Lumbar Spondylosis, Spondylolisthesis and Radiculopathy
- 2. LUMBAR SPONDYLOSIS Spondy means spine, losis means problem Degenerative spinal disorder Described as all degenerative conditions affecting the discs, vertebral bodies, and associated joints of the lumbar vertebrae. More than 85% of people over age 60 are affected. Area of max. mobility and stress L4-L5 and L5- S1 are common sites
- 4. CAUSES Aging : when we get older, the discs dehydrate, become thinner and become harder. They then provide less support to the vertebrae resting on the discs. Repetitive strain injury (RSI) caused due to lifestyle without ergonomic care, e.g., while working in front of computers, driving, traveling, intense work in farm, etc. Risk factors: Genetics Smoking Occupation: jobs with lots of spinal motion and overhead work Mental health issues :depression/anxiety Injuries/trauma: car wreck or on-the-job injury
- 5. PATHOPHYSIOLOGY When we get older dehydration sets in the disc resulting in disc space reduction Which leads to approximation of zygapophseal and facet joints Results in slackening of posterior logitudinal ligament
- 6. Leading to its detachment from periosteum due to increased intradiscal pressure resulting in disc extrusion Extruded disc material becomes fibrous and eventually gets calcified into a spur(osteophyte formation
- 7. CLINICAL SYMPTOMS Usually produces no symptoms Intermittent acute attacks of pain with total relief Morning low back stiffness after getting out of bed Pain that decreases with rest Low back tenderness Weakness, numbness, or tingling in the low back, legs, or feet Difficulty walking
- 8. DIAGNOSIS X-ray : These pictures are traditionally ordered as a first step in imaging the spine. X-rays will show aging changes, like loss of disc height or bone spurs. Magnetic resonance imaging (MRI) : This study can create better images of soft tissues, such as muscles, discs, nerves, and the spinal cord.
- 11. SURGICAL MANAGEMENT Surgery is reserved for patients who have severe pain that has not been relieved by other treatment. OPTIONS INCLUDE: Laminectomy Discectomies Foraminatomies Posterior lumbar interbody fusion
- 15. MEDICATIONS The goal of pharmacotherapy is to reduce pain and inflammation. Acetaminophen: Mild pain is often relieved with acetaminophen. Non-steroidal anti-inflammatory drugs (NSAIDs): Often prescribed with acetaminophen, drugs like ibuprofen and and naproxen are considered first-line medicines for neck pain. They address both pain and swelling, and may be prescribed for a number of weeks. Muscle relaxants: Medications such as cyclobenzaprine or carisoprodol can also be used in the case of painful muscle spasms.
- 16. PHYSIOTHERAPY Cryotherapy for acute pain Electrotherapy- Diapulse, Ultrasound, TENS Exercise therapy- Gentle spinal mobility exercises in early stages Gentle flexion rotatory manipulation Relaxed mobilisation of spine after recumbency
- 20. Ergonomic advice- proper lifting techniques restrict unwanted movements avoiding prolonged sitting or standing, and selecting the proper chair Workplace modifications and ergonomics serve to reduce strenuous back positions during work and leisure.
- 21. LUMBAR SPONDYLOLISTHESIS Greek word spondylos- Spine and olisthaneinto - slip. Forward translation of one vertebra on another in the sagittal plane of the spine Common at L4-L5 and L5- S1
- 22. ETIOLOGY Maldevelopment of superior articular facet Spondylolysis - defect in the pars interarticularis of lumbar vertebra Degenerative changes in facet joint Fracture of articular facets Pathologic causes like malignancy, osteoporosis
- 23. WILTSE,NEWMAN AND MC NAB CLASSIFICATION:- Type Name Description I Congenital Dysplastic abnormalities (Spina Bifida) II Isthmic Break in pars interarticularis A Lytic (stress fracture) B Healed fracture (elongated, intact) C Acute high energy fracture III Degenerative Ligamentous instability or facet joints degeneration IV Traumatic Fracture of hook other than pars (pedicle/lamina/facets) V Pathologic Underlying pathology (T.B., Neoplasms) VI Iatrogenic Surgical excision of posterior elements
- 24. PATHOPHYSIOLOGY DYSPLASTIC PATHWAY TRAUMATIC PATHWAY Congenitally illdeveloped pars interarticularis Repetitive activity at any age Microtrauma Weakened pars interarticularis People lifting heavy weights, improper repetitive strainful activity like driving Stress fracture Weakened pars interarticularis SPONDYLOLISTHESIS
- 25. Clinical Presentation Pain, may be unilateral or bilateral along the belt line History – repetitive activities/trauma Pain history- Chronic dull ache, constant/intermittent Aggravation: Hyperextension/rotation/prolong standing Relieve: Flexion/sitting down Radiation: initially no; later yes when pressure on nerve roots Lumbosacral instability Sway back posture Waddling gait Increased lumbar lordosis Localised tenderness Paraspinal muscle spam Palpable step sign Objective signs of motor weakness, reflex change and sensory deficit only seen with Severe slips.
- 26. PHALEN-DIXON SIGN sciatic crisis typically seen in high grade adolescent spondylolisthesis sign includes sciatic pain vertical sacrum and pelvis lumbosacral kyphosis tight hamstrings hyperlordotic lumbar spine waddling gait
- 27. DIAGNOSIS SPECIAL TESTS: One leg standing lumbar extension or Back walk over test- Position- standing Method- one leg standing spine extension Response- pain in back Interpretation- Pars interarticularis stress fracture SLR Test- usually negative; positive if sciatic nerve involvement Radiological Examination
- 28. Defect in the pars interarticularis – ‘collar’ around the ‘neck’ of an Illusory ‘dog’- oblique xray
- 29. Percentage of slip Percentage slip= Displacement of L5 on S1(x) X 100 Width of S1(y)
- 30. MEYERDING GRADING SYSTEM GRADING GRADE 1 displacement of 25% or less; GRADE 2 between 25% and 50% GRADE 3 between 50% and 75%; GRADE 4 more than 75% GRADE 5 the position of L5 completely below the top of the sacrum - SPONDYLOPTOSIS
- 32. SLIP ANGLE BY INTERSECTION OF A LINE DRAWN PARALLEL TO INFERIOR ASPECT OF L5 BODY AND LINE DRAWN PERPENDICULAR TO POSTERIOR ASPECT OF BODY OF S1.
- 33. ULLMANS SIGN A LINE DRAWN UPWARD FROM THE ANTERIOR SURFACE OF SACRUM NORMALLY IS PROJECTED AT OR IN FRONT OF THE ANTEROINFERIOR ANGLE OF BODY OF LAST LUMBAR VERTEBRA. WHEN ITS INTERSETED IT SHOWS FORWARD DISPLACEMENT.
- 34. MANAGEMENT
- 35. SURGICAL TREATMENT directed towards symptoms and etiology radiculopathy neurologic deficit from spinal stenosis instability pain discogenic pain OPTIONS INCLUDE: Decompression Fusions: i. posterolateral intertransverse fusion (PLF) ii. anterior lumbar interbody fusion (ALIF) iii. posterior lumbar interbody fusion (PLIF) iv. transforaminal interbody fusion (TLIF)
- 37. PHYSIOTHERAPY TREATMENT BRACING: Antilordotic total contact thoracolumbosacral moulded brace (orthosis) Bell et al. showed that adolescents with grade 1 and 2 isthmic spondylolisthesis who received brace treatment for 25 month were pain free and none had demonstrated a significant increase in slip percent.
- 38. PHYSIOTHERAPY TREATMENT Deep heat modality Correct posture- maintainence of flexion attitude is important Exercises Early stage- Relaxation and general mobility exercises Exaggerated lordosis obliterated in supine lying taught by active posterior pelvic tilt and its maintenance
- 39. Strong abdominal exercises-
- 41. Ergonomic advice Spinal extension exercises, which increase the lordosis further are containdicated Wrong body mechanics or excessive standing and ambulation may give rise to fracture of pars interarticularis so it should be restricted. Regular periods of prone lying and hams stretching- to control advancement of lordotic tendency.
- 42. Lumbar Radiculopathy Lumbar radiculopathy refers to disease caused by a compression of the spinal nerve root leading to its irritation and inflammation. This causes pain in the leg rather than in the lumbar spine, which is called "refered pain.“ Usual pattern is like a stripe down the leg
- 43. Causes a herniated disc, when a disc protrudes, compressing the nerve root sciatica degenerative disc disease bone spurs tumors of the spine OA spine/ Spondylosis spinal stenosis compression fractures spondylolisthesis scoliosis
- 44. Clinical symptoms Pain areas: in the back, buttocks, hip, or lower extremities Pain types: can be mild, severe, radiating, or sharp Muscular: difficulty walking or muscle weakness Sensory: leg numbness or pins and needles(hypersensitivity Also common: burning sensation, foot numbness, or weakness Reflex cahnges
- 47. Diagnosis X-rays are often obtained first. These can often identify the presence of trauma or osteoarthritis and early signs of tumor or infection. An MRI scan may then be obtained. This study provides the best look at the soft tissues around the spine including the nerves, the disc and the ligaments. If the patient is unable to obtain an MRI, they may obtain a CT scan instead to explore possible compression of the nerves. A nerve conduction study or electromyogram (EMG). These studies look at the electrical activity along the nerve and can show if there is damage to the nerve.
- 48. Special Tests Straight Leg Raise test (Lasègue test) Femoral Nerve Stretch Test Slump Test Lower Limb Tension Test(LLTT)
- 50. Femoral Nerve Stretch Test
- 52. Lower Limb Tension Test(LLTT) Sciatic Nerve: SLR, add. and internal rot.(hip), ankle dorsiflexion Tibial tract: ankle dorsiflexion with eversion Peroneal tract: ankle plantarflexion with inversion Sural nerve: ankle dorsiflexion with inversion
- 53. TREATMENT CONSERVATIVE Physical therapy and/or exercises that are designed to stabilize the spine and promote a more open space for spinal nerve roots are recommended. Medications Nonsteroidal anti-inflammatory drug Analgesic Muscle Relaxant Steroid Nerve pain medication Epidural steroid injections and nerve root injections
- 54. SURGICAL Surgical treatment can be varied depending on what causes the lumbar radiculopathy. Typically, these treatments involve some way of either decompressing the nerve or stabilizing the spine.It can include: Anterior Lumbar Interbody Fusion (ALIF) Extreme Lateral Interbody Fusion (XLIF) Lumbar Laminectomy Lumbar Microdiscectomy Laminotomy Lumbar Spinal Fusion Transforaminal Lumbar Interbody Fusion (TLIF) Posterior Lumbar Interbody Fusion (PLIF) Deformity correction
- 55. PHYSIOTHERAPY INTERVENTION Acute phase- moderate evidence for spinal manipulation for symptomatic relief Traction of the lower spine will also relieve the pain Stretching and Neural Tissue Mobilisation (NTM) Pain relief modalities- Hot pack, TENS, SWD, IFT Conditioning exercise- Flexibilty exc.’s, Pilates exercises, McKenzie exercise. Comprehensive rehabilitation program includes postural training, muscle reactivation, correction of flexibility and strength deficits, and subsequent progression to functional exercises.
- 74. THANKS