pelvic imbalances and the loss of the proper spinal curves create compensations throughout the kinetic chain. It s important to recognize that pain is a symptom. Surgery is an option, but even in the case of stenosis when the lamina is removed, the underlying structural and muscular dysfunction has not been dealt with. Further symptoms are bound to recur which is why many back surgeries are not successful. Back pain is most often a symptom of faulty structural alignment that has been generated by a loss of proper function. It can occur from sports, excessive activity or lack thereof, age, or illness, but whatever the contributing factors, the only treatment that will directly go after the root cause will require you change the body s structural alignment and muscular function. What can we do How stenosis is best treated, along with most other pain symptoms that are caused by a lack of correct structural alignment and muscular function, is to determine which load bearing joints are out of alignment. As a postural therapist, I begin by taking a photo to determine which joints have lost their 90 degree angles (see diagrams below). Look in the mirror: Do your feet point straight? Do your knees point straight? Are your hips level horizontally? Are your shoulders level horizontally? Turn to the side: Do your load bearing joints line up from the ankle? Are your hips tilted forward (anterior) or back(posterior)? Does your lower back (lumbar spine) have a slight curve or is the curve excessive or flat? Does your upper back have a slight curve or is it excessively rounded? Are your shoulders rounded forward (protracted)? Is your neck sitting above your shoulder or is it pulled forward? The pictures below illustrate functional joint alignment. By maintaining 90 degree angles at the joints, the structure of the body is the most stable and functional. If you were to build a stable building, you would place the bricks directly on top of each other vertically and side by side horizontally for the most stability right? The same applies to the human body.

5 To assess muscular function, try some of the following functional tests. Can you touch your toes? Can you balance on one foot and pull the other knee up to a 90 degree angle? (Do the hips maintain their horizontal alignment?) Can you flex and arch the spine without pain? (Can you go in both directions keeping horizontal alignment?) Can you lift both arms overhead keeping the elbows straight without the hips pulling forward or back and without pain? Pain or dysfunction that occurs in any of these movements indicates a dysfunctional muscular system often due to structural misalignments. Since we know that muscles move bones, it s obvious that the only way to treat this is with corrective based exercises that influence the muscular system to move the bones back to their functional state. Egoscue helps one to regain functional structural and muscular function by: Mitigating the pain symptoms, Reducing rotation Neutralizing the pelvis Working from the inside out Leaving the pelvis in neutral

6 It s important to remember that it took years for the body to create this dysfunctional structural alignment and it will take some time and work to correct the muscular imbalances that are causing the pain symptoms. Postural realignment is not a quick fix; it s a long term solution. It s a solution for those who want to increase their body awareness and educate themselves. It enables one to take control back of their body and pain symptoms without constantly relying on doctors and therapists. For more information on postural therapy, please visit my website at or contact me at You can also pick up one of the many books by Pete Egoscue such as Pain Free or Health through Motion for more detailed information.

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