Anatomy: There are 24 bones or vertebrae that make up the spinal column in our back. Sometimes a stress fracture can occur in one of these bones and this condition is called spondylolysis. If the stress fracture weakens the bone so much that it is unable to maintain its proper position, the vertebra can start to shift or slip out of place. This condition is called spondylolisthesis Causes:In children the cause is usually due to the individual being born with a thin vertebral bone that is more susceptible to this condition. Periods of rapid growth may also make the vertebrae of adolescents more susceptible to slippage. In adults, the most common cause is abnormal wear on the cartilage and bones such as arthritis. Acute trauma is another cause. Lastly, overuse in certain activities that place a repetitive stress on the bones of the lower back can cause spondylolisthesis. Participation in sports such as gymnastics, weight lifting, and football, or any other activity in which the athlete is constantly overstretching or hyperextending the spine can lead to this condition. The result is a stress fracture on both sides of the bone.
Symptoms: In many people, spondylolysis and spondylolisthesis are present without any obvious symptoms. When symptoms due occur, pain usually spreads across the lower back. Other symptoms can include pain into the buttocks or legs, numbness or tingling, stiffness, muscle tightness, weakness, and alterations in gait.
Diagnosis: An x-ray is used to visualize the stress fracture and to measure and determine if any slippage has occurred. If the vertebrae pushes on any nerves a CT scan or MRI may also be needed to further evaluate treatment options.
Treatment: Physical Therapy: Treatment of this condition is usually non-surgical at least initially. The individual needs to rest from activities that increase pain and sport until symptoms go away. A physical therapy program will be used to stretch or help improve lumbar range of motion of the spine. Strengthening of the low back and abdominal muscles will also help to decrease symptoms and prevent the reoccurrence of symptoms in the future. If surgery is required, post-operative physical therapy will be beneficial in improving range of motion, strength, and helping the patient safely and effectively return to sport, work, and/or activity.
Physician: A physician will order needed x-rays and often prescribe anti-inflammatory medication and pain medication if needed. Surgery: Surgery may be needed if slippage progressively worsens, if back pain does not respond to nonsurgical treatment and pain begins to interfere with activities of daily living, or if too much slippage occurs and the bone begins to press on the spine or spinal nerves. A spinal fusion is performed between the lumbar vertebra and/or the sacrum to correct the slippage and place the bone back in its original alignment. The goal of spinal fusion surgery is to stop the motion at the painful vertebral segment.
Overview: Spinal stenosis occurs when you have narrowing of the spinal canal or neural foramen, putting pressure on your spinal cord or peripheral nerves. That pressure can cause pain, numbness or weakness in your back, neck, shoulders or limbs. The most common cause is degenerative changes in the spine as people age. As the intervertebral discs lose height and the body adds bone around the vertebrae there can be narrowing of the openings for the spinal cord or nerves. If your spinal stenosis is severe, you may need surgery.
Anatomy: The spine is a column of connected bones called vertebrae. There are 24 vertebrae in the spine, plus the sacrum and tailbone (coccyx). Most adults have 7 vertebrae in the neck (the cervical vertebrae), 12 from the shoulders to the waist (the thoracic vertebrae), and 5 in the lower back (the lumbar vertebrae). The sacrum is made up of 5 vertebrae between the hipbones that are fused into one bone. The coccyx is made up of a small fused bone at the end of the spine. The spinal cord, the thick bundle of nerves that extends downward from the brain, passes through a ring in each vertebra. Those rings line up into a channel called the spinal canal. Between each vertebra, two nerves branch out off of the spinal cord (one to the right and one to the left). Those nerves exit the spine through openings called foramen and travel to all parts of your body. Normally the spinal canal and neural foramen are round enough for the spinal cord and nerves to exit without compression but as the degenerative process progresses in the spine this can change.
Causes: While some people have no signs or symptoms, spinal stenosis can cause pain, numbness, muscle weakness, and problems with bladder or bowel function. Spinal stenosis is most commonly caused by wear-and-tear changes in the spine related to aging. While some people are born with a small spinal canal, most spinal stenosis occurs when something happens to reduce the amount of space available within the spine. Some potential causes of spinal stenosis may include:
Wear and tear on your spinal bones can prompt the formation of bone spurs, which can grow into the spinal canal.
Intervertebral discs are the soft cushions that act as shock absorbers between your vertebrae and they may allow some of the soft inner material to escape and press on the spinal cord or nerves.
Ligaments that help hold the bones of your spine together can become stiff and thicken over time. These thicker ligaments can bulge into the spinal canal.
Tumors are abnormal growths that can form inside the spinal cord. These tumors can grow within the membranes that cover the spinal cord or in the space between the spinal cord and vertebrae.
Car accidents and other major trauma can cause dislocations or fractures of one or more vertebrae. Displaced bone from a spinal fracture may damage the contents of the spinal canal. Swelling of adjacent tissue immediately following back surgery also can put pressure on the spinal cord or nerves.
Symptoms: Many people have evidence of spinal stenosis on X-rays, but they might not have signs or symptoms. When symptoms do occur, they often start gradually and worsen over time. Symptoms vary, depending on the vertebral level of the stenosis.
Stenosis in neck can cause numbness, weakness or tingling in a leg, foot, arm or hand. In severe cases, nerves to the bladder or bowel may be affected, leading to incontinence. Often if you look up at the sky and get sx into both arms or legs this can be a tell tale sign of cervical stenosis.
Stenosis in the lower backcan cause pain or cramping in your legs when you stand for long periods of time or when you walk. The discomfort usually eases when you bend forward or sit down. Immediate resolution of back or leg pain when sitting is usually a good indicator of lumbar or low back stenosis. Severe cases of spinal stenosis may cause:
Arm and leg weakness
Incontinence (inability to control bladder or bowel)
Diagnosis: Spinal stenosis can be difficult to diagnose because its signs and symptoms resemble those of many age-related conditions. Imaging tests may be needed to help pinpoint the true cause of your signs and symptoms. Often the most effective way of diagnosing spinal stenosis is clinical; meaning combining information from questioning of the patient with measures that are taken during a physical examination. The clinical presentation of spinal stenosis can frequently be quite unique and not difficult to diagnose when a good examination is done.
Imaging tests can be used to help diagnosis spinal stenosis as well. These tests may include:
X-rays. Although an X-ray isn’t likely to confirm that you have spinal stenosis, it can help rule out other problems that cause similar symptoms.
Magnetic resonance imaging (MRI). In most cases, this is the imaging test of choice for diagnosing spinal stenosis. Instead of X-rays, an MRI uses a powerful magnet and radio waves to produce cross-sectional images of your spine. The test can detect damage to your disks and ligaments, as well as the presence of tumors. Most important, it can show pressure on the spinal cord or spinal nerves.
CT scan. Computerized tomography (CT) combines X-ray images taken from many different angles to produce detailed, cross-sectional images of your body — including the shape and size of your spinal canal.
Treatment-Surgical: In severe cases of spinal stenosis, doctors may recommend surgery to create additional space for the spinal cord or nerves. Surgery may be considered if:
More conservative treatments haven’t helped
You are disabled by your symptoms
You are having progressive weakness or losing control of bowel and bladder
The goal of surgery is to relieve the pressure on your spinal cord or nerve roots. This can be accomplished by decompressing the nerve root through increasing size of the neural foramen or improving alignment of the spine with a spinal fusion. A spinal fusion restores proper spine alignment while maintaining strength and stability. Surgery is often very successful at relieving pressure on the spinal cord or peripheral nerves though it often does not abolish all low back pain.
Treatment–Non–surgical: The type of treatment you receive for spinal stenosis may vary depending on the location of the stenosis and the severity of your signs and symptoms. Medications To control pain associated with spinal stenosis, your doctor may prescribe:
Nonsteroidal anti-inflammatory drugs (NSAIDs) help relieve pain and reduce inflammation. Some NSAIDs, such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve), are available without prescription.
Medications such as cyclobenzaprine (Amrix, Flexeril) can calm the muscle spasms that sometimes occur with spinal stenosis.
Nightly doses of tricyclic antidepressants, such as amitriptyline, can help ease chronic pain.
Some anti-seizure drugs, such as gabapentin (Neurontin, Gralise) and pregabalin (Lyrica), are used to reduce pain caused by nerve root irritation.
Physical Therapy for Spinal Stenosis: The most important aspect of physical therapy for spinal stenosis is the initial evaluation to ensure the source of your symptoms is in fact stenosis. Often patients are treated unsuccessfully because they have a diagnostic test reporting stenosis but that is not the main cause of their pain. Flexion exercises, core strengthening, lower extremity stretching, and mechanical traction are all treatments used to improve symptoms from spinal stenosis. The goal in physical therapy is to teach the patient how to successfully manage the condition because the degenerative process cannot be reversed. We are often very successful at getting patients back to their desired level of function with exercise and management tips. The following home treatments might help:
Hot or cold packs. Some symptoms of cervical spinal stenosis may be relieved by applying heat or ice to your neck.
Canes or walkers. In addition to providing stability, these assistive devices can help relieve pain by allowing you to bend forward while walking.
When to see a doctor Make an appointment with your doctor if you have persistent pain, numbness or weakness in your neck, back, legs or arms. Most people with spinal stenosis have passed the age of 50. When younger people develop spinal stenosis, the cause is typically a genetic disease affecting bone and muscle development throughout the body.
Anatomy: The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.
From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The mid back, or thoracic spine, curves outward. The outward curve of the thoracic spine is called kyphosis. The low back, also called the lumbar spine, curves slightly inward. An inward curve of the spine is called lordosis. A scoliosis is when the spine curves in the shape of a “C” or “S” and is different from the normal curves of the spine. The scoliosis can cause these vertebrae to rotate or turn which leads to one hip or shoulder being higher than the other one. In more severe cases the chest cavity can be effected and may leave less space for the chest organs. When this takes place the patients ability to breath deeply can be compromised.
Causes: The cause of scoliosis is typically “idiopathic” meaning there is no known cause. Sometimes the cause of the scoliosis is muscle spasm and usually in this case there is an underlying neurologic diagnosis such as spina bifida or cerbral palsy. Scoliosis occurs more often in girls and is often not severe enough to require any treatment.
Symptoms: Scoliosis does not typically cause any pain unless it becomes severe. We frequently see patients that believe a scoliosis is the cause of there pain when in fact they have a straightforward back problem that is unrelated to the mild scoliosis. In severe cases pain, neurologic dysfunction, or respiratory problems can be caused but the scoliosis is typically greater than 50º and this is rare.
Diagnosis: Scoliosis is relatively easily diagnosed. Your doctor or medical professional can diagnose a scoliosis by lifting the patients shirt and having them bend forward. This makes the spine easier to see and will usually show an abnormal curve. Further investigation can be done with X-ray to determine the degree measurement of the scoliosis.
Frequency of scoliosis: Scoliosis curves measuring at least 10° occur in 1.5% to 3.0% of the population Curves exceeding 20° occur in 0.3% to 0.5% of the population Curves exceeding 30° occcur in 0.2% to 0.3% of the population
Treatment: Physical Therapy: As stated earlier, scoliosis does not typically cause pain so when we get a referral for back pain from a scoliosis we do a thorough evaluation to determine the source of the back pain. In the event the scoliosis is not the source of pain we treat as we would most adolescents with back pain; posture, flexibility, and specific spine strengthening. If the scoliosis is the source of the pain we will try strengthening of the spine though this does not typically eliminate or stop the progression of scoliosis.
Physician treatment: If the curve is less than 20º or the child is near skeletal maturity the doctor may choose to observe it and routinely check every 3-6 months for progression. Bracing can be used for more severe cases 25º-45º in children that are still growing. This approach can be successful at preventing the curvature from becoming worse. This x-ray of a patient’s scoliosis measures 82° in the upper curve, and 75° in the lower curve. Surgery: Those adolescents who have a curve greater than 40º to 50º are considered for surgery. The goal of the surgery is to create a spinal fusion to stop the curve from getting any worse. Rods and screws are used as well as donated bone either from the bone bank or the patient. The surgery will typically correct the curve in the spine though not totally in many cases. Once the patients have recovered from surgery there is typically little pain. In 6-9 months the patients can return to full activity. Due to the resultant limitation in spinal motion from the fusion these kids are discouraged from playing contact sports.
Definition: Sciatica refers to a series of symptoms that describe pain or other sensations related to the low back area, or one or both lower extremities due to compromise of nerve tissue in the low back or lumbar spine. These symptoms may be referred to as back pain, low back pain, or lumbar radiculopathy as it may be called in some cases.
Anatomy: The anatomical structures involved in sciatica are the basic spinal unit comprised of two vertebrae and the intervertebral disc that lies between these to two bony structures which make up the spinal column. Equally the spinal cord and one or both spinal nerve roots in the adjacent area as well. (See Figure)
CAUSES: The primary cause of Sciatica involves the irritation of a specific nerve or nerve root by pressure resulting from the bulging or extrusion of the intervertebral disc. Most often the fluid or nucleus within the disc has exerted pressure on the nerve by a bulge or rupture of the disc wall that allows the fluid to move into the spinal canal and interfere with the nerve’s ability to carry on its normal function. Other causes include osteoarthritis, spinal stenosis or narrowing of the spinal canal, and rarely tumors of specific origins.
SYMPTOMS: Symptoms of Sciatica may involve but are not limited to pain, numbness or tingling, loss of normal sensation and even loss of reflexes in the lower extremity. Muscle weakness of specific muscles or muscle groups may occur as symptoms persist. These may occur in one leg or both. On occasion in more severe cases loss or compromise of normal bowel or bladder function may occur. These latter symptoms should not be ignored and medical attention shoulder by sought immediately.
DIAGNOSIS: In the majority of cases Sciatica is made with a clinical diagnosis. This means that your doctor will take a current history and perform an examination to assess pertinent medical findings. This examination will usually include assessing motion of the lumbar spine, a neurological exam to determine any nerve root involvement, and often basic X-Rays. Some cases may need further testing such as an MRI or other specialized testing to fully assess your specific case related to your symptoms.
FREQUENCY: Sciatica is one of the most common low back or spinal conditions that present for treatment. Studies continue to suggest that about 80% of us will experience back pain of this nature at some time in our life and about 90% of those may have some regular episodes of recurrence of such pain. TREATMENT: Treatment of Sciatica follows two basic approaches. These include the most common conservative and less frequent surgical approach. Conservative treatment involves several components that may include anti-inflammatory medications, muscle relaxants and pain medications used to modulate pain. Your doctor may include a brief period of rest from precipitating activities as well. Most often your doctor should include Physical Therapy. This will usually consist of specific exercises that are designed to restore motion and function while relieving pain and allowing you to resume most activities on a gradual basis. These include back specific exercises and general conditioning as well as stabilization and strengthening exercises to limit future flair-ups as often possible. Surgical intervention, if other measures fail, is designed to relieve pressure that the disc may be exerting on the particular nerve and therefore causing pain. Surgery involves brief hospitalization and usually rehabilitation post operatively to help restore functional ability as well as strength and endurance.
One Level Spinal Fusion
Anatomy: Small bones, called vertebrae stack on top of each other to form the spine. There are seven cervical, twelve thoracic, and five lumbar vertebrae, creating the natural curves important for support, balance, and flexibility. Intervertebral discs, made of a jelly-like nucleus pulposus and an innervated annulus fibrosus, act as shock absorbers. Facet joints, located between the back of the vertebrae, allow rotation of the spine. Spinal fusion is a surgical procedure that permanently joins one or more vertebrae with the goal of decreasing painful motion and/or improving stability. A one-level fusion requires fusing two vertebrae to stop motion at one segment.
Causes: Abnormal movement or rubbing together of the vertebra may occur from: Degenerative disc disease, spondylolisthesis, spinal stenosis, scoliosis, fracture, infection, or tumor.
Symptoms: Pain in the neck, back, arms, or legs; Difficulty with standing upright or maintaining posture ; Inability to bend and twist. Diagnosis: Physical examination, X-Ray, computed tomography (CT), magnetic resonance imaging (MRI) scans
Non Surgical Treatment: Consult a physical therapist credentialed in Mechanical Diagnosis and Therapy from the McKenzie Institute for exercise, postural correction, and proper lifting review.
Surgery: Types of fusions: Anterior, Posterior, or Lateral approach. Using your body’s natural healing; using bone from another place in your body (autograph); using bone from a bone bank (allograft); metal devices; ceramics. For a successful fusion, it is important to quit smoking as it will decrease blood circulation and increase risk for infection. A physical therapist will help with return to normal life activity and safely introduce exercises and low-impact aerobic activity.
Spinal Cord Injury
Spinal cord injury (SCI) is damage to any part of the spinal cord or the nerves at the end of the spinal cord. If an injury to the spinal cord occurs, it will likely affect significant parts of a patient’s daily life. What is the spinal cord? The spinal cord lies within the vertebral column or the bones in the neck and back. Its job is to carry signals to and from the brain and the rest of the body. It is divided into 4 sections. The top portion of the spinal cord/column is the cervical area which has seven vertebrae or bones and eight pairs of cervical nerves. These are identified as bones C1-C7 and nerves C-1 through C-8. The next area is called the thoracic spine or chest area. There are 12 bones and 12 pairs of thoracic nerves (T-1 through t-12). The lower back is called the lumbar spine. There are 5 lumbar bones and 5 pairs of nerves that exit the spinal column in this area (L-1 through L-5). The bottom section is the sacral area. There are 5 fused vertebrae and the coccyx or tail bone. This section contains nerve pairs S1 through S5 and a nerve pair at the very end called coccygeal nerves. The two areas of the spinal cord most commonly injured are the cervical spine and the lumbar spine. How does SCI occur? In most spinal cord injuries, the vertebrae (bones of the back) or disc material compress or pinch the spinal cord causing it to become bruised and swollen. Sometimes the injury may also tear the spinal cord. The vertebral bones can also shatter, causing the spinal cord to be punctured by a sharp fragment of bone. Common causes of injury are trauma including car accidents, diving accidents, gun shot wounds, or other trauma. SCI can also be non-traumatic and be caused by infection or disease such as transverse myelitis, polio, or spinal bifida. Victims of spinal cord injuries will suffer loss of feeling and function in certain parts of their body. In milder cases, a victim might only suffer loss of hand or foot function. More severe injuries may result in paraplegia or tetraplegia (see definitions below).
After a SCI all the nerves above the injury continue to work normally but at the level of injury, the nerve messages are unable to be transmitted from above that level to the level below the injury. The level of injury and whether the injury is complete or incomplete will determine how well an individual continues to function. Depending on the severity of injury, the resulting paralysis can result in an inability to breathe on one’s own; paralysis and/or loss of feeling in parts of the head, neck, trunk, arms, and/or legs; weakness; numbness; and loss of bowel and bladder control. There are also many secondary issues such as pressure sores/skin breakdown, respiratory problems, and difficulty controlling blood pressure.
Tetraplegia vs. Paraplegia Tetraplegia (also known as quadriplegia) is typically an injury to the cervical region. This individual can experience a loss of feeling and/or movements in their head, respiratory muscles, neck, arms, trunk, legs, and feet. Paraplegia is an injury in the thoracic, lumbar, or sacral areas (most commonly lumbar). This individual can experience loss of feeling and/or movement to the trunk, legs, and feet.
Complete vs. Incomplete Complete injuries are injuries in which all the ability to control movement are lost below the level of injury in the spinal cord. Incomplete injuries are injuries in which there is still some motor or sensory function below the affected area (or level of the spinal cord). There are varying degrees of incomplete injury. For example the triceps or the muscles that straighten the elbow are controlled by the C7 nerves. If an individual has a C5 complete injury they will have no function of the muscle at all. If the injury is incomplete they may have some movement of the triceps muscle and muscles that control the hand but still not have any control of the muscles in the trunk or lower extremities. This will vary greatly in each individual.
How can physical/occupational therapy help? SCI’s are life changing events. As a physical therapist, our job is to help individuals regain as much function as possible and help them to become as independent as possible. Physical therapy differs significantly for each individual and their level of injury. It will include strengthening, stretching, endurance exercises, transfer training (moving chair to chair, bed to chair, toilet to chair, etc.), patient education, and problem solving to come up with ways that an individual can complete activities of daily living. After a SCI, a patient will typically need multiple levels of physical therapy from in-patient, to rehabilitation hospital to outpatient therapy.
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