Lumbar Spine Conditions: PT 508

• Lumbar Spine Conditions, PT 508: Musculoskeletal PT II, Spring 2025

Learning Objectives

• Define lumbar spondylosis, spondylolysis, spondylolisthesis, and describe the pathology.
• Identify lumbar spondylosis, spondylolysis, and spondylolisthesis on X-rays.
• Physical therapy management of lumbar spondylolisthesis should be described.
• Intervertebral disc disease (IVD) pathophysiology should be described.
• Identify IVD on diagnostic images and describe identifying features on X-rays and MRI.
• Microdiscectomy should be described.
• Define lumbar spinal stenosis and compare central & lateral foraminal stenosis.
• Identify central & lateral foraminal stenosis on diagnostic images.
• Describe lumbar spinal stenosis symptoms, including the impact of weightbearing position of the spine on symptoms.
• Describe physical therapy management of lumbar spinal stenosis.
• Describe spondyloarthropathies classifications
• Differentiate radiologic from non-radiologic axial spondyloarthropathy
• Describe ankylosing spondylitis clinical/radiographic findings
• Define primary and secondary osteoporosis
• Identify risk factors for osteoporosis
• Describe osteoporosis diagnostic tests
• Identify effective physical therapy interventions to manage patients with osteoporosis

Review of Terms

• Radiopaque materials are not easily penetrated by x-rays.
  • Radiopaque materials appear white on plain films and CT scans.
  • Examples: metal, contrast media (barium sulfate), and calcified kidney stones
• Radiolucent materials are easily penetrated by x-rays.
  • Radiolucent materials appear black.
  • Example: air
• Radiodense is used to describe tissue
  • Gray-black: Fat
  • Gray: H2O based tissue- muscle, cartilage, nerve, etc.
  • White: bone, teeth

Radiologic Search Pattern: ABCDs

• Alignment
• Bone Density
• Cartilage Spaces
• Disc Spaces
• Soft Tissues

Routine Lumbar Radiographic Evaluation

• Standard Projections: AP, Lateral, Lateral L5-S1, Oblique
• Motion views can detect instability or spondylolisthesis
  • Motion views are usually lateral view flexion, extension

Spondylolysis

• Spondylolysis involves a defect in the pars interarticularis
• Causes of spondylolysis include Congenital issues, fatigue fracture, repeated microtrauma, or Hyperextension
• L5/S1 is the most common level for spondylolysis at 95%
• Spondylolysis can be either unilateral or bilateral
• It is common in children & adolescents
• Males are 2x more likely to have it
• Epidemiology has it affecting 6-11.5% of the population
• There is a higher incidence in athletes
• Sports with repetitive trunk extension, rotation, and loading can lead to it
  • Examples: Gymnastics, dance, figure skating, football, Olympic weight lifting, diving, martial arts

Spondylolysis & Pain

• Acute spondylolysis can produce pain
• There is a limited correlation between sub-acute/chronic spondylolysis & pain
• Theories why sub-acute/chronic spondylolysis generates pain include: Neighboring disc degeneration, Segmental instability, Scar tissue fills
• Scar tissue fills in space of pars defect
  • It contains nociceptive neural tissue that can generate pain when loaded (i.e. hyperextension with rotation)

Spondylolysis: Diagnostic Imaging

• Oblique radiograph are used
• Check for a normal "Scotty dog" which should have a collar in normal circumstances

Spondylolysis: Signs and Symptoms

• Local pain
• Decreased ROM
• Muscle guarding
• Pain with lumbar extension or rotation
• Pain with SLS +/- lumbar extension
• One-leg Standing Lumbar Extension Test (Stork Test) has low Sn & Sp
  • "...one-legged hyperextension test has virtually no value in diagnosing patients with spondylolysis.” Alqarni (2015)

Spondylolysis: Intervention

• Active rest from provocative activities/sports.
• Bracing/immobilization is more effective with acute injury.
• Lumbar stabilization exercises
• Flexibility is key, specifically: hip flexors, hamstrings

Spondylolysis: Healing & Progression

• 61 pts with spondylolysis managed conservatively
• 74% had no definitive healing on post-treatment imaging
  • Mean time after initial imaging: 10 months
• There is no correlation between degree of healing on imaging & pain level or disability
• 90% reported return to sport

Spondylolysis: Progression

• Prospective study followed 30 first-graders with spondylolysis over 45-year
  • Unilateral defects (n=8) had no slippage over course of study. 3 subjects healed
  • Bilateral defects (n=22) had 82% incidence of spondylolisthesis
    • Greatest amount of slippage occurred during childhood & adolescence
      • It decreases with each decade of life
    • There is a correlation between degree of slippage & disc degeneration
• Similar reports of pain and disability as general population
• Children are recommended to play competitive sports safely, as there is a 5% chance of developing symptomatic spondylolisthesis

Spondylolisthesis

• Spondylolisthesis is anterior displacement of vertebral body in relation to the one inferior
• It is most common at L4/L5 & L5/S1
• Prevalence: 2-6.8% of LBP population, higher in athletic population

Spondylolisthesis: Meyerding Grading

• Based upon percentage of anterior translation of superior vertebra on inferior vertebra:
  • Grade I: <25%
  • Grade II: 25-50%
  • Grade III: 50-75%
  • Grade IV: >75%

Spondylolisthesis: Signs and Symptoms

• Local LBP +/- LE pain
• Pain with lumbar extension, rotation, especially with standing & ambulation
• May observe hyperlordotic posture
• There is a Palpable “step off” deformity
• There may be associated spinal stenosis, with possible cauda equina syndrome
• Hamstring contracture in children

Spondylolisthesis: 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 involves repeated mechanical strain to pars interarticularis
  • Fatigue fracture, and/or possible elongated pars from healing of repeated microfractures
    • The Vertebra gradually slips
• It is a progression of spondylolysis when vertebra slips anteriorly
• It is most common type in patients <50
• It is common at L5/S1

Degenerative Spondylolisthesis: Etiology

• “An acquired anterior displacement over the subjacent vertebra, associated with degenerative changes, without an associated disruption or defect in the vertebral ring."
  • Facet arthrosis, disc degeneration
• It is most common type in patients >50
• There is a 3-4x more prevalent occurrence in females versus males
• Most common at L4/L5

Spondylolisthesis: Etiology

• Dysplastic is due to a Congenital malformation of facets:
  • Abnormal orientation allows slippage
  • 14-21% of spondylolistheses.
  • Can have central canal stenosis & significant neural compromise.
• Traumatic
  • Fracture other than at pars from severe trauma (i.e. facet, pedicle)
  • Slippage may be immediate or delayed
• Pathological is the result of bone weakening disease
  • Examples: Paget’s, Osteoporosis, Neoplasm, Tuberculosis
• Iatrogenic- Post- surgical
  • s/p laminectomy
  • Increased translation/slippage fromloss of stability
  • s/p fusion
  • Increased translation/slippage at level above fusion

Spondylolisthesis: Intervention

• Lumbar flexion-based exercises
• Avoidance of extension
• Correction of muscle imbalance via core & hip/pelvis stabilization
• Lumbar stabilization exercise
• Lumbar bracing
• Surgical fusion

Lumbar Intervertebral Disc: Nucleus Pulposus

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

Lumbar Intervertebral Disc: Annulus Fibrosus

• This is the outside of the disc. Made of 60-70% water, 20% of dry weight proteoglycans, and 50-60% of dry weight collagen
• It has concentric layers of lamellae
  • It is Thinnest at posterior aspect with the Postero-lateral AF weakest
• Outermost portion vascularized & innervated

Lumbar HNP

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

Lumbar Disc Nomenclature

• Disc
• Bulge
• Herniations
  • Protrusion
  • Extrusion
  • Sequestration.

HNP location and nerve roots

• Dural sac
• Spinal nerve with nerve root
• Areas of compression
• Disc
• Pedicle

Schmorl’s Nodes

• Herniation of NP through cartilaginous end-plate into adjacent vertebral body
• Most common T7-L1
• Correlated with presence of DDD
• Often asymptomatic, incidental finding on imaging

Lumbar HNP: Clinical Presentation

• Symptomatic depending on the location of herniation
• Back pain +/- leg pain (sciatica)
• Signs of radiculopathy: Sensory impairment in dermatomal pattern, DTR changes, Myotomal weakness

Lumbar HNP: Imaging

• MRI is gold standard

Microdiscectomy

• Considered gold standard for operative care of HNP
• Minimally invasive procedure
• Laminotomy followed by retraction of nerve root & excision of disc fragments
  • Complications: Dural tears, Neural injury, Infection, HNP recurrence (10-15%), Inadequate decompression, Iatrogenic instability

Degenerative Disc Disease (DDD)

• Decrease in proteoglycans
  • Less H2O content and the nucleus dries
• Increased collagen - The annulus becomes stiffer and and it can develop tears and fissures
• Often associated with disc bulge(s) or herniation(s)
• May have segmental microtranslation during active motions.

Lumbar DDD

• A midsagittal cadaveric dissection shows infiltrative tissue in the nuclear region. The disc height, however, is well preserved
• A midsagittal cadaveric dissection shows degenerative changes characterized by a loss of differentiation between the nucelus and annulous, and a severe amount of disc height.

Lumbar DDD on MRI

• T2 image: the disc appears darker
• Low signal intensity & Less H2O content

Lumbar DDD: Clinical Presentation

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

Lumbar DDD: Intervention

• Repeated movements should be used through assessments for directional preferences and centralization
• Manual therapy should be used.
  • Lumbar & hip mobilizations
• Flexibility should be worked on: hip flexors, hamstrings
• There is also Stabilization/Movement Control exercises and General strengthening

Spondylosis

• "Degenerative spinal changes due to osteoarthritis"
• Lumbar osteoarthritis, DJD
• Age-related changes: Osteophytes, disc degeneration/Disc space narrowing, facet hypertrophy, thickening of ligamentum flavum, can 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 & vascular structures
• 2 Systems to classify LSS: - Etiology: - Congenital/Developmental vs. Acquired - Anatomic location of narrowing: central vs. lateral

Classification By Etiology

• Congenital & Developmental LSS - Primary - The look similar so they are grouped together - Rare: 9% LSS
• Acquired LSS - Secondary - Most common cause of LSS - Degenerative changes - Is Spondylolisthesis, Lumbar HNP, Postsurgical scarring, and Miscellaneous rare causes

LSS: Classification By Anatomic Location

• Central Stenosis: Narrowing of spinal canal around cauda equina in thecal sac
• Lateral Stenosis: Narrowing of nerve root canal or IV foramen around nerve root

Lumbar Spinal Stenosis: Clinical Presentation

• Usually older
• LE pain and/or paresthesia +/- LBP
  • Could present as Bilateral LEs-central canal stenosis, or as Unilateral LE-lateral/foraminal stenosis.
• Symptoms worsen with spine in extended position or WBing
• Symptoms resolve with lumbar flexion or non-Wbing
• Look for Neurogenic Claudication

Neurogenic Claudication

• Compression and/or ischemia of spinal nerves
• This can happen Unilaterally or bilaterally
  • Pain, Heaviness, Cramping, Numbness, Tingling, or Weakness can be present
• Limits tolerance to ambulation and impacts QoL

Diagnosis of Lumbar Spinal Stenosis

• Clinical diagnosis, there is no clear association between symptoms & anatomical abnormalities - >30% asymptomatic population with + stenosis on imaging (<75 mm² central spinal canal cross-sectional area)
  • MRI preferred imaging modality
• Must rule out vascular claudication and peripheral neuropathies Assessment for tissue color and texture changes, palpation of LE pulses, and effect of posture on activity tolerance
  • Could use the Stoop Test, Bicycle Test of van Gelderen, or Two Stage Treadmill Test

CPR for Diagnosis of Lumbar Spinal Stenosis

• Check for Bilateral symptoms, LE pain > back pain, pain during walking/standing, and pain relieved with sitting
• IfIf If there is only one finding<1/5 met has a Sn of 0.96 and LR- of 0.19
• and 4/5 met has a Sp of 0.98 and LR+ of 4.6. It brings the Post-test probability up to 76%

Lumbar Spinal Stenosis: Intervention

• Activity modification, pacing, PPT
• Mobilization and manipulation- lumbar and thoracic spine, hips for Manual Therapy
  • This can include stretching and neurodynamic exercises
• Exercise can also be used with flexibility, strengthening, and aerobics

Lumbar Spinal Stenosis: Surgical Intervention

• This can include a Lumbar Laminectomy which is has the Most common
• A lumbr fusion can also be performed

Spondyloarthritis (SpA)

• Group of disorders characterized by inflammation of joints of the spine:
  • Chronic inflammation of SIJ & spine
  • Asymmetric inflammation of extremity joints
  • Inflammation at entheses
  • Genetic predisposition
  • (-) rheumatoid factor
  • Extra-articular involvement of eyes, skin, genitourinary tract, cardiovascular system

Spondyloarthritis (SpA)

• Axial Spondyloarthritis (axSpA)
  • Non-radiographic axSpA (nr-axSpA)
  • Radiographic axSpA (axSpA) Peripheral Spondyloarthritis (pSpA)
  • Psoriatic Arthritis
  • Reactive Arthritis
  • Enteropathic Arthritis

Axial Spondyloarthritis (axSpA)

• Inflammatory diseases that primarily effect the spine. There can also be Associated extra-articular findings
• Two Types occur: Non-radiographic axSpA (nr-axSpA) & Radiographic axSpA (axSpA)
  • Radiographic version features Ankylosing Spondylitis featuring Sacroiliitis with x-ray

Axial Spondyloarthritis Criteria

• Patient with predominant axial manifestations
• Sacroiliitis on imaging with more than 1 SpA feature, or HLA-B27
• Can also present with Inflammatory back pain, Arthritis, Enthesitis (heel), Uveitis, Dactylitis Psoriasis, Crohn's/colitis, Good response to NSAIDs, Genetics, and Elevated CRP

Non-radiographic axSpA (nr-axSpA)

• (-) findings on X-ray but there are Signs of inflammation on MRI with M:F having a 1:1 ratio
• There are Lower CRP levels and Less structural damage
• Earlier detection can prevent progression, this version has a Similar clinical presentation to AS
• It is estimated Progression to r-axSpA happens between 10-20% within 1 year and 20.3% within 2-6 years

Ankylosing Spondylitis

• Fibrous ossification of spinal ligaments and joint capsules

• Chronic, rheumatic, progressive, inflammatory disorder

• Chronic inflammation at entheses of ligaments, tendons, & joint capsules can disrupt enhesis with reactive bone formation occurring during repair

• Fibrosis leads to to calcification with ossification & fusion of involved joints which Progressively limits spinal mobility- Spine and SIJ fusion

• Prevalence: 13.1-31.9 per 10,000 in US

• There is Genetic susceptibility with high association in persons with HLA-B27 with around 5-15% Present in general population, and 85-90% of patients with AS

Ankylosing Spondylitis: Clinical Presentation

• There is a ≥3-month history of LBP, hip, or buttock pain & stiffness +/- morning stiffness lasting > 1 hour
• Male to Female ratio is M>F (2-3:1)
• Onset of symptoms before age 45
• Symptoms worsen with rest or prolonged inactivity & relieved with the exercise; Unilateral buttock pain and ↓ lumbar lordosis with ↑ overall kyphosis can occur
• Gradual loss of spinal ROM with Decreased chest wall excursion: < 2.5 cm suspicious

Ankylosing Spondylitis: Diagnosis

• MRI best for early detection using short tau inversion recovery(STIR) to suppress fat signal
• Early radiographic findings: Sacroiliitis, Ligamentous sclerosis,Joint space narrowing
• Later changes: “Squaring” of vertebral bodies and Syndesmophytes Ossification of spinal ligaments

Ankylosing Spondylitis

• Musculoskeletal Complications: Osteoporosis & increased fracture risk (T7- S1), Atlantoaxial subluxation, Spinal stenosis
• Extra-articular Complications: Uveitis- present in 20-30% of cases, Cardiac & pulmonary dysfunction

Ankylosing Spondylitis

• Pharmacologic Management through the use of NSAIDs or Biologic DMARDs
  • COX-2 specific inhibitor
  • TNF-α inhibitors
  • Non= TNF -α biologics
• Physical Therapy is also important to maintain Focus on maintaining upright posture and flexibility
• Look forConflicting evidence on appropriate intensity

Osteoporosis

• Osteoporosis has to do with Metabolic bone disease that results in loss of total bone mass & mineral density as well as a risk of fractures Osteoblasts- Decreased activity with ↓ bone formation Osteoclasts- Increased activity with ↑ bone resorption

Osteoporosis

• Primary
  • Age-related
  • Post-menopausal
• Secondary
  • Chronic renal failure
  • Hyperthyroidism
  • Prolonged immobilization
  • GI diseases

Prevalence of Osteoporosis

• around 10 million in the US or which 80% are female
  • about 34 million with low bone density

Osteoporosis: Risk Factors

• Primary risk factors include : Female, White or Asian descent, Family history, Small, thin body-type, Post-menopause, Sedentary lifestyle, Smoking There are also Dietary and Medical related causes: Diet low in Ca and Vit D, Anorexia nervosa, & Prolonged use of corticosteroids

Osteoporosis on Imaging

• Look for Cortical Thinning, Osteopenia, Increased bone radiolucency, Trabecular Changes, Thinner, decrease in number, Fractures

Imaging

• Use Dual Energy X-ray Absorptiometry (DXA) which is gold standard however Standard radiographs would need more than a 30% reduction in bone mass to detect changes
• Use number of standard deviations to find value. -1 or greater than is normal BMD; -2.5 to -1 is osteopenia; greater or = -2.5 is osteoporosis
• For something normal for that age: look for less than or equal to -2 (abnormal)

Osteoporosis: Clinical Presentation

Usually an asymptomatic presentation over 50 years of with Sudden onset spinal or hip pain, with past History of spinal compression Fx(s) as well as Dowager’s hump.

• Screen for risk factors, and refer if suspect undiagnosed Fx

Osteoporosis: Intervention

-Usefull exercises to management of osteoporosis women which provides a Small but statistically significant improvement in BMD loss vs placebo intervention or usual activity -Use WBing low-force exercise, walking/jogging, or Tai Chi

• Use high-force exercise with progression
• Use Balance training as well in a consistent 2-3 days/week schedule in moderate intensity with a 6-48+ months

Osteoporosis: Exercise Recommendations

• For Postmenopausal women it can help to slow decline of hip/femur BMD using Sustained SLS or PREs +/- dynamic low force exercise such as walking, jogging, aerobics in women to slow decline of lumbar BMD
• Use PREs + dynamic low force exercise such as (tai chi, walking) -For Premenopausal women , it can slow decline of femoral neck & lumbar BMD by performing PREs + dynamic high-force impact training which uses (jogging, stairclimbing) This type of Participation should be for a long duration: 6-48+ months as well as Apply it to transgender & cisgender patients

Female Athlete Triad

• This will present itself as a Condition in adolescent & young adult female athletes which involves

1. Low energy availability - Energy expenditure > nutritional intake (+/- eating disorder (e.g. Anorexia Nervosa/Bulimia)) 2. Menstrual Dysfunction presenting itself as Amenorrhea 3. Decreased BMD as Osteopenia/Osteoporosis -You will face risk stemming from a combination of: the not eating enough, irregular perods, and not having enough bone density - Stress fracture due to low BMD - Permanent loss of BMD

Female Athlete Triad: Interventions

• There should be an improvement in BMD & restoration of regular menstruation along with a diet & exercise regimen, Ca & Vitamin D supplementation, Estrogen replacement therapy, and Counseling