Spinal canal stenosis

1. Spinal canal stenosis
ASHISH KUMAR SHARMA
BPT 4TH YEAR
NOIDA INTERNATIONAL UNIVERSITY

2. SPINAL CANAL
 The spinal canal is the cavity within the vertebral
column which contains the spinal cord with its
associated nerve roots and vessels.
 The spinal canal becomes progressively narrower from
its superior opening at the foramen magnum to its
inferior opening at the sacral hiatus.
 The spinal canal fills with cerebrospinal fluid .The canal
originates at the base of the skull and ends the sacrum.

3.  The spinal cord descends through the canal nerve root emerge from
holes to each sides of the canal and at the end of the spinal cord
nerves branch out forming a horse like tail.
Boundaries
 anterior: vertebral bodies, intervertebral discs, posterior longitudinal
ligament
 posterior: ligamentum flavum lining the laminae
 lateral: vertebral pedicles

5. STENOSIS
 Stenosis is a narrowing or constriction of the diameter
of a body passage or orifice
 Example.
 Spinal canal stenosis
 Aortic stenosis
 Pyloric stenosis

6. SPINAL STENOSIS
 Spinal stenosis is a narrowing of the spaces within your
spine, which can put pressure on the nerves that travel
through the spine.
 Spinal stenosis occurs most often in the lower back
and the neck.
 Some people with spinal stenosis may not have
symptoms. Others may experience pain, tingling,
numbness and muscle weakness. Symptoms can
worsen over time.

7. CONTINUE
 Spinal stenosis is most commonly caused by wear-
and-tear changes in the spine related to osteoarthritis.
 Spinal canal narrowing is most often due to age-
related changes that take place over time. This
condition is called "acquired spinal stenosis." Spinal
stenosis is most common in people over 50 years of
age.
 Some people are born with a small spinal canal. This is
called "congenital stenosis”.

9. TYPES OF SPINAL STENOSIS
 The two main types of spinal stenosis are:
 Cervical stenosis. In this condition, the
narrowing occurs in the part of the spine in your neck.
 Lumbar stenosis. In this condition, the
narrowing occurs in the part of the spine in your lower
back. It's the most common form of spinal stenosis.

10. CAUSES
 Spinal stenosis has many causes.
1. Bone overgrowth/arthritic spurs: Osteoarthritis is
the wear and tear condition that breaks down
cartilage in your joints including your spine.
Cartilage is the protective covering of joints. As
cartilage wears away, the bones begin to rub against
each other.

11. CONTINUE
 Herniated disks:-The soft cushions that act as
shock absorbers between your vertebrae tend to dry
out with age. Cracks in a disk's exterior may allow
some of the soft inner material to escape and press on
the spinal cord or nerves.
 Thickened ligaments:- The tough cords that help
hold the bones of your spine together can become
stiff and thickened over time. These thickened
ligaments can bulge into the spinal canal

12. CONTINUE
 Spinal fractures and injuries: Broken or
dislocated bones and inflammation from damage
occurring near the spine can narrow the canal space
and/or put pressure on spinal nerves.
 Spinal cord cysts or tumors: Growths within the
spinal cord or between the spinal cord and vertebrae
can narrow the space and put pressure on the spinal
cord and its nerves. ,,,

13. LUMBAR CANAL STENOSIS
 Is a degenerative condition in which there is
diminished space available for the neural and vascular
elements in the lumbar spine secondary to
degenerative changes in the spinal canal.
 Is a Cauda Equina compression in which the lateral or
anteroposterior diameter of the spinal canal is narrow
with or without change in cross sectional area.
 It is defined as Narrowing of spinal canal nerve root
canal or vertebral foramina.

14. CLINICAL FEATURES
 Low back pain
 Pain
 Cramping in lower extremities
 Pain exacerbated by standing and walking.
 Pain got decreased during sitting and by forward
flexion.
 Cauda equina claudication is most common
 Loss of bladder or bowel control (in severe cases).

15. DIAGNOSIS
 Red flag symptoms must be assessed.
1. Radiography:- is usually the first step to identify a
degenerative process (disc degeneration,
osteophytes, facet hypertrophy). It is also helpful in
the evaluation of the alignment, loss of disc height
and osteophyte formation.
2. MRI (Magnetic Resonance
Imaging) :-is used for determining the degree
of stenosis and the thickness of Ligamentum
Flavum. A lack of fat around the root indicates
stenosis.

16. DIAGNOSIS….
 Ultrasound (US)
 Myelography :- It uses a contrast dye and X-rays or
computed tomography (CT) to look for problems in
the spinal canal. Problems can develop in the spinal
cord, nerve roots, and other tissues. This test is also
called myelography.
 Bone scan (shows where bone is breaking down or
being formed).

17. https://youtu.be/31RuBxzXhr0

18. SPECIAL TEST
1. Bicycle Stress Test:-During this test the patient
first pedals on a cycle ergometer in upright
position with preservation of neutral lumbar
lordosis.
2. The distance the patient has pedaled in a
certain amount of time is recorded. The patient
has to pedal a second time in a slumped
position with lumbar delordosing.
3. The distance the patient has pedaled in the
same time is recorded again. If the patient can
pedal further in slumped position than in
upright position, lumbar spinal stenosis is
indicated.

19. Upright position with
lumbar lordosis
Slumped posture with
decreased lumbar lordosi

20. Two-Stage Treadmill Test
1. This test is evaluated on a treadmill. When the patient walks on
the flat (0°) treadmill their back is in an extended position.
2. The walking distance in a certain amount of time is recorded.
3. The patient walks on the treadmill a second time with an uphill
slope, which means they walk in a flexed position.
4. The walking distance in the same amount of time is recorded
again. If the patient walks further on an uphill slope than on the
flat treadmill, lumbar spinal stenosis is indicated.

21. Upright posture
with no incline

22. The Trendelenburg test
 Is used to observe for hip
abductor weakness. Difficulty
with walking on the toes
suggests S1 root involvement.
Difficulty with heel walking
suggests L4 or L5 nerve
dysfunction.

23. CROSSED STRAIGHT LEG
RAISE TEST
 This test for examination of
the lower back.
 Patient should prone lying
position.
 The test is positive when the
pain occur with less then 60
degree of hip flexion.

24. Continue...
https://youtu.be/BCMY8LftLPw

25. Medical Management
Conservative treatment is the
first-line treatment for this
condition.
Conservative treatment options
include physical therapy, oral
anti-inflammatory medications,
and epidural steroid injections.

26. Medications
 Steroid Injections :-Injecting a corticosteroid into the
space around the compression can help reduce the
inflammation and relieve some of the pressure.
 Non-steroidal Anti-Inflammatory Medications:-
such as ibuprofen (Advil, Motrin), naproxen (Aleve),
aspirin – or acetaminophen (Tylenol) can help relieve
inflammation and provide pain relief from spinal
stenosis.

27. SURGICAL TREATMENT
 LEMINECTOMY:- The most common type of surgery for this
condition, laminectomy involves removing the lamina, which is a
portion of the vertebra. Some ligaments and bone spurs may
also be removed
 Laminotomy:-This procedure removes only a portion
of the lamina, typically carving a hole just big enough to relieve
the pressure in a particular spot.
 Laminoplasty:- This procedure is performed only on
the vertebrae in the neck (cervical spine). It opens up the space
within the spinal canal by creating a hinge on the lamina. Metal
hardware bridges the gap in the opened section of the spine.

.

28. PT .MANAGEMENT
 Pain Management By Electrotherapy
1. Ultrasound
2. Tens
3. Hot Packs
4. IFT

29. CONTINUE
1. Bed rest
2. Flexion-based exercise programs
3. Lumbar isometric and stretching exercises
4. Static and dynamic postural exercises
5. Individualized muscle strengthening
6. Endurance exercises
7. Cycling exercises

30. Spinal Mobility and Lumbar
Flexion Exercises
Lumbar flexion exercises are done to
reduce the lumbar lordosis. This is the
most comfortable position for the
patient because the symptoms reduce
in combination with a decrease of the
epidural pressure in the lumbar spinal
canal

31. SINGLE KNEE TO CHEST
STRETCH
 While lying on your back,
use your hands and
gently draw up a knee
towards your chest.
 Keep your other knee
straight and lying on the
ground.
 Repeat 5 Times Hold 15
Seconds
 Complete 1 set Perform
2 Times a Day.

32. DOUBLE KNEE TO CHEST
STRETCH
 While lying on your back, hold
your knees and gently pull them
up towards your chest.
 Repeat 5 Times Hold 15 Seconds
 Complete 1 Set Perform 2 Times
a Day

33. PIRIFORMIS STRETCH
 While lying on your back and leg
crossed on top of your opposite
knee.
 Hold your knee with your opposite
hand and bring your knee up and
over across your midline towards
your opposite shoulder for a stretch
felt in the buttock.
 Repeat 5 Times Hold 15 Seconds
Complete 1 Set
 Perform 2 Times a Day

34. Lumbar rotation stretch

35. Posterior Pelvic Tilt Exercise
 Lie on the floor (or on a mat on the floor) with your
knees bent and your feet flat on the floor.
 Allow your back to maintain a natural curve, leaving
space between your low back and the mat.
 Inhale. As you exhale, engage your abdominal muscles,
allowing that action to tilt your tailbone upward and
close the space between your low back and the mat or
floor. You'll feel a gentle stretch of your low back.
 Do 5 to 10 reps.

37. SUPINE ACTIVE HAMSTRING
STRETCH
 Grasp behind knee and keep leg
at arms length. Extend leg up until
a gentle stretch is found behind
your knee.
 The opposite knee can be bent or
straight at your therapists
discretion.
 With this do ankle pumps .
 Repeat 10 Times Hold 15 Seconds
Complete 1 Set.
 Perform 2 Times a Day

38. SEATED LUMBAR FLEXION
 Sit upright in a chair.
 Slowly bend forward until you feel tension in your
back.
 Repeat exercise 2 in a daytimes.
 Hold position for 5 to 10seconds.
 Option: Perform with rotation to painful side

39. Cervical Stenosis
1. Cervical stenosis is a narrowing of the cervical
spinal canal.
2. This narrowing of the spinal canal may result in
compression of the spinal cord and/or the nerve
roots and affect the function of the spinal cord or
the nerve, which may cause symptoms associated
with cervical radiculopathy or cervical myelopathy.

41. Pathophysiology
1. The spinal cord can be directly compressed by
osteophytic bones and ligamentous hypertrophy.
2. Compression of local vascular structures can lead to
ischemia of the spinal cord.
3. A herniated disk can exert repeated local trauma to
the spinal cord or nerve root during repetitive
flexion and extension movements .

42. Clinical Presentation
 Cervical stenosis does not necessarily cause symptoms, but if
symptoms are present they will mainly be caused by
associated cervical radiculopathy or cervical myelopathy.
 C4-5 disk herniation can lead to deltoid weakness and shoulder
paresthesia. Patients also can experience pain and paresthesia in
the head, neck, and shoulder.
 C6-7 disk herniation is the most common, leading to a wrist drop
and paresthesia in the 2 and three fingers.
 C5-6 disk herniation is the next common, resulting in weakness in
forearm flexion and paresthesia in the thumb and radial forearm.
 In severe cases, bowel or bladder dysfunction (urinary urgency and
incontinence)
 Problems with walking and balance

43. ETIOLOGY
 Overgrowth of bone. Wear and tear damage from
osteoarthritis on your spinal bones can prompt the
formation of bone spurs, which can grow into the
spinal canal.
 Herniated disks.
 Thickened ligaments.
 Tumors.
 Spinal injuries.

44. DIFFRENTIAL DIAGNOSIS
 Diabetes
 Ankylosing spondylitis)
 Peripheral neuropathy (paralysis)
 Peripheral vascular disease
 Single level lumbar disc herniation
 Spinal cord tumor
 Vascular insufficiency (atherosclerosis of the aorta
and/or leg arteries)

45. CONTINUE
 CT can help differentiate calcified disks or bone
osteophytes from “soft disks,” differentiate ossification
of the posterior longitudinal ligament from a
thickened posterior longitudinal ligament and detect
bone fractures .
 MRI is the gold standard; it is able to show intrinsic
cord abnormalities, the degree of spinal stenosis, and
differentiate other conditions such as tumors,
hematoma, or infection.
 If a patient has a pacemaker and cannot obtain an
MRI, a CT myelogram can be performed to identify
the level and degree of stenosis.

46. Medical Management
 Initial treatment can include both conservative and
nonsurgical methods. These methods include physical
therapy such as stretching, strengthening, and
aerobic fitness to improve and stabilize muscles and
posture; anti-inflammatory and analgesic
medications; and epidural steroid injections.
 Surgery is for only those who fail repeated
nonoperative treatments .

47. PT.MANAGEMENT
 Stretching exercises: These exercises are aimed at restoring the
flexibility of the muscles of the neck, trunk, arms and legs.
 Manual therapy: Cervical and thoracic joint manipulation to
improve or maintain the range of motion.
 Heat therapy: to improve blood circulation to the muscles and
other soft tissues.
 Cardiovascular exercises for arms and legs: This will improve
blood circulation and enhance the patient's cardiovascular
endurance and promote good physical conditioning.
 Aquatic exercises: to allow your body to exercise without
pressure on the spine.
 Training of activity of daily living (ADL) and functional
movements.

48. CONTINUE
 Aquatic exercises: to allow your body to exercise
without pressure on the spine.
 Training of activity of daily living (ADL) and functional
movements.
 Proper lifting, pushing, and pulling.

49. CHIN TUCKS
 Begin in either a standing or
seated position.
 Align your chin so that it’s
parallel to the floor.
 Place 2 fingers on your chin.
 Tuck your chin in, and pull your
head back (help with your
fingers).
 Hold this retracted position for
5 to 10 seconds.
 Aim for 10 repetitions of this
exercise.

50. Fwd Neck Stretch
 Begin sitting in an upright position, shoulders
slightly back, head looking straight ahead. It
might be easiest to begin doing this in front of a
mirror.
 While keeping your face and mouth relaxed,
slowly glide your head straight back, as if you are
trying to make a “double chin.
 Make sure not to open your mouth with this
movement.
 While holding this position, slowly look down
towards your chest with your entire head (help
with arm).
 Hold this position for 10 seconds, then repeat it 10
times.
 Remember to keep the “tucked” position the
entire time.

51. Median Nerve Slider
 This exercise will help to relieve
tension on the nerves coming out
of the neck as they travel down
your arm. Be careful, if this exercise
causes any pain, stop doing it.
 Gently bend the hand back toward
the forearm, then extend the
thumb out to the side.
 Using the opposite hand, apply
gentle pressure on the thumb to
stretch it. For each change of
position, hold for 3–7 seconds.
 Release and repeat the whole
exercise on the other hand.

52. Doorway Stretch
 This is a good stretch to help open up the
chest area and upper back, to improve your
posture.
 Position your elbows and hands in line with
a door frame.
 Step through the door slowly, until you feel
a stretch.
 Hold this end position for 20 to 30 seconds
before returning to the starting position.
 Repeat this stretch 2-3 times.