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Lumbar Spinal Stenosis — A Clinical Update and Approach to Patient Care with a Lumbar Spinal Stenosis Model

Lumbar Model with NervesJerome Fryer

Goal of the Study?

Lumbar spinal stenosis affects approximately 11% of the population, primarily in the adult population.1 In this article, the authors worked to provide a clinical update giving practitioners a “what you need to know” perspective on the ins and outs of clinical practice.

 

Why are they doing this study?

Because of its prevalence and challenge to accurately diagnose, it is important to understand the clinical presentation of lumbar spinal stenosis from a symptomatology standpoint. This careful attention to a patient’s symptoms can help guide an appropriate care plan. The clinical challenge can be cloudy as other conditions like vascular claudication can lead even the best clinicians down the wrong diagnostic path.

 

What was done?

A review of the anatomy is important when understanding the clinical symptoms of lumbar spinal stenosis. In this clinical update, the authors revisit the degenerative changes of the spinal canal and the intervertebral foramen related to spacing and the nerves that travel through these spaces.

Spinal Canal Spacing, Lumbar Spinal Stenosis Education Model

Lumbar spinal stenosis model

 

What did they find?

As the discs lose height, the associated anatomical changes can lead to narrowing. Degenerative discs lose height over time, and in doing so, the facets approximate, leading to hypertrophy of the bony architecture. Facet arthropathy (as seen in the Lumbar Spinal Stenosis Dynamic Disc Model) can take up valuable spinal real estate for lateral recess and intervertebral foramen; furthermore, discs lose height, discs bulge. And with this bulging, just as a tire bulges when it loses air pressure, it can often take up spinal canal spacing. This can also lead to the ligamentum flavum bulging itself (also thought of as buckling or thickening), encroaching on the valuable room the vasculature around the cauda equina must have to function.

The classic presentation is the patient reporting of not being able to distance walk as they have previously. They also report that standing often generates lower leg symptoms or buttock/leg weakness and relief of these symptoms by sitting and/or using the upper extremities to offload and flex the spine, like that seen with the shopping cart posture.

The authors point out that lateral recess stenosis and foraminal stenosis can mimic radiculopathy as seen in sciatica related to a disc herniation and report that a combination of these symptoms and subtypes is common.

 

How is Lumbar Spinal Stenosis Diagnosed?

A careful history and examination are at the roots of a proper diagnosis. Imaging has been relatively unreliable and likely due to the static nature of MRI and CT. It is suggested that clinicians can ask suspected patients to walk or to have patients extend the lumbar spine for thirty seconds to recreate the symptoms.

The authors have created these points and to be mindful of patients over 50 present with these symptoms:

  • pain in lower extremities/buttocks while walking
  • flexion to relieve
  • relief if using the upper extremities to push down and generate lumbar flexion like that seen using a shopping cart or riding a bicycle
  • unsteady motor disturbance while walking
  • tingling or numbness in the legs while walking
  • pulses equal and bilateral in lower extremities
  • low back pain

 

How do Clinicians Talk about Lumbar Spinal Stenosis with their patients?

Lumbar Spinal Stenosis Model

What tools do you use to educate your patients?

 

 

 

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ISSLS Prize in Bioengineering Science 2021: in vivo sagittal motion of the lumbar spine in low back pain patients – a radiological big data study

Sagittal

Goal of the Study?

In this study 1, the authors investigated the flexion-extension range of motion (ROM) and centre of rotation (COR) of lumbar motion segments in a large population, as well as the relationship between lumbar movement and sex, age and intervertebral disc degeneration (IVD).

 

Why are they doing this study?

Research on the in vivo motion of the spine has a long history. However, many of these studies have used non-invasive technologies with inherent limitations impacting their accuracy and precision. Moreover, many studies have included a lower number of subjects, preventing the ability of the data to represent the general population.

The authors argue that radiographic techniques in this study help overcome these limitations as the images allow for better visualization of each vertebra and movement of the lumbar segments. Additionally, the use of a large sample size for this study addresses the issue of representation and is the largest study to date looking at in vivo lumbar motion. 

 

What was done?

The researchers did a retrospective study looking at the radiographs of the lumbar spine in full flexion and extension for 602 patients, with the age and sex documented for each one.  Additionally, they used MRI scans of 354 patients. 

All spinal levels between T12-L1 and L5 – S1 were analyzed, resulting in 3612 lumbar motion segments from the radiographic images. They also examined 2124 images from the MRI scans looking at disc degeneration. ROM and COR were calculated for all lumbosacral segments using the software. They then examined the associations between motion and age, sex, spinal level and disc degeneration.

 

What did they find?

The median ROM in this study was 6.6 °. The researchers found an association between age and ROM, with older individuals, have lower ROMS. They argue these findings clearly demonstrate a relationship between age and lumbar spine flexibility independent of any signs of spinal degeneration. They also found that lower ROMS were associated with disc degeneration. However, they did not find any association between sex and ROM.   

In this study, they did not find an association between the position of the COR and the spinal segment. The most common COR was at the centre of the lower endplate of the IVD or slightly lower. With degeneration, particularly severe degeneration, they found the location of the COR spread randomly around the centre of the intervertebral space.

 

Limitations?

One of the main limitations of this study was the sole focus on the flexion-extension motion of the lumbar spine rather than including information on movements of different areas of the back. 

 

Why do these findings matter?

This study comprises the largest examination of the in vivo lumbar spine in flexion-extension, paying attention to age and spinal degeneration issues. Understanding the relationship between age and spinal mobility provides patients and doctors with information to better treat back pain and instability.

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The Clinical Diagnostic Value of Lumbar Intervertebral Disc Herniation Based on MRI Images

Facet angle

Goal of the Study? 

In this study 1 the authors use MRI to measure changes in the facet angles of the lumbar spine and analyze the relationship between angle changes and the herniated lumbar intervertebral disc. 

 

Why are they doing this study?

The incidence of lower back pain (LBP) is prevalent in today’s society and can place an enormous burden on individuals and health systems. There are many causes of LBP, including lumbar facet joint (LFJ) degeneration, lumbar disc herniation (LDH), compression of nerve roots, and others. There is currently little understanding of the role of lumbar facet joint angle changes and lumbar disc herniation play in LBP. The authors comment that there is a lack of knowledge on whether the structural abnormality of the spine resulting from LFJ degeneration causes the abnormal force of the lumbar intervertebral disc herniation. Additionally, there is a need to understand whether lumbar facet joint angle changes are common in patients with lumbar disc herniation.

 

Professional LxH Model (L4-5) with asymmetric facet angles

 

What was done?

First, the authors review both direct and indirect signs of lumbar disc herniation as seen on MRI. They state that MRI provides an advantage to obtain horizontal and sagittal three-dimensional scanning of the spinal cord, subarachnoid space, vertebral body and intervertebral discs. They review the various signs of the nucleus pulposus, schmorl nodules, lumbar dural sac, lumbar spinal cord and nerve root compression.

The authors used cross-sectional images of the MRI to measure angles of the articular processes on both sides. They included 500 cases of patients with a clinical diagnosis of lumbar disc herniation and concurrent lumbar disc MRI examination. This included 227 males and 273 females with an average age of 41. This was broken down into 137 cases in the central LDH group, 140 cases in the left paralateral LDH group, 127 cases in the right-side LDH group and 75 cases in the control group. The cases were based on those who met the diagnostic criteria over 18 and relevant imaging and clinical data. Statistical software was used for statistical analysis.

 

What did they find?

The authors found no statistically significant relationship between age, gender, height and weight of the groups and LDH. They found no statistically significant relationship between MRI and CT measurements of the facet joint angle. They argue a correlation between the changes illustrated in MRI images of lumbar disc herniation and the TCM syndromes of lumbar intervertebral disc herniation. They found that the L4/5 and L5/S1 segments of the lesion in the central LDH group and the left paralateral LDH and right-side LDH were all significantly different from the control group.  Facet joint asymmetry is closely related to lateral lumbar disc herniation. However, the asymmetry of the facet joints is not related to the central lumbar disc herniation. They argue that MRI has a high sensitivity concerning measuring angles of the facet joint and changes to those angles and how they correlate with herniated discs. 

 

Why do these findings matter?

Understanding the relationship between lumbar facet joint angle changes and lumbar disc herniation is useful for preventing and treating LBP. 

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ISSLS Prize in Bioengineering Science 2021: in vivo sagittal motion of the lumbar spine in low back pain patients – a radiological big data study

Centre of Rotation

Goal of the Study?

In this study 1, the authors investigated the flexion-extension range of motion (ROM) and centre of rotation (COR) of lumbar motion segments in a large population, as well as the relationship between lumbar movement and sex, age and intervertebral disc degeneration (IVD).

Why are they doing this study?

Research on the in vivo motion of the spine has a long history. However, many of these studies have used non-invasive technologies with inherent limitations impacting their accuracy and precision. Moreover, many studies have included a lower number of subjects, preventing the data’s ability to represent the general population.

The authors argue that the use of radiographic techniques in this study helps to overcome these limitations as the images allow for better visualization of each vertebra and movements of the lumbar segments. Additionally, the use of a large sample size for this study addresses the issue of representation and is the largest study to date looking at in vivo lumbar motion. 

What was done?

The researchers did a retrospective study looking at the lumbar spine radiographs in full flexion and extension for 602 patients, with the age and sex documented for each one.  Additionally, they used MRI scans of 354 patients. 

All spinal levels between T12-L1 and L5 – S1 were analyzed, resulting in 3612 lumbar motion segments from the radiographic images. They also examined 2124 images from the MRI scans looking at disc degeneration. ROM and COR were calculated for all lumbosacral segments using the software. They then examined the associations between motion and age, sex, spinal level and disc degeneration.

What did they find?

The median ROM in this study was 6.6 °. The researchers found an association between age and ROM, with older individuals, have lower ROMS. They argue these findings clearly demonstrate a relationship between age and lumbar spine flexibility independent of any signs of spinal degeneration. They also found that lower ROMS were associated with disc degeneration. However, they did not find any association between sex and ROM.   

In this study, they did not find an association between the COR and the spinal segment’s position. The most common COR was at the centre of the lower endplate of the IVD or slightly lower. With degeneration, particularly severe degeneration, they found the COR location spread randomly around the centre of the intervertebral space.

Limitations?

One of the main limitations of this study was the sole focus on the lumbar spine’s flexion-extension motion rather than including information on movements of different areas of the back. 

Why do these findings matter?

This study comprises the largest examination of the in vivo lumbar spine in flexion-extension, paying attention to age and spinal degeneration issues. Understanding the relationship between age and spinal mobility provides patients and doctors with information to better treat back pain and instability.

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The degenerative lumbar disc: not a disease, but still an important consideration for OMPT practice: a review of this history and science of discogenic instability

degenerative disc

Goal of the Review?

In this article, 1, the authors ask the question of whether current manual intervention practice reflects the scientifically proven biomechanical aspects of degenerative disc disease (DDD) or if the field is ignoring the science in an effort to discard the diagnostic label?

 

Why are they doing this study?

The American Academy of Orthopedic Manual Physical Therapists (AAOMPT), released a position paper that opposes the use of the term degenerative disc disease (DDD), saying that the diagnostic label can result in overuse of diagnostic imaging and treatment. They assert that DDD is a common age-related issue, not a disease. 

While the authors agree that diagnostic labels must be well thought out, they argue there are significant physiologic and biomechanical changes that occur as a result of disc degeneration. Therefore, scientific evidence such as imaging findings that illustrate these changes should serve to guide treatment decisions as one aspect of larger clinical reasoning. 

 

Degenerative spondylolisthesis

Degenerative Disc Language Should Be Reframed

 

What was done?

The authors perform a narrative review to examine the literature on DDD. This includes a look at the historical research on disc instability, the role of the disc as a pain generator, a review of the science on the cycle of disc degeneration, as well as the impact of rotation on the degenerated disc. In addition to the biomedical research, they provide an overview on the implications of this research for manual therapy and recommendations for evidence-based treatments.

 

What did they find?

 In response to the literature review, the authors make a few evidence-based recommendations for manual therapy treatment. First, they suggest that traction-based manual interventions should be done in mid-position without side bending or axial rotation. This recommendation is in response to evidence suggesting that forceful rotatory treatments may cause further damage and potentially lead to loss of structural integrity of the disc. 

Next, they argue that current clinical practice of spinal manual therapy may not be paying enough attention to the frequency of early disc degeneration, and resulting instability, in the asymptomatic population. Therefore, they recommend that oscillatory traction-based manual interventions be applied in combination with stabilization exercises and neuromuscular re-education thereby serving to enhance disc rehydration and nutrition, as well as facilitate neuromodulation and reduce muscular reticence. 

 

Why do these findings matter?

Many patients use manual spinal therapy for pain and mobility. Understanding how to implement evidence-based treatments that will benefit, and not harm, patients is critically important for providers and patients.

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Does Forward Head Posture Cause Neck Pain? – A Systematic Review

head posture and pain

A recent systematic review 1 published in November of 2019 in ‘Current Reviews in Musculoskeletal Medicine’ went over the relationship between neck pain and head posture. The results of the review found that age played a vital role.

What Was the Purpose?

Research has shown that neck pain is a common issue in the human population. It goes on to adversely impact a person’s family, business, healthcare, etc. Apparently, human neck pain’s overall prevalence in the general population can be more than 86%. When considering the physical factors, neck pain showed a strong association with a person’s neck having a forward bent for a long time as well as making repetitive movements.

The risk of neck pain has increased due to more people spending hours in front of screens for work or leisure in unhealthy postures. The forward head posture or FHP is the most common cervical postural fault. A higher FHP level is linked to higher deficits in a person’s cervical range of motion (specifically the neck’s flexion and rotation).

Furthermore, static balance control in asymptomatic adults is reported to be negatively impacted by FHP. However, there are still contradictory results. That’s why this study set out to determine whether or not FHP showed any differences between asymptomatic and neck pain subjects — investigating the relationship between neck pain and head posture was the study’s secondary objective.

The Methodology

This review covered the electronic databases EMBASE, MEDLINE/PubMed, Cochrane Library Web search, Physiotherapy Evidence Database (PEDro), and CINAHL for observational studies that were published in English and indexed from 2009 to April 2017. Also, an updated search was performed on 19 September 2018. Mendeley Desktop was used for importing abstracts and titles. The duplicates and irrelevant articles were removed.

An adapted form of the EPHPP (Effective Public Health Practice Project) assessment tool was utilized for determining the quality of selected articles.

What Did the Results Show?

A total of 15 cross-sectional studies were deemed eligible to be included in this meta-analysis and systematic review procedure. A total of 10 studies compared FHP between the group of participants with neck pain and a group of asymptomatic participants. Eight studies displayed a significant negative correlation between the intensity of neck pain and FHP (as well as disability in older adults and adults).

Furthermore, when it came to adolescents, the significant predictors of FHP were doctor visits and lifetime prevalence.

What was Concluded?

The current review shared that age seemed to play a vital role as a confounding factor when it came to the relation between neck pain and FHP. Also, the results of this review helped conclude that increased Forward Head Posture was seen in adults with neck pain when compared to adults that were asymptomatic.

Other than that, FHP was determined to be highly correlated with neck pain measures linked to adults as well as older adults. Take note; no association could be found between most neck pain measures in adolescents and FHP.

More in-depth research is required to help people realize the damaging effects of their posture and how it relates to them experiencing neck pain.

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Over 15 years of use

Mark Bodnar

I strongly recommend clinicians take advantage of the ddd spine models.  I find the model helps patients get a better understanding of the anatomy and the mechanics of what is happening and where the pain is coming from.  With a better understanding they can be a more active participant in their recovery and less a passive bystander hoping the problem gets better.  Especially effective at teaching about flexion intolerance and discogenic/neurogenic pain.

I’ve been using a Dynamic Disc Designs model since they first started producing them, I think 15+yrs, and my original model is just now ready to be replaced.

Thanks for the help all these years

Dr. Mark Bodnar, B.Sc., D.C., FCCPOR(c)

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