spinal canal stenosis / definition/ pathophysiology/ clinical features/ diagnosis/ functional limitation/ treatment

1. PRATIGYA DEUJA
SPINAL CANAL
STENOSIS

2. DEFINITION
 Spinal canal stenosis is
a condition where there
is a narrowing of the
spinal canals or tunnels
of the intervertebral
foramen.
 Occurs mostly in lower
back and the neck.

3. DEFINITION
Studies have indicated that
people older than 40 years have
significant narrowing of lumbar
spinal canal.
Stenosis causes symptoms
only when there is sufficient
impingement on neural
structures, including cauda
equina or exiting nerve roots.

4. CLINICALFEATURES
Onset:-
Insidious
Patient
present with
LBP,
diffuse
radiation into
the gluteal
region and
back of
thighs.
Pain:-
Neurogenic
claudication
pain which is
relieved by
sitting/lying
down and
increased by
standing and
walking
Root
symptoms
may
occasionally
occur
stimulating
disc lesion.
Aching,
heaviness,
Numbness
and
paraesthesia
in thighs and
legs.

5. Pathophysiology
Developmental factors
that lead to a small
canal include
statistically
significantly shorter
pedicles and a trefoil-
shaped canal.
In acquired types of spinal stenosis
the first stage is degenerative
process which includes;
Degradation of the
hydrophilic
proteoglycans within
IVD
Attendant disc
desiccation
Loss of disc height

6. Pathophysiology
These 3 causes the
shift of load onto
the posterior
structures of canal,
in particular facet
joints, which
normally provide
support during axial
loading but may
bear up to 47% with
degeneration of the
disc.
Facets bear
more burden
and
undergoes
degeneration.
One aspect,
there’s
formation of
osteophyte

7. Pathophysiology
Osteophyte diminishes
the cross-sectional
area of canal and can
result in stenosis of the
neural foramina
(foraminal stenosis).
IVD decreases,
ligamentum flavum
buckles
The epidural fat may
contribute to reduced
canal space in some
patients.

8. ETIOLOGICALclassification
• Achondroplasia
• Hypochondroplasia
Combined
• Degenerative
• Post-traumatic
• Spondylolytic (Isthmic spondylolisthesis)
• Latrogenic
• Metabolic (paget disease, pseudogout,
flurosis)
Acquired
• Congenital and acquired
congenital

9. ANATOMICAl classification
Central
canal
Caused by posterior disc
bulging, thickening of
ligaments, osteophytes,
outgrowth of the facet
joints, degenerative
spondylolisthesis and
retrolisthesis
AP
diameter
of spinal
canal ≤
12mm
Lateral canal
Caused by lateral disc
bulge, assymetrical
loss of disc height,
osteophyte
outgrowth of the
pedicles and superior
lumbar facets
Lateral recess
height ≤3mm
or lateral
recess depth
≤5mm
Foraminal and
Extraforaminal

10. PhysicalExamination
1)Wide based gait
2) Abnormal
romberg test
3) Decrease DTR
4) Sensory
dysfunction
5) +ve lasegue test
result
6) No pain with
lumbar flexion
7) Improved walking
tolerance on
inclined Vs level
treadmill
8) LE weakness
9) Pinprick vibration
deficit
10) Intermittent
claudication

11. Functional limitation
Worsening leg and back pain from walking, back extension
and prolonged standing
Difficulties with walking long distances, going downstairs and
house hold and yard work (e.g, dish walking, lawn mowing,
vacuuming) overhead activities ( which may include spinal
extension)
Balance deficit from sensory deficits may increase fall risk

12. RADIOLOGICALFEATURES
 AP and lateral view of
spine:- degenerative
spondylolisthetic/advanced
disc degeneration and OA,
Mid sagittal diameter and
inter perpendicular distance
will be decreased
 Myelogram (shows level of
block and effect of spinal
flexion and extension)
 CT scan
 Electromyography

13. treatment
conservative:- Rest,
Analgesic, Back exercise
Physio means:-
Electro; TENS, IFT, US,
IRR, Iontophoresis, hot
packs and cold packs
Exercise; stretching,
strengthening,
mobilzation, physio ball
Surgical:-
laminectomy,
foraminotomy, spinal
fusion,
Decompression of
cauda equina

14. treatment
Spinal manipulation
Spinal mobilization exercises
Hip joint mobilization
Hip flexor stretching
Muscle retraining
Body weight supported ambulation
Daily walking with properly prescribed orthotics
Body weight supported ambulation acts to decrease the
axial loading of spine to increase the cross-sectional area
of the neural foramina

15. treatment
CORE STABILITY EXERCISES
 Prone bridging/ plank
 Side plank
 Extensor endurance
 Cat and camel
 Clam exercises
 Brid dog exercise

16. treatment
STRENGTHENING
 Plyometric
 Physio ball
FUNCTIONAL EXERCISES
 Sprint
 Agility drills

17. ARTICLEREVIEW
• Luciana et al. in their review on degenerative lumbar
spinal stenosis have concluded that there was a low-
quality evidence suggesting that modalities have no
additional effect to exercise and that surgery leads to
better long term (2 years) outcomes for pain and
disability. Because of the limitation of the study no
conclusion was drawn regarding which physical
therapy treatment is superior to LSS.

18. ARTICLEREVIEW
Saurabh et al. in their RCT took 30 patients, experimental
group(n=15) and control group (n=15) with lumbar spinal
stenosis. Experimental group were prescribed (flexibility exercise,
specific experimental canal enlargement exercise, strengthening
exercise, functional/recreational activities), while control group
were given electrotherapy and exercise program (hot water
fermentation, IFT, Flexion exercises). The outcome measures were
Owestery Disabiliy Questionnaire, NPRS, SLR, SLUMP and
modified schober test. The exercises were done for 3 weeks and it
concluded that integrated exercise approach has significant effect
compared to conventional physiotheray treatment.

19. references
 Clinical orthopaedic rehab by S. BRENT Brontzman and
Kevin E.WILK (second edition)
 Physical Medicine and Rehabilitation by Walter R. Frontera
 Dutton’s Orthopaedic Examination, Evaluation, and
Intervention by Mark Dutton (third edition)
 Lucina et al. Physical Therapy interventions for Degenerative
Lumbar Spinal Stenosis: A Systematic Review. December,
2013
 Saurabh kumar and Narkeesh A (2017) Effect of Integrated
Exercise Protocol in Lumbar Spinal Stenosis as comapre with
Conventional Physiotherapy : A randomized Control Trial. Int
J Neurorehabilitation
 Myoclinic