Case 17 Lumbar Stenosis


Case 17
Lumbar Stenosis
Age ?old                                              What happened ? Back Ache with b/l  leg pain initially buttock then at calf
How much they can walk ?                 What eases pain ? Sitting down,leaning forward ,
Introduction ownself
Exposure – whole body
Hand scrubbing
Look- Standing Patient
Attitude of the body                           stooping posture
Look
Alignment       -           Front        Both shoulders and Pelvis are leveled,
                                                     Stooping posture
                                                     No wasting of Quadriceps muscles
                                                      Patella facing forward and at equal height
Leg, foot and toes look normal with normal        
overlying skin
                                    Side           Elbows straight overlying greater trochanter
                                                       Transverse Loin Creases
     Knee Straight
      Foot Arches maintained 
                                    Back               
Maintained Spinal curvature
 Normal overlying skin on back with no dimpling , tuft of hair
  and swelling
  Calf symmetrical with normal overlying skin
  Heel has – Normal varus
 Feel
Temperature – Normal
Superficial Palpation
Bony Palpation  - Generalized spinal tenderness +
Movement –                            Restriction of extension 

Gait                                         Stooping
Tip toe , heel walking ,

Squating                                  Heel at the same level
Standing –      Special tests -Trendelenburg test
Lie down Patient
SLR                                        
Movement                               Hip / Knee / Ankle / Toes                   
LLD                
Neurovascular Assessment
Sensory Examination             L 2 – S 5  
Motor Examination  -               Global muscle weakness
Power of the Muscles –                      
                                    Supine             Quadriceps ,
TA / EHL /EDC / TP / Peronei
                                                Lateral             Abductor /Adductor
Prone               Gastrosoleus / FHL/FDC /Hamstring/Gluteal Maixums /Medius/Minimus
Reflexes
Vascular Examination – DPA / PTA on supine position
Discussion
D/Ds
Intermittent Arterial Claudication
Standing makes easier
Flexion – no effect
Cycling makes it worst
Prone – no effect
Venous Claudication
            From Previous Thrombosis

Type
Primary – Congenital Malformations , developmental flaws
Congenital –        Spinal Dysraphism ,Segmental failure , Achondroplasia, Osteopetrosis

Developmental – Vertebral arch ossification , Shortened Pedicles , Apical Vertebral
    wedging , Anterior Vertebral Beaking (Morquio Syndrome )
           
Secondary (Acquired )– Degenerative Changes , iatrogenic , trauma,
Degenerative Changes – Central Canal and lateral recess stenosis from
    posterior disc protusion , ligamentum flavum
    hypertrophy ,
                                    Iatrogenic                    -    laminectomy , Fusion , dissectomy ,
                                    Systemic                      -   Paget’s ,Acromegaly, Ankylosing Spondylitis


Investigations
AP , Lateral Radiographs
MRI

Management
Physiotherapy
Spinal Surgeon Consultation
            Laminectomy +/- Fusion





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