Lumbar Spine Conditions

• The lecture covers conditions of the lumbar spine
• PT 508: Musculoskeletal PT II, Spring 2025

Learning Objectives

• Define lumbar spondylosis, spondylolysis, and spondylolisthesis, noting each pathology
• Recognize lumbar spondylosis, spondylolysis, and spondylolisthesis on conventional radiographs
• Describe physical therapy management for lumbar spondylolisthesis
• Explain the pathophysiology of intervertebral disc disease (IVD)
• Recognize IVD on diagnostic images, identifying characteristics on radiographs and MRIs
• Describe microdiscectomy
• Define lumbar spinal stenosis, distinguishing between central and lateral foraminal stenosis
• Identify central and lateral foraminal stenosis on diagnostic images
• Describe lumbar spinal stenosis symptoms, including the impact of weightbearing on spinal symptoms
• Describe physical therapy management for lumbar spinal stenosis
• List the different spondyloarthropathies classifications
• Differentiate radiologic from non-radiologic axial spondyloarthropathy
• List common clinical and radiographic indications of ankylosing spondylitis
• Define primary and secondary osteoporosis
• Identify osteoporosis risk factors
• Describe common diagnostic tests for osteoporosis diagnosis and management
• Identify effective physical therapy interventions utilized in osteoporosis management

Radiography Terms

• Radiopaque means not easily penetrated by x-rays
  • radiopaque objects appear white on plain films and CT scans, such as metal, contrast media (barium sulfate), calcified kidney stones
• Radiolucent means easily penetrated by x-rays -radiolucent objects appear black, such as air
• Radiodense is term used to describe tissue, which includes:
  • Gray-black: Fat
  • Gray: H2O based tissue, like muscle, cartilage, and nerves
  • White: bone, teeth

Radiologic Search Pattern

• To conduct a radiologic search, remember the ABCDs
  • Alignment
  • Bone Density
  • Cartilage Spaces
  • Disc Spaces
  • Soft Tissues

Lumbar Radiographic Evaluation

• Standard projections: AP, Lateral, Lateral L5-S1, and Oblique
• Motion views are sometimes needed to assess instability or spondylolisthesis
  • Motion views usually involve a lateral view in flexion and extension

Spondylolysis

• It is a defect found in the pars interarticularis
• Causes include, congenital, fatigue fracture involving repeated microtrauma, or trauma (hyperextension)
• Most prevalent at L5/S1, accounting for 95% of cases
• Can be unilateral or bilateral
• Most common in children and adolescents, occurring twice as often in males
• Higher incidence in athletes
• Is associated with sports with repetitive trunk extension, rotation, and loading such as gymnastics, dancing, figure skating, football, Olympic weight lifting, diving, and martial arts
• Acute spondylolysis can produce pain
• There is limited correlation between sub-acute/chronic spondylolysis and pain
• 3 theories explain pain generation in sub-acute/chronic spondylolysis:
  • disc degeneration in the neighboring area
  • Segmental instability
  • Scar tissue filling the pars defect space which contains nociceptive neural tissue generating pain when loaded (hyperextension with rotation)
• An oblique radiograph can be used in diagnostic imagining
• A normal oblique radiograph will show a "Scotty dog" with a collar
• Signs and Symptoms are: Local pain, decreased ROM, muscle guarding, pain during lumbar extension or rotation, and pain during SLS with/without lumbar extension
• One-leg Standing Lumbar Extension Test (Stork Test) sensitivity and specificity are low
• "...one-legged hyperextension test has virtually no value in diagnosing patients with spondylolysis."
• Interventions include: active rest from provocative activities/sports, bracing/immobilization which is more effective with acute injury, lumbar stabilization exercises, & flexibility exercises such as hip flexor and hamstring stretches
• With conservative management, 74% do not achieve definitive healing on post-treatment imaging after a mean time of 10 months
• No correlation has been found between the degree of healing on imaging and pain or disability levels
• 90% can return to sport

Spondylolysis Progression

• Prospective study followed 30 first-graders with spondylolysis over 45 years
• Unilateral defects (n=8) showed no slippage during the study, with the exception of 3 subjects that healed
• Bilateral defects (n=22) showed an 82% spondylolisthesis incidence
  • Greatest amount of slippage occurred during childhood and adolescence
  • Decreased with each decade of life
  • There is a correlation between degree of slippage and disc degeneration
• Pain and disability reports are similar to the general population
• It is recommended that children can safely play competitive sports
• Developing symptomatic spondylolisthesis has a 5% chance

Spondylolisthesis

• It is the anterior displacement of a vertebral body in relation to the one inferior to it
• Most common at L4/L5 and L5/S1
• Prevalence ranges from 2-6.8% in the LBP population, but is higher in athletic populations
• Meyerding Grading is based upon percentage of anterior translation of superior vertebra on inferior vertebra
  • Grade I is less than 25%
  • Grade II: 25-50%
  • Grade III: 50-75%
  • Grade IV: greater than 75%
• Signs and Symptoms are: Local LBP with or without LE pain, pain with lumbar extension or rotation which may worsen in standing, a hyperlordotic posture, a palpable "step off" deformity, spinal stenosis may be present, Possible cauda equina syndrome, & hamstring contracture

Wiltse Classification

• Type I: Dysplastic/Congenital
• Type II: Isthmic
• Type III: Degenerative
• Type IV: Traumatic
• Type V: Pathological
• Type VI: Iatrogenic

Isthmic Spondylolisthesis Etiology

• It occurs due to a repeated mechanical strain to pars interarticularis from a fatigue fracture, or possible elongated pars from healing of repeated microfractures which leads to gradual slippage of vertebra
• Progression of spondylolysis occurs when vertebra slips anteriorly
• The most common type in patients that are younger than 50 is at L5/S1

Degenerative Spondylolisthesis Etiology

• An acquired anterior displacement over the subjacent vertebra
• This is associated with degenerative changes, without an associated disruption or defect in the vertebral ring such as Facet arthrosis or disc degeneration
• It is most common in patients older than 50
• Occurs 3-4x more frequently in females
• Usually occurs at L4/L5

Spondylolisthesis Etiology

• Dysplastic is a congenital malformation of facets where an abnormal orientation allows slippage, this account for 14-21% of all cases, and can cause central canal stenosis and significant neural compromise
• Traumatic is a fracture other than at pars from severe trauma (i.e. facet, pedicle) where slippage may be immediate or delayed
• Pathological cases result from bone weakening diseases such as Paget's, Osteoporosis, Neoplasm, or Tuberculosis
• Iatrogenic cases are post-surgical situations where a s/p laminectomy increases translation/slippage from loss of stability or s/p fusion increases translation/slippage at the level above fusion

Spondylolisthesis Intervention

• Lumbar flexion-based exercises
• Avoidance of extension
• Correction of muscle imbalance: Core stabilizers & Hip/pelvis should be targeted
• Lumbar stabilization exercises
• Lumbar bracing
• Surgical fusion

Lumbar Intervertebral Disc: Nucleus Pulposus

• The Nucleus Pulposus (NP) is 70-90% water, 65% proteoglycans of dry weight, and 15-20% Type II collagen of dry weight
• NP is incompressible
• Distributes pressure to AF
• It is avascular

Normal Disc

• It displays a midsagittal cadaveric dissection from a 20-year-old female, where the homogenous appearance of the nucleus is obvious from the annular regions and compressive loading indicates how the well-hydrated nucleus exerts tensile force on the annulus and the vertebral endplate

Lumbar Intervertebral Disc: Annulus Fibrosus

• The Annulus Fibrosus (AF) is 60-70% water, 20% Proteoglycans of dry weight, and 50-60% of the dry weight is Collagen
• Layers of the AF are concentric lamellae
  • The thinnest portion is in the posterior aspect, with the postero-lateral AF being the weakest
  • The Outermost portion vascularized and innervated

Lumbar HNP

• Focal displacement of disc material beyond the intervertebral disc space
• Most common in the 3rd to 5th decades
• Occurs in a 2:1 Male to Female ratio
• Postero-lateral HNPs are the most common
• 95% occur at L4/L5 or L5/S1

Lumbar Nomenclature

• Lumbar Disc Nomenclature consist of: protruding disc, bulge, herniations, Protrusion, Extrusion, & Sequestration

Schmorl’s Nodes

• They result from Herniation of NP through cartilaginous end-plate into adjacent vertebral body
• Most often seen in T7-L1
• Correlated with presence of DDD
• Often asymptomatic, incidental finding on imaging

Lumbar HNP Clinical Presentation

• Symptomatic presentations vary depending on the location of the herniation
• Back pain is present with or without leg pain (sciatica)
• There are signs of radiculopathy, Sensory changes in dermatomal pattern, DTR changes, Myotomal weakness

Lumbar HNP Imaging

• MRI is the gold standard tool

Microdiscectomy

• Considered a gold standard operative procedure for HNP; It is a minimally invasive procedure
• A laminotomy is made followed by retraction of nerve root and excision of disc fragments
• Complications can include Dural tears, Neural injury, Infection, HNP recurrence (10-15%), Inadequate decompression, or Iatrogenic instability

Degenerative Disc Disease (DDD)

• Characterized by a Decrease in proteoglycans which causes a Less H2O content in the nucleus
• This leads to Increased collagen, therefore the Annulus becomes stiffer which leads to Tears and fissures
• Often associated with disc bulge(s) or herniation(s)
• May have segmental microtranslation during active motions

Lumbar DDD on MRI

• A T2 image indicates that there is disc is darker in these cases -This means that Low signal intensity & Less H2O content

Lumbar DDD Clinical Presentation

• Often asymptomatic
  • 80% prevalence in asymptomatic people in their 50s
• May have LBP +/- LE symptoms
• Stiffness
• Decreased ROM

Lumbar DDD Intervention

• Repeated movements should be given to Assess for directional preference & centralization
• Manual therapy with Lumbar mobilization & Hip mobilization exercises
• Flexibility, with Hip flexors & hamstrings should be the focus
• Exercises for the Stabilization of movement control can give back proprioception
• General strengthening can also be helpful in patients

Spondylosis

• Degenerative spinal changes occur due to osteoarthritis
• Also described as Lumbar osteoarthritis, or DJD
• Age-related changes include: Osteophytes, Disc degeneration and Disc space narrowing, Facet hypertrophy,Thickening of ligamentum flavum, and thisCan lead to impingement of nerve roots and spinal cord

Lumbar Spinal Stenosis

• Narrowing of the spinal canal, nerve root canals, or intervertebral foramina
• Compression of neural and vascular structures
• Two systems to classify LSS: First, Etiology which is either Congenital/Developmental versus Acquired. And secondly, Anatomic location of narrowing which is either Central versus Lateral

Classification By Etiology

• Congenital and Developmental LSS are either Primary or Very similar radiologically, in this case they are grouped together
  • Are rare and account for 9% of LSS
• Acquired LSS is Secondary and is the Most common cause of LSS -Results from: Degenerative changes, Spondylolisthesis, Lumbar HNP, Postsurgical scarring, and Miscellaneous rare causes

Classification By Anatomic Location

• Central Stenosis which involves the Narrowing of spinal canal around cauda equina in thecal sac
• Lateral Stenosis is the Narrowing of nerve root canal and IV foramen around nerve root

Lumbar Spinal Stenosis Clinical Presentation

• Most patients are older
• LE pain and or paresthesia is present with or without LBP where Bilateral LEs is often associated with central canal stenosis or Unilateral LE is often associated with lateral or foraminal stenosis
• Symptoms worsen with spine in extended position or WBing, and improve with Lumbar flexion or non-Wbing
• Neurogenic Claudication can also be present

Neurogenic Claudication

• Occurs when there is compression and or ischemia of spinal nerves
• Can be Unilateral or bilateral, often with Pain, Heaviness, Cramping, Numbness, Tingling, or Weakness
• Limits tolerance to ambulation and impacts QoL

Diagnosis of Lumbar Spinal Stenosis

• It is a Clinical diagnosis based on the symptoms and there is No clear association between symptoms and anatomical abnormalities

  • 30% of the population is asymptomatic with a positive stenosis on imaging (<75 mm² central spinal canal cross-sectional area)

• MRI is the preferred imaging modality
• Vascular claudication and peripheral neuropathies need to be ruled out Assess for changes in tissue color and texture, Palpation of LE pulses, and Effect of posture on activity tolerance, with a possible Stoop Test, Bicycle Test of van Gelderen, & Two Stage Treadmill Test

CPR to diagnose Lumbar Spinal Stenosis

• If <1/5 met on exam: Sensitivity is 0.96 and LR- is is 0.19
• If 4/5 is met: Specificity is 0.98 & LR+ is 4.6, for a Post-test probability= 76%

Lumbar Spinal Stenosis Intervention

• Education patients on Activity modification, pacing, and PPT
• Manual Therapy is good with Mobilization of manipulation to lumbar and thoracic spine and hips, Stretching to increase hip ROM and ankle DF & Neurodynamic exercises
• Exercise; Flexibility to the lumbar and hip ROM, plus Strengthening of theLlumbar and hip stabilizers & Aerobics with an unweighted or inclined treadmill ambulation, or cycling

Lumbar Spinal Stenosis Surgical Intervention

• Most commonly a Lumbar Laminectomy or a Lumbar Fusion

Spondyloarthritis (SpA)

• It is a group of disorders characterized by inflammation of the joints of the spine, Chronic inflammation of SIJ and spine, Asymmetric inflammation of extremity joints,Inflammation at entheses, Genetic predisposition, with a (-) rheumatoid factor
• Also displays Extra-articular involvement of eyes, skin, genitourinary tract, cardiovascular system

Spondyloarthritis (SpA) Types

• Axial Spondyloarthritis (axSpA) is characterized by Non-radiographic axSpA (nr-axSpA) and Radiographic axSpA (axSpA)
• Peripheral Spondyloarthritis (pSpA) is characterized as Psoriatic Arthritis, Reactive Arthritis, or Enteropathic Arthritis

Axial Spondyloarthritis (axSpA)

• Inflammatory diseases that primarily affect the spine with Associated extra-articular findings
• Two Types: Non-radiographic axSpA (nr-axSpA) or Radiographic axSpA (axSpA) which may involve Ankylosing Spondylitis and Sacroiliitis on X-ray

Non-radiographic axSpA (nr-axSpA)

• Characterized by (-) findings on X-ray, but there are Signs of inflammation on MRI
• The disease has a and Male to Female (1:1) ratio
• Lower CRP levels, Less structural damage
• Earlier detection can prevent progression and is considered to have a Similar clinical presentation to AS
• Progression to r-axSpA: 10-20% within 1 year to and 20.3% within 2-6 years

Ankylosing Spondylitis

• It is a Fibrous ossification of spinal ligaments and joint capsules
• It is a Chronic, rheumatic, progressive, inflammatory disorder
• Involves the Chronic inflammation at entheses of ligaments, tendons, & joint capsules leading to a Disruption of enthesis with reactive bone formation during repair
• This lead to Fibrosis, which involves Calcification, then finally Ossification & fusion of involved joints
• Progressively limits spinal mobility- affecting both the Spine and SIJ resulting in a fuse
• Overall Prevalence: 13.1-31.9 per 10,000 in US
• Characterized with Genetic susceptibility due to and higher association in persons with HLA-B27 -Present in 5-15% of the general population, but in 85-90% of patients with AS

Ankylosing Spondylitis Clinical Presentation

• Characterized with a ≥3-month history of LBP, hip, or buttock pain and stiffness with or without morning stiffness lasting > 1 hour
• Affects Males more than Females (2-3:1)
• Onset of symptoms usually begins before age 45
• Back pain worsens with rest or prolonged inactivity and symptoms improves with exercise
• Present with Unilateral buttock pain which alternates
• Demonstrates a decrease inlumbar lordosis with an increase in overall kyphosis
• Gradual loss of spinal ROM in all directions
• Decreased chest wall excursion which presents with < 2.5 cm

Ankylosing Spondylitis Diagnosis

• MRI can be useful, especially on early detection cases where a (STIR) short tau inversion recovery is able to suppress fat signals
• Early radiographic findings: Sacroiliitis, Ligamentous sclerosis, Joint space narrowing
• Later changes: "Squaring" of vertebral bodies & Syndesmophytes, as well as Ossification of spinal ligaments

Ankylosing Spondylitis Findings on X-ray

• Bamboo Spine with Syndesmophytes

Ankylosing Spondylitis Musculoskeletal and Extra-articular Complications

• Musculoskeletal Complications usually demonstrate Osteoporosis and an increased risk of fracture between T7- S1, Atlantoaxial subluxation, and Spinal stenosis
• Extra-articular Complications often involve a Uveitis in 20-30% of cases Cardia,c and pulmonary dysfunction

Ankylosing Spondylitis Intervention

• Pharmacologic Intervention usually includes: NSAIDs & COX-2 specific inhibitors with Biologic DMARDs and TNF-α inhibitors, and Non-TNF-a biologics
• Physical Therapy aims at Focusing on maintaining upright posture and flexibility with conflicting evidence on appropriate intensity
  • Aquatic therapy can also be used
• Prognosis variable
  • Improvements can be made with earlier detection

Osteoporosis

• Metabolic bone disease results in loss of total bone mass and mineral density
• Osteoblasts demonstrate Decreased activity, decreasing bone formation
• Osteoclasts demonstarte Increased activity
• bone resorption
• This Increases risk of minimal trauma fracture to the Vertebrae, femur, and wrist

Osteoporosis Types

• Primary which is either Age-related or Post-menopausal
• Secondary which can stem from Chronic renal failure, Hyperthyroidism, Prolonged immobilization, or GI diseases

Osteoporosis Risk Factors

• Female
• White or Asian descent
• Family history
• Small, thin body-type
• Post-menopause
• Sedentary lifestyle
• Smoking
• Diet low in Ca and Vit D
• Anorexia nervosa
• Prolonged use of corticosteroids

Osteoporosis on Imaging

• Characterized by Cortical Thinning
• Osteopenia, with Increased bone radiolucency
• Trabecular Changes, which are Thinner while demonstrating a decrease in number of trabeculae
• Fractures

Imaging to detect Osteoporosis

• Using a Dual Energy X-ray Absorptiometry (DXA) is the gold standard
  • Standard radiographs are not sensitive enough for early detection and does not detect changes until 30% reduction in bone mass
• T-Score measures the Number of standard deviations above or below a reference value of healthy young Caucasian women: -Score is ≥ -1 if demonstrating normal BMD
  • From -2.5 to -1 if demonstrating osteopenia
  • ≤ -2.5 if demonstrating osteoporosis
• Z-Score, which measures the Number of standard deviations above or below what's normally expected for someone of same age
  • If less than or equal to -2 there is and the reading is recorded as abnormal

Osteoporosis Clinical Presentation

• The conditon is Usually asymptomatic

• 50 year old female

• Sudden onset spinal or hip pain
• History of spinal compression Fx(s) with Dowager’s hump
• It i recommended to Screen for risk factors
• Refer patient for imaging if suspecting a previously undiagnosed Fx for clinical confirmation

Osteoporosis Intervention

• Exercise is a key element in the management of osteoporosis in post- menopausal women
  • Exercise has has shown a small but statistically improvement in BMD loss vs placebo intervention or usual activity
• Utilizing WBing low-force exercises, like Walking or jogging paired with Tai Chi
• Or WBing and Non-WBing high-force exercise utilizing PREs
• Balance training to Prevent Falls
• It is recommended 2-3 days a week at moderate level for long duration: 6-48+ months

Osteoporosis Recommendations w/ Exercise

• Postmenopausal women should participate exercises to help low decline of hip and lumbar BMD Sustained SLS exercises and PREs with or without dynamic low force exercise (walking, jogging, or aerobics)
• Premenopausal women should participate to slow decline of the femoral neck and lumbar BMD through PREs as well as high force impact training such as (jogging and stairclimbing)
• The patient Should participate in long duration sessions, 6-48+ months
• Apply exercise techniques to transgender and cisgender patients

Female Athlete Triad

• It is a condition that primarily affects and most often diagnosed in adolescent & young adult female athletes
• It is usually classified through 3 different presentations:
  • Low energy availability: Energy expenditure > nutritional intake with or without an eating disorder like (Anorexia Nervosa/Bulimia)
  • Menstrual Dysfunction: Amenorrhea
  • Decreased BMD: Osteopenia or Osteoporosis
• Risks can include: Stress fracture due to low BMD or Permanent loss of BMD

The Female Athlete Triad Interventions

• Overall Goal is improved BMD & restoration of regular menstruation in these patients
  • Interventions should include: modification of diet & exercise regimen, Ca and Vitamin D supplementation, Estrogen replacement therapy, and Counseling