2.3 Spinal Conditions

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. Because the lumbar nerve roots exit below their named vertebra, an L4-L5 disc usually compresses the L5 root, and an L5-S1 disc usually compresses the S1 root.

Classic findings, mapped to PTA-collectable data:

A positive straight leg raise (SLR) reproducing leg symptoms between 30-70 degrees supports lower-lumbar radiculopathy. 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 toward the spine) as favorable and peripheralization (symptoms moving distally) as unfavorable, reporting peripheralization to the PT.

Spinal Stenosis

Narrowing of the central canal or neuroforamen, usually degenerative in older adults. The hallmark is neurogenic claudication: bilateral leg pain, heaviness, or paresthesia with standing and walking that improves with flexion — leaning on a shopping cart, sitting, or walking uphill (the 'shopping cart sign'). This contrasts with vascular claudication, which is relieved simply by stopping activity regardless of spinal position.

A PTA-implemented flexion-bias program includes posterior pelvic tilts, single and double knee-to-chest, seated lumbar flexion, stationary cycling in a flexed posture, and progressive walking with rests on a bench or cart. Prolonged extension activities (prone press-ups, overhead reaching) are avoided because extension narrows the canal further.

Spondylolisthesis (Meyerding Grading)

Spondylolisthesis is anterior translation of one vertebra on the one below, most often at L5-S1. The Meyerding grade is based on percentage of slip.

Flexion-bias (Williams-style) exercise generally off-loads the posterior elements; aggressive end-range extension is avoided because it increases the anterior shear that drives the slip.

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 from adaptively 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's job inside an MDT program is to deliver the prescribed repeated movements, count repetitions, and track the symptom response: centralization means continue the chosen direction, while a previously centralizing direction that begins peripheralizing must be reported to the PT for reassessment.

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, no Twisting of the trunk — for about 4-6 weeks. Early PTA focus is log-roll transfers, hip-hinge body mechanics, walking in 5-6 short bouts daily, and progressive abdominal and gluteal activation.

Lumbar Fusion

BLT precautions extend longer, typically 6-12 weeks, and bony fusion can take 6-12 months. The PTA avoids spinal flexion past neutral early, defers prone press-ups and 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 (retention or incontinence)
• 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, because cauda equina syndrome is a surgical emergency in which delay risks permanent deficit.

Distinguishing Spinal Presentations on the Exam

Many NPTE-PTA spinal items hinge on matching a symptom pattern to the correct directional bias, then choosing the intervention the PTA may implement. Use the response to position as the discriminator.

Centralization Is the Master Sign

Regardless of the named condition, centralization (symptoms retreating proximally toward the spine) is the favorable response a PTA tracks rep-by-rep, and peripheralization (symptoms spreading distally) is the unfavorable response that triggers PT communication. The PTA documents the segment level of symptoms before and after each set, not just a pain number.

Body Mechanics and Patient Education

For every spinal patient the PTA reinforces neutral-spine lifting, the hip-hinge, log-roll bed mobility, and frequent position changes. After laminectomy or fusion these are not optional comfort tips but the BLT precaution made practical: a log roll prevents the trunk twist that BLT forbids, and a hip-hinge keeps lifting below the 5-10 pound limit while sparing forward flexion. Teaching and reinforcing this education is squarely within PTA scope, whereas changing the precaution timeline is not.