How to Manage Spinal Stenosis | Spoon-Feed Version

June 8, 2022

Written by Aaron Lacy

Spoon Feed
Lumbar spinal stenosis affects more than 1 in 10 U.S. citizens and over 100 million patients worldwide. This painful condition is diagnosed clinically with confirmatory imaging. Firstline treatment is activity modification, analgesia, and physical therapy, and careful selection of surgical candidates should be done only if conservative management fails.

Why does this matter?
Musculoskeletal and stenotic back pain are both painful for patients and their doctors, as treatment with significant relief is challenging and improvement is usually not immediate or may never come. With 103 million patients affected worldwide and 11% of all U.S. adults having the condition, with 600,000 related surgical procedures done each year for spinal stenosis, we must equip ourselves with the knowledge on how best to handle this painful pathology.

Spinal stenosis ≠ MSK back pain

Pathophysiology and presentation of lumbar spinal stenosis

• Narrowing of the lumbar spinal canal and/or neural foramina causes compression of the spinal nerve roots.
• Compression most commonly happens secondary to spondylolisthesis (vertebral body misalignment) and acquired degeneration, and less commonly secondary to congenital or metabolic conditions.
• Patients present with activity-limiting pain in the lower spine, buttocks, and thighs, and pain may be bilateral or unilateral.

Diagnosis of lumbar spinal stenosis

• A diagnosis based on history and physical examination is key, as indiscriminate imaging can be harmful.
• 20% of patients older than 60 years old have imaging evidence of spinal stenosis, but over 80% are asymptomatic.
• Patients will have pain exacerbated by activities that narrow the canal (leg extension, standing) and better with leaving forward. The spine and surrounding musculature are normally non-tender.
• Confirmatory testing with MRI is the imaging modality of choice. This can be done as an outpatient, but MRI should be done urgently if there is any concern for cauda equina.

Treatment of lumbar spinal stenosis

            Exercise and PT

• Physical therapy and manual therapy (stretching, mobilization, muscle strengthening) are effective over time. Supervised PT and comprehensive programs are more effective than home exercise or self-directed programs (63% vs 33% at 6 weeks, 82% vs 63% at 6 months, respectively).

Medications

• Acetaminophen, NSAIDs, and duloxetine do not have specific studies for the treatment of lumbar spinal stenosis.
• Gabapentin improved pain, but 40% of patients experienced significant drowsiness.
• Epidural steroid injections were no better than lidocaine injections at 3 and 12 months.

Surgery

• Decompressive surgery improved the Oswestry Disability Index score 3.5 to 7.8 points (on a scale of 0-100). The improvement was less if patients had rigorous PT prior to surgery.
• 2/3 studies showed pairing a lumbar fusion with decompressive surgery did not improve symptoms.

The conclusion here is…unsatisfying. Much of what we know in treating musculoskeletal back pain does not cross over into treating spinal stenosis. There are no medications that appear to be particularly effective in reducing pain, including NSAIDs and acetaminophen. Opioids must be avoided as they are both ineffective and lead to further healthcare usage. Rigorous and supervised physical therapy seems to be the best and safest route, with select patients needing surgery. Much of medicine is expectation management, and using motivational interviewing and laying out the path to recovery for these patients is key when they arrive for evaluation.

Source
Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA. 2022 May 3;327(17):1688-1699. doi: 10.1001/jama.2022.5921.