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Lumbar Stenosis
THE CONDITION
Stenosis is a spinal condition in which the holes, called foramen, between the vertebrae close down, crushing the delicate nerves that travel through them. This can be caused by any number of causes, from tumors to discs to genetics, but the primary cause is from degeneration of the discs in the spine. When these nerves get compressed, any number of symptoms can result. Often, symptoms will get worse slowly over time. Most often, symptoms will be on one side of the body or the other. Symptoms include pain, numbness and weakness, and in the case of stenosis patients, and gets worse with walking or standing. Unlike the typical lumbar disc injury patient, the symptoms often lessen or disappear with sitting or leaning forward. Most people with spinal stenosis cannot walk for a long period of time, and then slowly regain their abilities after resting. Legal caveat: If you are experiencing: difficulty or poor balance when walking, or problems controlling urine or bowel movements, please call your doctor immediately. This article is not written for you… go to the ER, or you regular doctor immediately. Unfortunately, many people who are reading this have already been diagnosed with the condition, looking for a possible treatment. Unfortunately, just as stenosis comes on slowly, it doesn’t go away quickly, either, unless you opt for surgery, which we call the “Roto Rooter method”. The reason I’m writing this article is to offer a new way to look at lumbar stenosis, and how it occurs, and how to identify patients BEFORE they reach the neverending circle of pain and dysfunction stage of this condition. I’d like to start with what I call the “typical patient”.
TYPICAL PATIENT
It’s written in the literature that patients can be any sex, and across body types, with patients usually showing signs in their mid 50’s. Lumbar Spinal Stenosis: A Definitive Guide, by Peter F. Ullrich, Jr., MD, but it’s been my clinical experience that this occurs far more frequently in men. Sorry, guys. The signs of stenosis are related directly to pressure on nerves. Motions or actions that increase the pressure on the nerves increases the patient’s pain levels, and those that relieve it are the ones that patients adopt. Usually, patients find it best to slightly lean forward , gapping the hole at the rear of the vertebrae. This often results in the stooped, shuffling posture we often see in older men, as a longer stride would force extension of the lumbar spine and compression of the nerve roots. These patients slowly develop more problems, as they are compressing the disc, and often slowly “grind to a halt” , where they can’t lean forward without hurting, and can’t lean back without hurting, either. Eventually, lying down is the only comfortable position, and every other position causes or increases their pain. The condition results in the loss of exercise, usually leading to added weight gain. The literature is now shoing a significant tie between chronic pain and depression, as well. These once active patients slowly dissolve into the “Damned if you do, damned if you don’t.” situation, when it comes to moving. However, as we age it’s clear that while symptoms show up later in life, it’s usually due to issues that start earlier in life. In my opinion, this occurs much earlier, in our teen years.
THE LUMBAR SPINE
Sparing the reader a basic anatomy lesson, we’re going to talk about the spine from a structural integrity standpoint. Basically, on its own, the spine is unstable in the vertical position. Hundreds of studies involving the cutting of various cadaver muscles show at what point the spine becomes unstable, and it’s appalling, in my opinion. (However, those opposable thumbs are hard to beat.) We as humans are forced to use the muscles that surround the spine, to support it. Words like “the core” are often used to describe these muscles: The abs, the extensors, the transverse abdominis. I like to include three more: the diaphragm, the pubococcygeus (Kegel), and the iliopsoas. The first two of these muscles are unique in that they are horizontal, and lend stability as being the top and bottom of the core group. The primary reason for writing this article however, is the iliopsoas. The iliopsoas hold great esteem in the hearts of meat eaters: the cut of beef it yields is the revered filet mignon. It is internal for the entirety of its length, living unseen below the tissues of the body. It begins, or inserts, by attaching to the lumbar spine vertebrae and discs, running inferiorly (down) the leg, attaching to the femur. It is actually comprised of the psoas, which we described, and the iliacus, which runs along the inner border of our hip bone, looking like a tarp covering the inside bowl of a stadium, with the fibers going down the leg, eventually joining with the tendon of the psoas. Using the iliopsoas as a stabilizer of the lumbar spine is certainly possible, as seen with various studies: 1. 2. 3. and there’s many more.
THE PROBLEM
My postulation is this…. Wait for it…… MANY PATIENTS WHO OVERUSE THE ILIOPSOAS AS A STABILIZER EVENTUALLY DECAY THE LUMBAR SPINE TO THE POINT IT CAUSES SPINAL STENOSIS.
A good way to think of this method of stabilizing the lumbar would be to imagine five oranges (or grapefruit, if you prefer) in a row. It’s entirely possible to hold them in a row while using a compression load (squeezing them), but the slightest insult will disturb the line, allowing it to bend. This constant overcompression of the lumbar spine results in a slow grinding down of the discs in the spine, and results in an overextension of the lumbar spine, which give the patient the look of a large, extended belly. This belly is now different than that of a pregnant woman’s, and will result in a condition common to pregnant women called diastasis recti. It’s a football- shaped hernia, essentially, that comes about as the wall of the abdomen breaks down with the increased pressure from the internal organs, due to the increased curve of the low back. *picture* It is this condition that triggered the need for this article. Diastasis recti is easy to spot, simply by having a patient do a small sit up from a supine position, and looking. However, this is not a good finding. In fact, I feel it is the sign of a long-standing biomechanical problem. I have not been able to determine if by fixing the biomechanics that the diastasis recti woiuld heal itself, but as it does repair on pregnant women, it should with the cases of stenosis we see in practice.
The swelling directly under the painting is a great example of Diastasis Recti... A. Patient
FIXING THE PROBLEM
How then, do we go about alleviating this issue? There are two issues that must be addressed. The first is to elongate the iliopsoas. The second is to train the patient to use other muscles for stabilizing the low back.
STRETCHING THE ILIOPSOAS
The failure of other practitioners to achieve success with “psoas” stretching is the inability to, or unwillingness to, recognize that the iliopsoas muscle should be treated as a fully 3 dimensional object, with muscle fibers crossing not only the x, but y and z axes. Therefore, the muscle needs to be stretched around ALL THREE axes. (It is actually “theta x, y and z, meaning rotation around… sorry to get a little nerdy there) These exercises will soon be outlined in the “Self Help” section, under Psoas Stretching… enjoy.
STRENGTHENING THE LUMBAR SPINE
One of the best ways to stabilize the lumbar spine is to use the two horizontal muscles of the thorax to give stability to the low back: the diaphragm, and the pubococcygeus, or Kegel muscles. Diaphragmatic breathing I svery important. As the diphragm stabilizes the lumbar spine 12 to 20 times a minute, it seems silly not to teach breathing techniques to stenotic patients. It's amazing how how many people simply don't know how to breathe! A future article will outline why and how patients who use their accessory muscles of the neck as primary breathing muscles, and how that decays the neck, but or now we'll stick to stenosis.
Kegel use is very important from a neurologic standpoint, as its innervations is the same as that of the transverse abdominis, the most important “core” muscle in the low back. As much as I would love to go into detail about exercises for this,
it’ll take more input from you, the reader, for me to further expound on these… it takes more work that I’d admit to get these articles written and published than I thought!
Dr. Peter Carr
