patient with disc bulge and spinal stenosis at L3-L4, L4-L5, L5-S1, spondylolithesis of L4 on L5

i have a question regarding treatment for you. this is the most complicated pt i have seen till date, obese patent, 70 years old, complains of pain leg with walking, relived by sitting but also pain with bending forward, sitting too long

CT scan results:

grade 1 retrolithesis of L3 on L4, anterolithesis of L4 on L5, retrolithesis of L5 on S1, no fracture

L3-L4, L4-L5, L5-S1: hypertrophy of ligamentum flavom, bilat neuroforaminal narrowing because of disc bulge leasing to spinal stenosis

so my dilema is i can't give him flexion exercises because that would worsen the disc bulges but i can't give extension exercise because that will worsen the spondylolithesis of L4 0n L5

his LE strength is very good, no neurlogical deficits.

i have been working on hamstring flexibility, hip flexors atretghing, and strenghtening the global core mm like bridging, and have worked on TA activation, multifidi

any suggestions?

Passive stabilisation is key here. The back has failed! It is really pain management until pain can be significantly reduced. I am a chiropractor so we pick up and treat a great deal of these cases - here is my protocol for spinal stenosis from stabilisation phase of discal degeneration:

Passive support a brace is key here bauerfeind a German company do great ones fitted for spondylolisthesis.
Next flexion is key the osteophytic formation around the facets is impinging on the neural forama press in on the nerve - leading to pain down legs. We have a device called a flexion distraction bench. This allows the pt to lie prone and for us to passively induce flexion by lowering legs. If you don't have this it's a problem because the spine is so unstable that if you passive do this by hand it would be hard to control and even hard to replicate. However if pt was placed in swimming pool so weight on spine is reduced you may be able to either flex hips to offer some natural flexion traction into lumbar segments.
Next use EMS to stimulate multifidus muscles in a aim to enhance natural stability.

Do this 2 week for 2 weeks then 1 a week for 3 and review pain levels.
Note: you concern about flexion further damaging the discs is unwarranted in a pt of this age. Would be good to review some of the latest research on disc anatomy and aging. Basically the disc has at this point losses most of its water content and is unable to herniated further.

Does that help?

Hi Pad,
These are difficult to treat, no question. My first question is how bad is the spondylolesthesis? You mention a grade 1?
In that case, while I wouldn't do end of range extension, I'd definately get them prone. If the client is getting leg ache from the stenosis this may well bring on the symptoms if they are too lordotic, but often you will find they tolerate prone, even if you have to put a small pillow under the stomach. From there you just do a very slow progression into more extension.
I agree that stabilisation exercises may help, however, if you can do some extension to reduce the disc bulge ( age may be against you here) then the stenosis will likely reduce as well (as the disc is contributing less). I have found in the 45-55 age group this works well to clear both flexion and extension, but it is slow (weeks) and they need to be very strict on avoiding flexion postures.

For the stabilisation stuff pick exercises with an extension bias.

Hope this helps.

BB

Doing any extension exercise would be mad in my book there is clearly no mechanical advantage to this in a patient with stenosis. You need to make the foramina gap (flexion) not close (extension). Remember why this condition happened the disc bulged, then losest height, then caused rubbing of the facets; which went through a defensive osteophytic formation to stabilise.
By entering the facets you will make them worse!!! Before you make them better. By using flexion distraction method you should see results by forth treatment. This can also be by hunching them over a pillowed stool and genteelly pushing cephalad aspect of the spinous processes individually into flexion.
Also get them to sleep in fetal position at night. Assuming that offers relief - does it?

One thing of note from your discription: is pain when they bend forward is it when sitting, standing that cause pain?

Is it due to muscle spasm. Very likely to happen in a failed spine like this.
Or is it due to facet capsule aggravation very common to happen in grade 1 spondy.
Or is it just nerve tension.

Grade one spondylolisthesis is stable if that helps.

agree no extensions as likely to make matters worse. especially given worse with walking (extension) and better in sitting (flexion). give flexion exercises to gap and open foramen to rleive nerve irritation, try some gentle neural flossing/gliding work, either in supine, or sitting to decrease the neural sensitivity. active support with core+++ in neutral. teach to maintain neutral. consider biomechanics at foot, either orthotic, barefoot science product etc. agree sometimes passive support necessary also in short term to relieve neural sensitivity.
if all fails surgical opinion to stabilise

good luck

I didn't see a description of osteophyte formation or severe degeneration of the facets on what was described on CT.

The last two posts reaction to my suggesting extension has validity in that yes, it will close the foramen, however, they are clearly ignoring your description of pain with sitting too long and bending.

To me this suggests that, yes while the disc is likely compromised by the persons age, it is possibly still behaving dynamically, and indeed flexion, as described by your history, is an aggravating factor and could in all reality make him worse too.

I am not suggesting, as you may be picturing, a full prone McKenzie extension.

Just lay him prone. If things ease a little, then bring him into less than 5 deg extension. If the stenosis is still being contributed too by a dynamically acting disc this position will be tolerated, if, as suggested there is gross degenration then it won't be toleratedand of course you would cease.

To those that so strongly argue for flexion, in light of bending and sitting being aggravating factors, why would you only treat the stenosis and ignore its underlying cause?

bluebear, you may be right, with limited extension being ok, but i would only stabilise in neutral. from my experience anyway, extensions may help if it is hydrated disc, but then you need force to 'reduce' any disc bulge, ie mckenzies. otherwise all you are doing is gradually improving an extension dysfunction. also with spondy extension tends to make it worse, regardless of any osteophyte or other degeneration, which there is likely to be anyway, as it exagerates the slip, further closing the foramen and irritating the nerve. there are other causes of pain with prolonged sitting than a disc, postural overload, muscular-ligamanetous tension etc which would be better suited to advice to avoid prolonged sitting rather than to do extensions. my opinion anyway and difficult without patient to assess and try out on

These are difficult to treat, and you quite rightly point out other possible causes of pain in flexion and prolonged sitting.

The limited amount of extension I am proposing, unless the spondy was advanced, would cause minimal impact, and may just provide some relief.

I agree on the stabilisation front, but by the sounds of it that has been tried.

Good luck Pad, let us know how you get on.
BB