Jennifer Belu, PT, MPH - - Physical Therapy Physical Therapy - PowerPoint PPT Presentation

Jennifer Belu, PT, MPH - - Physical Therapy Physical Therapy Jennifer Belu, PT, MPH Joe Tu, MD - - PM&R PM&R Joe Tu, MD James Thoman, MD – – Neurosurgery Neurosurgery James Thoman, MD Elizabeth Yu, MD - - Orthopedics Orthopedics Elizabeth Yu, MD

Case Presentation – Lumbar Stenosis  Patient is a 68 year old female with a chief complaint of pain in legs with walking.  She has had low back pain for 7 years, but in the past year the pain has changed and is now down her right leg.  It used to occur between sitting and standing, but now it is painful to stand or walk.  The pain is zero sitting and 8 standing. She can walk 25 feet and then has to sit down. She can walk further if she uses a grocery cart.  She gets a feeling of weakness in her legs if she keeps walking

Case Presentation – Lumbar Stenosis (cont)  Her pain is in the hips, the lateral thigh on the right and then into the anterior leg.  She says that she feels some numbness in the top of the foot with some tingling if she stands for longer times.  She has no bowel or bladder difficulty.  Her physical exam showed some mild tenderness in the greater trochanteric bursae bilaterally.  She had minimal weakness in both EHL. SLR is negative. She had absent AJ bilaterally. Flexion causes no pain in the back, but extension causes pain in the back that then radiates down the right leg into the lateral thigh, but is immediately relieved with flexion.

1. Stenosis is a product of aging 1. Stenosis is a product of aging A. Facets get larger (spurs) A. Facets get larger (spurs) B. Thicker ligamentum flavum B. Thicker ligamentum flavum C. Facets become unstable listhesis C. Facets become unstable listhesis (especially in females) (especially in females) D. Veeerrrrryyyyy slow process D. Veeerrrrryyyyy slow process 2. Patients may remain stable for years 2. Patients may remain stable for years 3. Very Very Very rarely become paralyzed 3. Very Very Very rarely become paralyzed

Neurogenic Claudication  Pain in legs  Occurs with standing  Doesn’t go away with just resting after walking, has to sit down  Vascular claudication improves with standing rest, no problem with standing, and going up hill worse than with neurogenic claudication

Low Back Pain: Physical Therapy Perspective – Jennifer Belu, PT, MPH  Managing symptoms  Activity modification  Therapeutic exercise to improve overall strength and condition BELU

Lumbar Stenosis: Managing Symptoms  Home modalities  In clinic, electrical stimulation/TENS  Medication as advised by their primary care provider or specialist BELU

Lumbar Stenosis: Activity Modification  Walking with known rest areas  Track how long able to walk before caudication symptoms  Kitchen tasks with foot stool to flex lumbar spine BELU

Lumbar Stenosis: Therapeutic Exercise  Look at musculature: iliopsoas restricted (often more sitting results in pattern of restriction which exacerbates symptoms)  Weak hip abductors, extensors, and rotators  Trunk weakness  Posture: compensation (i.e. excessive cervical extension to compensate for forward flexed trunk)  Treadmill with incline to increase endurance and increase time to symptoms  Aquatics! BELU

Spinal Stenosis Management Strategies Joseph Tu, MD Introduction  Discuss spinal stenosis  Discuss symptoms and characteristics  Discuss management strategies  Discuss possible use of injection therapy  Indications/contraindications  Risks/side effects/benefits  Data TU

Symptoms  Degenerative lumbar spinal stenosis (LSS) is a common source of pain and disability in the elderly population  Neurogenic claudication is the hallmark symptom of LSS  Classic Symptoms:  Buttock and bilateral leg pain  Worse with walking, prolonged standing, relative lumbar extension)  Typically relieved by sitting, bending forward, or pushing a grocery cart TU

Symptoms  Vascular Claudication:  Relieved solely by rest (not having to sit or bend forward)  Walking uphill is worse TU

Symptoms  LSS is a result of the degenerative spine cascade thus can affect  Central spinal canal  Lateral recesses  Intervertebral foramina  Result in: Unilateral or bilateral, and monoradicular or polyradicular symptoms TU

Symptoms  Axial back pain is also present  Quality of this axial symptom is consistent with osteoarthritis of the lumbar spine (stiffness with a dull, aching pain)  default to a stooped-forward posture to alleviate pain by widening the spinal canal and decreasing the forces on the zygaphophyseal joints TU

Etiology  Not simply due to mechanical compression  Multi-factorial  There are vascular, biochemical, and biomechanical factors that contribute to the symptoms of LSS TU

Etiology  Venous engorgement theory  Spinal veins dilate during ambulation in stenotic patients  Blood flow stagnates and intrathecal pressures rise  Microcirculatory neuroischemic insult  Claudication symptoms TU

Etiology  Arterial insufficiency:  Normally, lower limb exercise, including ambulation, the lumbar radicular arterioles dilate to provide nourishment to the spinal nerve roots  Arterial dilation may be defective in LSS TU

Etiology  The inflammatory cascade:  Stenosis acts as mechanical compression of a nerve root may be a ‘‘primer’’ for a subsequent inflammatory response  Causes the radicular symptoms  Chronic LSS to have periodic acute flares of symptoms  Chronically inflamed nerve root, with increased mechanical sensitivity, can become perturbed by a new inflammatory precipitator, vascular changes, or degenerative instability (listhesis causing radicular symptoms) TU

Management  Conservative  Activity modification (limit extension-based activity)  Assistive device for ambulation (walker)  Medications (Tylenol, NSAIDs, neuromodulating agents, and low dose opiates)  Physical therapy and exercise  Interventional  Epidural corticosteroid injections  Surgery TU

Prognosis  Natural history of LSS is not entirely known  It is known that rapid neurological progression is rare  Chronic degenerative process  Worsen with age TU

Surgery vs Non-surgical  Studies of nonoperative therapy for lumbar stenosis report 15–45% improvement, 15–30% worsen, and the rest remain symptomatically about the same  Outcomes at 1 and 4 years favored surgical management  After 8–10 years, low back pain outcome, predominant symptom (either back or leg pain) improvement, and satisfaction with their current status were similar  Leg pain relief, though, still favored those treated surgically TU

Epidural Steroid Injection (ESI)  Epidural steroid injections are frequently used in nonoperative management regime  Used as an adjunct to a comprehensive rehabilitation program and not used in isolation  Pain relief obtained with injections can facilitate the patient’s tolerance of a rehabilitation program TU

ESI  No clear evidence on when to initiate a trial, the frequency, nor duration of epidural steroid injection  Literature does support their use for predominantly radicular symptoms, especially acutely, and less for axial symptoms. TU

ESI  ‘‘Series of three’’:  No literature support for this  If one well-placed injection is not effective, then it is unlikely that a second or third administered in the same location will be  However, potentially a different route of administration could be utilized for a second injection TU

ESI  Mechanisms of pain relief of corticosteroids:  Inhibition of nerve root edema  Improved microcirculation  Reduced ischemia  Inhibition of prostaglandin synthesis  Non-inflammatory action of direct inhibition of C- fiber neuronal membrane excitation TU

Different Approaches  Interlaminar  Transforaminal  Caudal  Interlaminar with catheter  Particulate vs non-particulate steroids  Conflicting study results TU

Different Approaches  Interlaminar  Transforaminal  Caudal  Interlaminar with catheter  Particulate vs non-particulate steroids  Conflicting study results TU

Different Approaches  Most studies noted:  Short-term benefit ranging from 1 week to 2 months of relief  One demonstrated a longer term benefit with up to 10 months of relief  Studies Varied in different approaches TU

Different Approaches  Unilateral single dermatome symptoms, or post-laminectomy:  Transforaminal  Particulate: risk of arterial thrombosis  Non-particulate: no risk of thrombosis  May be superior for radiculitis/radiculopathy  Bilateral, non-specific symptoms:  Interlaminar  Paramedian approach  Catheter  Particulate  Severe LSS, Post-laminectomy:  Caudal TU

Interlaminar TU

Transforaminal TU

Caudal TU

Conclusion  Limited research evaluating the appropriate use of lumbar ESIs specifically to treat LSS  Specific conclusions cannot be drawn  There is no information to conclude which injection technique is most efficacious TU

Take Home  Trial Conservative management  Surgical candidate?  Failed conservative management?  May trial ESI  Various approaches to place the medication  Trial and error for patient TU