Spinal Canal Narrowing at Disc Level Between T6 – T7/Lumbar spinal stenosis is a narrowing of the spinal canal in the lower part of your back. Stenosis, which means narrowing, can cause pressure on your spinal cord or the nerves that go from your spinal cord to your muscles. Spinal stenosis can happen in any part of your spine but is most common in the lower back.
Spinal stenosis is a condition that is caused by the narrowing of the central canal, the lateral recess, or neural foramen. This condition can cause significant discomfort, interfere with activities of daily living, and may result in progressive disability.[rx][rx][rx] With the increasing longevity of humankind, degenerative diseases of the spine and its sequelae are bound to have an immense negative impact on the global front.[rx] It is important to appreciate that spinal stenosis is part of the aging process, and predicting who will develop symptoms is not always easy.
|Anatomic area||Anatomic region (local segment)|
|Congenital forms of spondylolisthesis|
|Degenerative and inflammatory||Osteoarthritis|
|Diffuse Idiopathic skeletal hyperostosis|
|Degenerative forms of spondylolisthesis|
Causes of Spinal Canal Narrowing at Disc Level Between T6 – T7
Spinal stenosis/narrowing of the spinal canal most commonly is caused by degenerative osteoarthritis of the spine or spondylosis and occurs most frequently at the L4 to L5 level, followed by L5 through S1 and L3 to L4. Additional risk factors include obesity or a family history of this condition. Other factors such as disc protrusion or bulging (for example, caused by progressive disc degeneration with aging or trauma), loss of disc height, facet joint arthropathy, osteophyte formation, or ligament flavum hypertrophy can all lead to encroachment on and narrowing of the central canal and neural foramina.[rx][rx]
Spondylolisthesis, the translation of one vertebral body anteriorly or posteriorly relative to an adjacent vertebral body, may also exacerbate spinal canal narrowing.
Additional acquired causes of spinal stenosis include space-occupying lesions such as synovial or neural cysts, neoplasms, or lipomas; traumatic or postoperative changes such as fibrosis; and skeletal diseases such as ankylosing spondylitis, rheumatoid arthritis, or Paget disease.
Congenital or developmental causes of spinal stenosis include dwarfism, namely achondroplasia, Morquio syndrome, and spinal dysraphism such as spina bifida, spondylolisthesis, and myelomeningocele.
Spinal stenosis is most commonly classified as either primary, caused by congenital abnormalities or a disorder of postnatal development,(rx) or secondary (acquired stenosis) resulting from degenerative changes or as consequences of local infection, trauma, or surgery. The focus of this review is on the most common cause, a slowly progressive degenerative process that predominates at the three lower lumbar levels.(rx) The natural history of spinal stenosis remains poorly understood with studies reporting about half of the patients remain clinically stable, with a quarter worsening or improving.(rx) For any individual patient, the course can be unpredictable with flares and stable periods over time.(rx)
Degenerative LSS anatomically can involve the central canal, lateral recess, foramina, or any combination of these locations. Central canal stenosis may result from a decrease in the anteroposterior, transversal, or combined diameter secondary to loss of disc height with or without bulging of the intervertebral disc, and hypertrophy of the facet joints and the ligament flavum. Fibrosis is the main cause of ligamentum flavum hypertrophy and is caused by accumulated mechanical stress, especially along the dorsal aspect of the ligamentum flavum. Transforming growth factor (TGF)-β released by the endothelial cells may stimulate fibrosis, especially during the early phase of hypertrophy. (rx) The same processes, decreased disc height, facet joint hypertrophy (with or without spondylolisthesis), and/or vertebral endplate osteophytosis can also result in lateral recess stenosis. Foraminal stenosis can be either anteroposterior resulting from a combination of disc space narrowing and overgrowth of structures anterior to the facet joint capsule and/or vertical resulting from posterolateral osteophytes from the vertebral endplates protruding into the foramen along with a laterally bulging annulus fibrosis or herniated disc that compresses the nerve root against the superior pedicle. (rx) Foraminal stenosis more frequently involves the L5 nerve root, as the L5-S1 foramen is the one with the smaller foramen/root area ratio.(rx)
Symptoms of Spinal Canal Narrowing at Disc Level Between T6 – T7
This presentation is attributable to the sequence of Porter’s concept of two-level stenosis, narrowing of the spinal canal vascular compromise due to central stenosis, and the compression of a nerve root due to degenerative pathology due to lateral stenosis.[rx]
- Neurogenic claudication refers to leg symptoms encompassing the buttock, groin, and anterior thigh, as well as radiation down the posterior part of the leg to the feet. In addition to pain, leg symptoms can include fatigue, heaviness, weakness, and/or paresthesia.
- Patients with LSS also can report nocturnal leg cramps(rx) and neurogenic bladder symptoms.(rx)
- Symptoms of spinal stenosis narrowing of the spinal canal, generally as a result of spinal nerve root involvement within the lumbar spinal canal, may include general discomfort, weakness in the legs, numbness, or paresthesias.
- A key feature of neurogenic claudication is its relationship to the patient’s posture where lumbar extension increases, and flexion decreases pain, thereby attributing a specific “simian stance” seen among these subsets of patients.
- The same phenomenon is accountable for better tolerance to climbing uphill compared to downhill walking.[rx] Pain is exacerbated by walking, standing, or upright exercises.
- Pain relief occurs with sitting or forward flexion at the waist such as involved with squatting, leaning forward, or lying down. Many patients are asymptomatic when inactive.
- Extending the back while standing leading to the development of symptoms which promptly resolve by subsequently leaning forward 20 to 40 degrees at the waist a classic presentation.
- Standing discomfort (94%)
- Discomfort/pain, in the shoulder, arm, hand (78%)
- Bilateral symptoms (68%)
- Numbness at or below the level of involvement (63%)
- Weakness at or below the level of involvement (43%)
- Pain or weakness in buttock/thigh only (8%)
- Pain or weakness below the knee (3%)[rx]
- Cervical (spondylotic) myelopathy,[rx] a syndrome caused by compression of the cervical spinal cord and narrowing of the spinal canal which is associated with “numb and clumsy hands”, imbalance, loss of bladder and bowel control, and weakness that can progress to paralysis.
- Pinched nerve,[rx] causing numbness.
- Intermittent neurogenic claudication characterized by lower limb numbness, weakness, diffuse or radicular leg pain associated with paresthesia (bilaterally),[rx] weakness, and/or heaviness in buttocks radiating into lower extremities with walking or prolonged standing.[rx]
- Symptoms occur with extension of the spine and are relieved with spine flexion. Minimal to zero symptoms when seated or supine.[rx]
- Radiculopathy (with or without radicular pain)[rx] neurologic condition—nerve root dysfunction causes objective signs such as weakness, loss of sensation, and of reflex.
- Lower extremity pain, weakness, numbness that may involve perineum and buttocks, associated with bladder and bowel dysfunction.
- Lower back pain[rx][rx] due to degenerative disc or joint changes with narrowing of the spinal canal.
Diagnosis of Spinal Canal Narrowing at Disc Level Between T6 – T7
History in these patients should include the chief complaint, onset of symptoms, alleviating and aggravating factors, radicular symptoms, and any past treatments history and previous treatment history, or surgery. The most common subjective complaints are axial lumbar pain and ipsilateral arm pain or paresthesias in the associated dermatomal distribution.
|Q1||Numbness and/or pain in the thighs down to the calves and shins.|
|Q2||Numbness and/or pain increase in intensity after walking for a while, but are relieved by taking a rest.|
|Q3||Standing for a while brings on numbness and/or pain in the thighs down to the calves and shins.|
|Q4||Numbness and/or pain are reduced by bending forward.|
|Key questions for diagnosis of cauda equina symptoms:|
|Q5||Numbness is present in both legs.|
|Q6||Numbness is present in the soles of both feet|
|Q7||Numbness arises around the buttocks.|
|Q8||Numbness is present, but the pain is absent.|
|Q)||A burning sensation arises around the buttocks.|
|Q10||Walking nearly causes urination.|
A careful neurological examination can help in localizing the level of the compression. The sensory loss, weakness, pain location, and reflex loss associated with the different levels are described above. A thorough neurological examination is necessary to evaluate sensory disturbances, motor weakness, and deep tendon reflex abnormalities. Typical findings of solitary nerve lesion due to compression by a herniated disc with bulging in the lumbar spine
- L1 Nerve – pain and sensory loss are common in the inguinal region. Hip flexion weakness is rare, and no stretch reflex is affected.
L2-L3-L4 Nerves – back pain radiating into the anterior thigh and medial lower leg; sensory loss to the anterior thigh and sometimes medial lower leg; hip flexion and adduction weakness, knee extension weakness; decreased patellar reflex.
L5 Nerve – back, radiating into buttock, lateral thigh, lateral calf and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex.
S1 Nerve – back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot; weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction.
S2-S4 Nerves – sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex.
A physical exam for diagnosing disc pain may include one or more of the following tests
- Palpation – Palpating (feeling by hand) certain structures can help identify the pain source. For example, worsened pain when pressure is applied to the spine may indicate sensitivity caused by a damaged disc.
- Movement tests – Tests that assess the spine’s range of motion may include bending the neck or torso forward, backward, or to the side. Additionally, if raising one leg in front of the body worsens leg pain, it can indicate a lumbar herniated disc (straight leg raise test).
- Muscle strength – A neurological exam may be conducted to assess muscle strength and determine if a nerve root is compressed by a herniated disc. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle atrophy, or other abnormal movements.
- Reflex test – Nerve root irritation can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine.
- A medical history – in which you answer questions about your health, symptoms, and activity.
- A physical exam to assess your strength – reflexes, sensation, stability, alignment, and motion. You may also need blood tests.
- Laboratory testing – may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
- Elevated ESR – could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
- Elevated CRP – levels are associated with infection.
- X-rays – view the bony vertebrae in your spine and can tell your doctor if any of them are too close together or whether you have arthritic changes, bone spurs, or fractures narrowing of the spinal canal. It’s not possible to diagnose a herniated disc with paracentral disc herniation in this test alone.
- Magnetic Resonance Imaging (MRI) scan – is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with a bulging disc and paracentral disc herniation. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression. It can also detect bony overgrowth, spinal cord tumors, abscesses, or narrowing of the spinal canal.
- A myelogram – is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, a bulging disc paracentral disc herniation, in detail. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, narrowing of the spinal can spinal cord tumors, and abscesses.
- Computed Tomography (CT) scan – is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc and narrowing of the spinal canals are damaged.
- Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc, paracentral disc herniation.
- Discogram – A discogram may be recommended to confirm which bulging disc is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure. Electrodiagnostic evidence of fibrillation potentials and the absence of a tibial H-wave may aid in further confirming the diagnosis of lumbar canal stenosis.[rx]
Treatment of Spinal Canal Narrowing at Disc Level Between T6 – T7
- Spine-Specialized physical therapy – typically includes a combination of stretching, strengthening, and aerobic exercise to provide better stability and support for the spine.
- Massage therapy – can help reduce muscle tension and muscle spasms, which may add to back or neck pain. Muscle tension is especially common around an unstable spinal segment where a disc is unable to provide the necessary support
- Ice & Moist Heat Application – Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provides the same benefit.
- Hot Bath – Taking a hot bath or shower also helps in dulling the pain from a disc bulge. Epsom salts or essential oils can be added to a hot bath. They will help in soothing the inflamed region.
Collar Immobilization – In patients with acute neck pain, a short course (approximately one week) of collar immobilization may be beneficial during the acute inflammatory period.
Traction – This May be beneficial in reducing the radicular symptoms associated with disc herniations. Traction is the best essential treatment for bulging discs, narrowing of the spinal canal, pinched nerves, radiating pain management. It can be done in a manual and dynamic way to relieves pain in bulging discs. Theoretically, traction would widen the neuroforamen and relieve the stress placed on the affected nerve, which, in turn, would result in the improvement of symptoms. This therapy involves placing approximately 8 to 12 lbs of traction at an angle of approximately 24 degrees of neck flexion over a period of 15 to 20 minutes.
- Massage therapy – may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower back pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
- Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
- Spinal manipulation – is a widely-used method of treating back pain, although there is no evidence of long-term benefits. Complications from manipulation are rare and can include worsening radiculopathy, myelopathy, spinal cord injury, and vertebral artery injury. These complications occur ranging from 5 to 10 per 10 million manipulations.
- Back school – is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether the back school is effective or not.
- Patient education – on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk)
- Physical therapy – which may include ultrasound, massage, conditioning, and exercise. The goal of physical therapy is to help you return to full activity as soon as possible and prevent re-injury. Physical therapists can instruct you on proper posture, lifting, and walking techniques, and they’ll work with you to strengthen your lower back, leg, and stomach muscles. They’ll also encourage you to stretch and increase the flexibility of your spine and legs. Exercise and strengthening exercises are key elements to your treatment and should become part of your life-long fitness. Physiotherapy is an accepted treatment for LSS. Physiotherapy related treatments include, but are not limited to:
Exercise (aerobic, strength, flexibility)
Specific exercises in lumbar flexion (cycling)
Bodyweight supported treadmill walking
Muscle coordination training
Lumbar semi-rigid orthosis
Braces and corsets
Pain-relieving treatments (heat, ice, electrical stimulation, massage, ultrasound)
One study found that treatments most commonly used by patients are massage (27%), strengthening exercises (23%), flexibility exercises (18%), and heat or ice (14%), whereas physiotherapists most often advocate flexibility exercises (87%), stabilization exercises (86%), strengthening exercises (83%), heat or ice (76%), acupuncture (63%), and joint mobilization (62%).[rx]
- Over the Door Traction – This is a very effective treatment for a disc bulge. It helps in relieving muscle spasms and pain. Typically a 5 to 10-pound weight is used and it is important that patients do this under medical guidance.
- Weight control – By keto diet or maintaining or changing the food habit to reduce the weight not any movement during the time of acute pain.
- Use of lumbosacral back support – Generally, back braces are categorized as flexible, semi-rigid, and rigid. Rigid braces tend to be used for moderate to severe cases of pain and/or instability, such as to assist healing of spinal fractures or after back surgery. Semi-rigid and flexible braces are used for more mild or moderate pain.
- Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal back pain of all types of lumbar disc disease. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID, and narrowing of the spinal canal. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
- In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.
- Analgesics – Such as paracetamol and prescription-strength drugs that relieve pain but not inflammation.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenac, etoricoxib, ibuprofen, and naproxen.
- Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
- Dietary supplement – to remove general weakness & improved health.
- Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
- Oral Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation throughout the skin.
- Steroid injections The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves (Fig. 3). About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with physical therapy and/or a home exercise program.
- epidural steroid injection. A steroid solution is injected into the epidural space (outer layer of the spinal canal) to reduce inflammation. This injection is by far the most common one used for herniated discs.
- Selective nerve root injection. A steroid solution and anesthetic is injected near the spinal nerve as it exits through the intervertebral foramen. This injection is also used to help diagnose which nerve root might be causing pain.
- Microdiscectomy – for a herniated disc, a minimally invasive procedure in which the herniated portion of the disc is removed.
- Artificial disc replacement – for degenerative disc disease and herniated discs is a minimally invasive procedure that replaces a damaged disc with a specialized implant that mimics the normal function of the disc, maintaining mobility.
- Spinal fusion – fusion for degenerative disc disease, in which the disc space is fused together to remove motion at the spinal segment. Spinal fusion involves setting up a bone graft, as well as possible implanted instruments, to facilitate bone growth across the facet joints. Fusion occurs after the surgery.
- Open Back Surgery – Traditionally, bulging discs are treated with an open back procedure, meaning the surgeon makes a large incision into the skin and cuts muscle and surrounding tissue to gain access to the problematic disc. This traditional surgical option is invasive, requires overnight hospitalization, general anesthesia, and requires a lengthy recovery coupled with strong pain medication.
- Endoscopic Surgery – Fortunately, you have a second option with endoscopic spine surgery. Thanks to the advancement of surgical technology a bulged disc surgery can be performed using endoscopic procedures, meaning the surgeon makes a small incision to insert special surgical tools. During an endoscopic bulging disc operation, the surgeon uses a tiny camera to visualize and gain access to your damaged disc. This minimally invasive new approach offers shorter recovery, easier rehabilitation, and a much higher success rate than open back or neck surgery. A local anesthetic is all that is usually required.
Surgery is for only those who fail repeated nonoperative treatments.[rx] In most cases, surgical treatment of spinal stenosis narrowing of the spinal canal is elective, aimed at improving symptoms and function rather than preventing neurologic complications, and merits consideration only after attempting nonsurgical modalities, or if a patient’s symptoms result in disability. If a patient presents with rapidly progressive neurological deficits or if there is the presence of bladder dysfunction, urgent surgery is necessary. This situation may present in cases of cauda equina syndrome, conus medullaris syndrome, trauma, or an intraspinal canal tumor. The surgical approach is multilevel decompressive laminectomy with or without lumbar fusion. Lumbar fusion is generally reserved for patients with spondylolisthesis.[rx][rx][rx][rx]
Patients with symptomatic spinal stenosis treated surgically maintain substantially greater clinical improvement than those treated nonsurgical.[rx] For patients with lumbar stenosis without spondylolisthesis, a decompression alone is recommended.[rx] The Spine Patient Outcomes Research Trial (SPORT) provided level II evidence indicating laminectomy and fusion did provide better results than nonoperative approaches.[rx]
The golden rule in performing these procedures has its basis in the concept that underperforming leads to the failed back syndrome, whereas overdosing leads to instability.[rx] Laminectomy accounts for significant blood loss, surgical site pain, prolonged hospital stay, and weakening paraspinal muscles, thereby leading to possible spinal instability.[rx] To minimize this outcome, surgeons rely on newer surgical techniques such as laminoplasty, hemilaminectomy, laminotomy, and undercutting laminotomies. However, no statistically significant differences appear in the literature between laminectomy and laminotomy in terms of clinical outcomes.[rx] Preservation of the posterior elements or the “posterior tension band” is the most important factor in preventing instability. However, during minimal invasive approaches such as the endoscopic interlaminar approach and bilateral laminotomy, there is an increased risk for neural injury.[rx][rx] However, following a learning curve period, data shows the risk of dural tears to be substantially reduced (5 to 15% in laminectomy vs. 2 to 6% in laminotomy).[rx]
Another major issue in the minimally invasive spine (MIS) approaches shows in higher rates of reoperation for residual stenosis not adequately addressed in the initial operation.[rx] On the other hand, the Spinal Laminectomy versus Instrumented Pedicle Screw (SLIP) study provided level I evidence supporting decompression with fusion since one-third of patients undergoing standalone laminectomy developed instability within four years.[rx] The key issue is identifying those subsets of patients who are at risk of postoperative spinal instability in cases of grade I spondylolisthesis.[rx]
Lumbar fusion was associated with meaningful improvement in overall physical health-related quality of life than laminectomy alone.[rx] Paradoxically spinal fusion surgeries account for the highest aggregate hospital costs of any surgical procedure performed in U.S. hospitals.[rx] Advocating the same guidelines for patients in the middle and low-income nations is justifiable only if they provide durable clinical benefits.[rx] There have been few alternative solutions such as the use of interspinous distractors; however, though researchers observed fewer complications in these procedures, there were higher risks for redo surgery.[rx][rx]
Recently, posterior fixation surgery with facet distraction, without decompression has shown to have good clinical outcomes among similar patients.[rx]
Physiotherapy Treatment For Spinal Canal Narrowing
Most minor and moderately bulging disc injuries are treated conservatively without the need for surgery. Torn fibers of the annulus will heal and the disc bulge to usually resolve fully.
- While this occurs, your bulging disc treatment centers on encouraging the fluid to return and remain in the center of the disc. This rehabilitation keeps the torn fibers closer to one another and the structure of the annulus as healthy as possible.
- Your physiotherapist will advise you on the best positions to stay in and may tape or brace your spine. They’ll also explain to you the postures to avoid, which can be detrimental to your recovery.
- By maintain the disc fluid in the central position that you intend it to stay, you are helping Mother Nature to lay down its scar tissue optimally for an excellent long-term solution. Please remember that scar tissue formation will take at least six weeks, so the longer that you avoid aggravating postures, the better!
PHASE I – Pain Relief & Protection
- Managing your pain is usually the main reason that you seek treatment for a bulging disc. In truth, it was the final symptom that you developed and should be the first symptom to improve.
- You are managing your inflammation. Inflammation is the primary short-term reason why you have suddenly developed bulging disc symptoms. It is best reduced via ice therapy and techniques or exercises that unload the inflamed structures.
- Your physiotherapist will use an array of treatment tools. They aim to reduce your pain and inflammation. These treatment modalities may include ice, electrotherapy, acupuncture, unloading taping techniques, soft tissue massage, gentle exercise, and temporary use of a back brace. Your doctor may recommend a course of non-steroidal anti-inflammatory drugs such as ibuprofen.
PHASE II – Bulging Disc Exercises
- As your pain and inflammation settle, your physiotherapist will turn their attention to restoring your normal joint alignment and range of motion, muscle length and resting tension, muscle strength, and endurance.
- Your physiotherapist will commence you on a lower abdominal and core stability program to facilitate your important muscles that dynamically control and stabilize your spine.
- Researchers have discovered the importance of your back and abdominal core muscle recruitment patterns. Standard recruitment order of your deeper muscles, then intermediate and finally, superficial muscle firing patterns are typically required to prevent back pain. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you, specific to your needs.
- Your physiotherapist may recommend a stretching program or a remedial massage to address your tight or shortened muscles. Please ask your physio for their advice.
PHASE III – Restoring Full Function
- As your back’s dynamic control improves, your physiotherapist will turn their attention to restoring your normal pelvic and spine alignment and its range of motion during more stressful body positions and postures. They’ll also work on your outer core and leg muscle power.
- Depending on your chosen work, sport, or activities of daily living, your physiotherapist will aim to restore your function to allow you to return to your desired activities safely. Everyone has different demands for their body that will determine what specific treatment goals you need to achieve. For some, it is merely to walk around the block. Others may wish to run a marathon.
Your physiotherapist will tailor your back rehabilitation to help you achieve your own functional goals.
PHASE IV – Preventing a Recurrence
- Back pain does tend to return. The main reason back pain recurs is due to insufficient rehabilitation. In particular, poor compliance with deep abdominal and core muscle exercises. You should continue a version of these exercises routinely a few times per week. Your physiotherapist will assist you in identifying the best activities for you to continue indefinitely.
- In addition to your muscle control, your physiotherapist will assess your spine and pelvis biomechanics and correct any defects. It may be as simple as providing you with adjacent muscle exercises or some foot orthotics to address any biomechanical faults in the legs or feet.
- General exercise is a vital component to successfully preventing a recurrence. Your physiotherapist may recommend pilates, yoga, swimming, walking, hydrotherapy, or a gym program. These modalities all appear to help back pain. Exercise will assist your back pain relief in the long term.
What is Physiotherapy Treatment for Spinal Canal Narrowing?
Physiotherapists help people affected by illness, injury, or disability through exercise, manual joint therapy, soft tissue techniques education, and advice. Physiotherapists maintain physical health, help patients to manage pain, and prevent disease for people of all ages. Physiotherapists help to encourage pain relief, injury recovery, enabling people to stay playing a sport, working, or performing activities of daily living while assisting them to remain functionally independent.
There is a multitude of different physiotherapy treatment approaches.
Acute & Sub-Acute Injury Management
- Early Acute Injury Treatment
- Sub-Acute Soft Tissue Injury Treatment
Hands-On Physiotherapy Techniques
Your physiotherapist’s training includes hands-on physiotherapy techniques such as:
- Joint Mobilisation (gentle joint gliding techniques)
- Joint Manipulation
- Physiotherapy Instrument Mobilisation (PIM)
- Minimal Energy Techniques (METs)
- Soft Tissue Techniques
Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled, and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors, and occupational therapists, just to name a few.
Your physiotherapist is a highly skilled professional who utilizes strapping and taping techniques to prevent and assist injuries or pain relief and function.
- Supportive Strapping
- Kinesiology Taping
Alternatively, your physiotherapist may recommend a supportive brace.
Acupuncture and Dry Needling
Many physiotherapists have acquired additional training in the field of acupuncture and dry needling to assist pain relief and muscle function.
- Dry Needling
Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly skilled in the prescription of the “best exercises” for you and the most appropriate “exercise dose” for you depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga, and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.
- Muscle Stretching
- Core Exercises
- Strengthening Exercises
- Balance Exercises
- Proprioception Exercises
- Real-Time Ultrasound Physiotherapy
- Swiss Ball Exercises
Biomechanical assessment, observation, and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.
- Biomechanical Analysis
- Bike Fit Setup
- Gait Analysis
- Video Analysis
Aquatic water exercises are an effective method to provide low bodyweight exercises.
Sports physio requires an extra level of knowledge and physiotherapy skill to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.
- Sports Injury Management
- BPPV Manoeuvres
- Vestibular Physiotherapy
- Falls Prevention
Women’s Health Physiotherapy is a particular interest group of therapies.
- Women’s Health Physiotherapy
- Pelvic Floor Exercises
Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstations set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.
- Home / Office Workstation Setup
- Corporate Wellness
- Workplace Wellness
- Electrotherapy & Local Modalities
- Therapeutic Ultrasound
- TENS Machines
- EMS Machines
Plus Much More
Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your individual problem, please contact your PhysioWorks team.
1. Hamstring exercises
- For those with a slipped disk in the lower spine, strengthening the hamstring muscles can help better support their core and back. Try the following hamstring stretches:
2. Seated chair stretch
For a gentle, seated stretch along the hamstring:
- Sit in a chair with one foot on the floor and the other extended out straight, with the heel on the floor.
- Straighten the back and lean forward over the extended leg until there is a stretch along the back of the upper thigh.
- Hold this position for 15–30 seconds.
- Switch legs and repeat several times.
3. Towel hamstring stretch
For a deeper hamstring stretch, try the following:
- Lie flat on a yoga mat with one leg lifted into the air.
- Wrap a towel around the foot of the leg in the air.
- Holding the towel, pull the leg toward the body.
- Hold for 15–30 seconds.
- Switch legs and repeat several times
Exercises for low back pain
The following exercises can help ease pain in the lower back by building the muscles in the back. This will provide more support and help prevent future injuries.
4. Back flexion stretch
Back flexion exercises stretch the spine and back muscles. Speak to a doctor before performing these exercises after a back injury. To perform a back flexion stretch:
- Lie on the back and hold both knees toward the chest.
- At the same time, move the head forward until there is a comfortable stretch across the mid and low back.
- Repeat this several times.
5. Knee to chest stretch
A knee to chest stretch will work the muscles on each side of the body separately for a gentler stretch. Try the following:
- Lie on the back with the knees bent and both heels on the floor.
- Place both hands behind one knee and pull it toward the chest.
- Switch legs and repeat several times.
6. Piriformis muscle stretch
The piriformis muscle is a small muscle located deep in the buttocks. To stretch this muscle:
- Lie on the back with the knees bent and both heels on the floor.
- Cross one leg over the other, resting the ankle on the bent knee.
- Gently pull the crossed knee toward the chest until there is a stretch in the buttock.
- Repeat on both sides.
How can exercises help?
Exercises and physiotherapy are often important parts of recovery from a herniated disk. A doctor will usually recommend a few days of rest after experiencing a herniated disk.
Doing gentle activities and exercises will strengthen the muscles that support the spine and reduce pressure on the spinal column. They will also promote flexibility in the spine and may help reduce the risk of a herniated disk from recurring.
A doctor may suggest starting small and building up the level of activity slowly. They will discuss specific exercises that a person should and should not perform during the recovery period.
Gentle activities that can help with a herniated disk include:
Perform all exercises in a slow and controlled manner, especially when bending or lifting. Exercises should not hurt. If a person feels pain, they should stop doing the exercises and speak with their doctor.
Exercises to avoid
- A person can get a herniated disk through heavy lifting, sudden pressure on the back, or repetitive strenuous activities. People with a herniated disk should avoid doing strenuous activities during recovery.
- People should avoid all exercises that cause pain or feel as though they are making the pain worse. Avoid hamstring exercises when experiencing sciatica.
- People might wish to avoid high-impact activity, such as jogging or martial arts. These can jar the spine.
- Starting small and building up to more intense exercise is the safest way to reduce symptoms. That said, starting exercises and stretches early can also help improve a person’s outcome.
When should I see my Doctor?
- You should see the doctor when your back pain has been bothering you and not responding to over-the-counter painkillers or when you find yourself incapable of performing certain activities or movements that you had been able to in the past.
- If the low back pain and symptoms start getting worse and/or not improving or if the pain is associated with the below mentioned “red flags”:
- The risk is higher when your age is under 20 or above 55. If light tapping causes pain over low back area.
- Associated with fever and chills of unknown cause.
- Associated with numbness and tingling in legs.
- Associated with weight loss.
- Associated with difficulty in urination, involuntary urination, numbness around the groin, foot drop, and weakness in lower limbs (all these are probable signs of a neurological connection).
What are the risk factors for slip disc?
About 90% of your bone mass is acquired by the age of 20 years and your bones begin to lose their bone mass around the age of 40. The following are the risk factors for slip disc if
- You are under 20 or above 50 years
- If your job entails more lifting and carrying heavy items or forward bending activities.
- Individuals who are overweight and taller
- Smoking is an important cause of spinal disc herniation as nicotine and carbon monoxide prevent the disc cells from absorbing nutrients from the blood. This could lead to desiccation and dehydration of the discs, leading to degeneration.
- Lack of physical exercise, a sedentary lifestyle may cause your muscles to become weak and put you at an increase
- risk of developing a spinal disc herniation.
- Cardiovascular factors including high blood pressure are significantly associated with lumbar disc herniation.
- Genetic factors can also contribute to slip disc as specific genes may be linked to inherited forms of disc disease
- Prolonged hospitalization can also cause an increased risk of lumbar disc herniation due to weakness of the supporting muscles from underuse
When should I consider surgery?
- If you are suffering from persistent disabling low back pain lasting for more than six weeks, and if you have failed non-surgical interventions like epidural injections, pain medication, and physical therapy, then you may be an ideal candidate for spinal decompression surgery.
- If along with the back pain, if you have progressively worsening weakness, numbness, and tingling, which is not responding to conservative therapy, then a visit to the surgeon is recommended
- If you have developed cauda equina syndrome, which is a rare condition in which the bundle of nerves below the end of the spinal cord gets damaged producing low back pain with numbness, surgical intervention may be warranted. If left untreated, this may lead to loss of control over your bowel or bladder movements
A person should speak to a doctor about the best exercise regimen for their specific needs.