Introduction
Cause
Symptoms
Diagnosis
Physiotherapy
Conclusion
Lumbar stenosis is defined as the reduction in the diameter of the spinal canal, lateral nerve canals, or neural foramina. Neurogenic claudication is the typical symptom, usually brought on by standing or walking and relieved by sitting. It is diagnosed more frequently in elderly patients. For patients with severe symptoms, surgical decompression with or without fusion is often necessary for relieve of symptoms. There are studies demonstrating favorable results after conservative treatment in mild to moderate stenosis. Efficacy of the conservative treatment tends to co-relate greatly on the nature and severity of the symptoms as well as the radiological features
The narrowing of the spinal canal or the outlets for the neural structures could be attributed to facet joint arthrosis and/ or hypertrophy, thickening and bulging of the ligamentum flavum, collapse of the intervertebral disc, spondylolisthesis or any combination of these elements.
Neurogenic claudication, typically the symptoms involve pain and numbness on the legs, aggravated by standing, walking but much better with sitting or squatting. Patient may has persistent tolerable symptom for years, with recurrent spells of exacerbation of symptoms. Symptoms of could be exacerbated due to inflammation of structures such as the neural tissues, the soft tissues surrounding the facet joints in respond to repeated irritation and stress. The space available to the neural tissues could be further jeopardized.
The radiological finding does not necessarily co-relate with the clinical presentation. Detail history taking, physical examination and assessment of the disability take a major role in diagnosis and management.
The size of the spinal canal and the neural foramen can be manipulated by posture. Bending the back backward ( extension of the back) will decrease the size of the canal. This effect can be significant at an already narrowed level. Bending the trunk forward (flexion of the back ) will increase the size of the canal.
Apart from the posture, loading on the spine such as carrying heavy objects, is also one of the factors which can significantly reduce the size of the spinal canal.
General back mobilizing and strengthening exercises are important in aiming to re-mobilize the spinal segments and to strengthen the back muscles. It is more effective if exercises are performed in lying position or in the pool in order to reduce loading on the spine. Exercises involving arching the back backward and weight lifting training wound aggravate the symptom, and should be avoided at the early stage.
Neuro-mobilization is always included in the program and aims to break up adhesion surrounding the neuro-tissues, to release nerve root(s) entrapment and to restore the vascular function to the neural tissues.
In order to correct or to keep a better posture with ‘bigger’ canal in standing, tailor-made soft tissue stretching program are emphasized.
In addition, strengthening exercises on certain muscle groups are also important in improving the long term alignment of the spine by adjusting the muscle imbalance. To make the rehabilitation more complete, conditioning exercise and balance training are also included when the acute symptom is settled.
Passive modalities such as electrotherapy, is only recommended at the acute phase for reducing the inflammation, improving circulation, reducing swelling, modulating the pain and reducing the paraspinal muscle spasm. It should be stopped after settling the severe/acute pain. The emphasize should be on the active training afterwards.
Patients should be encouraged to maintain his/her condition by regular self exercise.
It is appropriate to try period of conservative treatment before considering surgical intervention. It helps to learn more about the patient’s need, causes of the disorder, response to the conservative treatment. It allows the patient understand her/ his situation. The conservative management should be tailored to the history and physical examination of the patient and should be individualised. Comprehensive active training programme such as specific stretching exercises, back mobilizing and strengthening exercises, neuro-mobilization, conditioning exercises and balance training are recommended rather than passive modalities.
Regular home maintenance exercises are essential.
Good clinical result always comes from good compliance to the programme.