2.3 Spinal Conditions
Key Takeaways
- Lumbar disc herniation most often occurs at L4-L5 or L5-S1, presenting with radicular pain in a dermatomal pattern and a directional preference (often extension-bias for posterolateral herniations).
- Lumbar spinal stenosis improves with flexion (the 'shopping cart sign') and worsens with extension; programs emphasize flexion-bias exercise, posture, and walking with support.
- Spondylolisthesis grades use the Meyerding system: Grade I (<25% slip), II (25-50%), III (50-75%), IV (75-100%), V (>100%, spondyloptosis); grades I-II are most common and respond to stabilization.
- McKenzie (Mechanical Diagnosis and Therapy) classifies pain as derangement, dysfunction, or postural, and uses directional preference and centralization of symptoms to guide exercise direction.
- After lumbar laminectomy or fusion, BLT precautions — no bending past 90 degrees at the hip, no lifting more than 5-10 pounds, no twisting — typically apply for 6-12 weeks per surgeon.
Disc Herniation
A disc herniation occurs when nucleus pulposus material protrudes through annulus fibrosus fibers and irritates a nerve root. In the lumbar spine, L4-L5 and L5-S1 account for the majority of clinically significant cases; cervical herniations cluster at C5-C6 and C6-C7.
Classic findings:
- Radicular pain in a dermatomal distribution (e.g., lateral foot for S1)
- Myotomal weakness (e.g., great toe extension weakness with L5)
- Reflex changes (e.g., diminished Achilles reflex with S1)
- Positive straight leg raise (SLR) between 30-70 degrees for lower lumbar herniation
Many posterolateral herniations centralize with lumbar extension — repeated prone press-ups, prone propping, and posture re-education. The PTA monitors for centralization (symptoms moving proximally) as a favorable sign and peripheralization (symptoms moving distally) as an unfavorable sign that warrants PT communication.
Spinal Stenosis
Narrowing of the spinal canal or neuroforamen — typically degenerative in older adults. Hallmark neurogenic claudication: bilateral leg pain/heaviness with standing and walking that improves with flexion (leaning on a shopping cart, sitting, or walking uphill). This is the classic 'shopping cart sign.'
PTA-implemented flexion-bias program: posterior pelvic tilts, single and double knee-to-chest, seated lumbar flexion, stationary cycling (flexed posture), and progressive walking with rests on a bench or cart. Avoid prolonged extension activities.
Spondylolisthesis (Meyerding Grading)
Spondylolisthesis is the anterior translation of one vertebra on another, often at L5-S1.
| Grade | Slip Percent | Typical Management |
|---|---|---|
| I | <25% | Conservative — core/abdominal stabilization, hamstring stretching, posture |
| II | 25-50% | Conservative; activity modification |
| III | 50-75% | Often surgical consideration |
| IV | 75-100% | Surgical |
| V (spondyloptosis) | >100% | Surgical |
Flexion-bias exercise (Williams flexion-style) is generally favored to off-load the posterior elements; aggressive extension is avoided.
McKenzie / Mechanical Diagnosis and Therapy (MDT)
MDT classifies non-specific spinal pain into three syndromes:
- Postural syndrome: Pain only with sustained end-range posture; resolves with posture correction.
- Dysfunction syndrome: Pain at end-range due to shortened tissue; treated with repeated end-range loading in the direction of the dysfunction.
- Derangement syndrome: Most common; pain that varies and has a directional preference (often extension). Treatment uses repeated movements in the direction that centralizes symptoms.
The PTA monitors centralization carefully and reports if a previously centralizing direction starts peripheralizing.
Post-Operative Spinal Precautions
Laminectomy / Discectomy
Most surgeons impose BLT precautions — no Bending past 90 degrees at the hip, no Lifting more than 5-10 pounds, and no Twisting of the trunk — for 4-6 weeks. Log-roll transfers, hip-hinge body mechanics, walking 5-6 short bouts daily, and progressive abdominal/glute activation are the PTA's early focus.
Lumbar Fusion
BLT precautions extend longer — typically 6-12 weeks — and bony fusion may take 6-12 months. The PTA avoids spinal flexion past neutral early, defers any prone press-up or end-range extension until cleared, and progresses walking, core endurance, and posture per the PT's phase plan.
Red Flags Requiring Immediate Escalation
- New saddle anesthesia
- New bowel or bladder dysfunction
- Progressive bilateral lower extremity weakness
- Suspected cauda equina syndrome
A PTA who encounters any of these stops the session and notifies the supervising PT and physician immediately.
A PTA is implementing a McKenzie-based program for a patient with low back and right calf pain. After 10 repetitions of prone press-ups, the patient's calf pain decreases and the pain centralizes to the low back. What does this finding indicate?
A patient 3 weeks post lumbar laminectomy reports new urinary retention and numbness in the perineal region during a PTA session. What is the PTA's MOST appropriate immediate action?