Lumbar spinal stenosis is a condition where there is inadequate space for the neural and vascular elements in the lumbar spinal canal. The reduced space is often due to to age-related spinal degeneration and typically occurs in one of 3 regions.

  • The Central Canal
  • The Lateral Recess
  • The Lumbar Intervertebral foramen.

Symptoms, causative factors, and therapeutic approaches differ depending on the region of involvement. Uncertainty in diagnosis and treatment arise when more than one of the above 3 regions is involved.

This post will focus on the 4 most important things that a patient with Lumbar Central Canal Stenosis should know. 

The topic is important because Lumbar Canal Stenosis is becoming more prevalent as the population ages and is a common reason patients undergo spine surgery. (1,2)  In fact, studies now estimate that over the next decade more than 65 million people will be afflicted with this disorder. (3,4)

[1]  The natural history of lumbar spinal stenosis is favorable.  This means that there is no urgency for any type of treatment, especially surgery.  Consider the following:

  • 2 studies evaluated lumbar stenosis pain over a 5 year period.  70% of these patients showed no worsening, 15% worsened and 15% had pain that disappeared spontaneously. (5,6)  Spontaneous improvement (that occurring without treatment) has also been reported by others. (10,11)
  • In another group, close to 90% of patients with asymptomatic lumbar spinal stenosis remained symptom free over a 5 year observation period. (7)
  • If symptoms do worsen, they typically do so gradually. (8) This allows an opportunity to assess the benefit of conservative care, which may lead to improvement over time. (9)

[2]  There is little, if any, correlation between the severity of  lumbar stenosis seen on an MRI and a patient’s symptoms or functional status.  

  • One study illustrated this by noting the presence of a large number of patients with spinal canal narrowing and a complete lack of symptoms.  They further described how diagnostic accuracy is compromised due to inconsistencies in the criteria used for measurement. (12)
  • Another study of 115 patients with intermittent lumbar claudication found that the degree of stenosis on MRI neither correlated with the severity of symptoms nor had the ability to predict success with lumbar surgery. (13)
  • The above findings were reinforced in a recent paper where the authors concluded, “The radiologic severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes and should not be overemphasized in clinical decision making.” (14)
  • The results are similar when larger groups are observed.  Out of 938 patients with MRI confirmed lumbar stenosis only 5.3% of mild, 9.9% of moderate, and 17.5% of severely stenotic patients were symptomatic. (15)
  • The imprecise correlation becomes even more evident with studies showing how patients with lesser degrees of stenosis may have symptoms more limiting than those with severe stenosis. (10)

[3]  Symptomatic lumbar spinal stenosis, or neurogenic claudication, affects the legs much greater than the low back and is clearly modified by posture or activity.  

  • The complaints most strongly associated with lumbar spinal stenosis (LSS) are lower extremity pain, fatigue, or weakness, more prominent with standing and walking. These symptoms are consistently relieved by sitting or forward bending. Non-specific urinary symptoms are not uncommon. (16)
  • Diagnostic certainty is reportedly increased to 80% when the following 6 features are present: (17)
    • Leg or buttock pain while walking.
    • Bending forward relieves symptoms.
    • Relief is experienced leaning on a shopping cart.
    • Leg weakness or tingling and numbness occurs with walking.
    • Symptoms are minimal or absent when riding a bicycle.
    • Leg pulses are normal.
  • Low back pain, without leg symptoms, is not a feature of lumbar stenosis.  In these situations, lumbar MRI’s are not only misleading, but have also been shown to relate to an increased risk of having unnecessary spine surgery. (18,19,20,21) 

[4]  The best type of treatment for lumbar spinal stenosis has not been established. Patients have options and should be informed about them.

Because no one type care has been shown to be consistently better than another, the right choice often depends on how each option fits into a person’s lifestyle, finances, and expectations.

The following are some things to consider.

  • Patients should work with clinicians who are knowledgeable, unbiased, and willing to discuss treatment alternatives rather than apply undue pressure to choose a specific form of treatment.
  • Any program should include instruction on self-care to help patients independently manage their symptoms. (23).  For example, aqua therapy, including water jogging, has been found to be helpful. (24) Riding a stationary bicycle has been shown to be about as effective as a formal therapy program. (25).  Instruction on proper postures are also important because spinal extension (backward bending) increases nerve compression and flexion (forward bending) lessens it. (26)

Most authorities suggest a trial of conservative care before considering surgery.  In fact, a recent review found no clear benefits for surgery compared to non-surgical treatment, a 10-24% complication rate with surgery, and no complications with conservative care. (22). The authors recommended, “These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects.”

To be balanced, other studies have shown surgery to offer more benefit than conservative care, at least over a 4-year observation period, although the comparative benefits of surgery diminished beyond that time frame. (27)

My next post will provide an overview of what a patient could expect from some of the different types of conservative care for lumbar spinal stenosis.

I welcome any correspondence.  Feel free to email me at nrvdoc@hotmail.com and to follow my twitter posts @spinelinenet

Dr. Ronald D. Fudala

References:

  1. Skolasky RL, Maggard AM, Thorpe RJ, et al. United States hospital admissions for lumbar spinal stenosis;; racial and ethnic differences, 2000 through 2009. Spine 2013;; 38:2272-­2278.
  2. Aebi M, Gunzburg S, Szpalski S. The aging spine. Germany: Springer; 2005
  3. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med 2008;; 358:818-­825.
  4. Deyo RA. Treatment of lumbar spinal stenosis: a balancing act. Spine J 2010;;10:625-­627.
  5. Johnsson KE, Rosen I, Uden A: The natural course of lumbar spinal stenosis. Acta Orthop Scand Suppl 1993, 251:67–68
  6. Schulte TL, Bullmann V, Lerner T, Schneider M, Marquardt B, Liljenqvist U, Pietila TA, Hackenberg L: [Lumbar spinal stenosis].Orthopade 2006,35(6):675–692.
  7. Tsutsumimoto T , Shimogata M, Yui M, Ohta H, Misawa H. The natural history of asymptomatic lumbar canal stenosis in patients undergoing surgery for cervical myelopathy. J Bone Joint Surg Br. 2012 Mar;94(3):378-84
  8. Steurer J, Nydegger A, et al. LumbSten: The lumbar spinal stenosis outcome study. BMC Musculoskeletal Disorders 2010 11:254
  9. Weinstein JN, Tosteson TD, Lurie JD, Tosteson A, Blood E, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, et al.: Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 2010,35(14):1329–1338.
  10. Kuittenen P et al.  Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability. BMC Musculoskeletal Disorders. 2014, 15:348
  11. Ji Hee Hong, Mi Young Lee, et al.  Does spinal stenosis correlate with MRI findings and pain, psychologic factor, and quality of life?  Korean J Anesthesiol. 2015 Oct;68(5)
  12. Sirvanci M, Bhatia, M et al. Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.  Eur Spine J. 2008 May;17(5) 679-685
  13. Moojen WA, Schenck CD et al.  Preoperative MR Imaging in Patients with Intermittent Neurogenic Claudication: Relevance for Diagnosis and Prognosis.  Spine. 2015 Nov. 30
  14. Weber C, Giannadakis C et al.  Is There an Association Between Radiological Severity of Lumbar Spinal Stenosis and Disability, Pain, or Surgical Outcome?: A Multicenter Observational Study.  Spine 2016 Jan;41(2)
  15. Ishimoto Y, Yoshimura N et al.  Associations between radiographic lumbar spinal stenosis and clinical symptoms in the general population:  the Wakayama Spine Study. Osteoarthritis and Cartilage, Vol. 21, Issue 6. June 2013
  16. Onel D, Sari H, Dönmez C. Lumbar spinal stenosis: clinical/radiologic therapeutic evaluation in 145 patients. Spine. 1993;18:291–298.
  17. Tomkins-Lane C , Melloh M, Lurie J, et al.  Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study.  Spine (Phila Pa 1976). 2016 Feb 1. [Epub ahead of print]
  18. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002 Oct 1;137(7):586–97.
  19. Djais N, Kalim H. The role of lumbar spine radiography in the outcomes of patients with simple acute low back pain. APLAR Journal of Rheumatology 2005;8:45–50.
  20. Gilbert FJ, Grant AM, Gillan MG, et al. Low back pain: influence of early MR imaging or CT on treatment and outcome–multicenter randomized trial. Radiology 2004;231:343–51.
  21. Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine 2003;28:616 –20.
  22. Zaina F, Tomkins-Lane C, Carragee E, et al.  Surgical versus non-surgical treatment for lumbar spinal stenosis.  Jan. 2016.  http://www.cochrane.org/CD010264/BACK_surgical-versus-non-surgical-treatment-lumbar-spinal-stenosis
  23. Carlo Ammendolia, DC, PhDNgai Chow, BSc, DC  Clinical Outcomes for Neurogenic Claudication Using a Multimodal Program for Lumbar Spinal Stenosis: A Retrospective Study. JMPT.  Volume 38, Issue 3, March–April 2015, Pages 188–194
  24. Lee JH1, Sung E2. The effects of aquatic walking and jogging program on physical function and fall efficacy in patients with degenerative lumbar spinal stenosis.  J Exerc Rehabil. 2015 Oct 30;11(5):272-5
  25. Luciana Gazzi Macedo, Abraham Hum, Laura Kuleba, Joey Mo, Linda Truong, Mankeen Yeung, Michele C. Battié.  Physical Therapy Interventions for Degenerative Lumbar Spinal Stenosis: A Systematic Review.  Phys Ther. 2013 Dec; 93(12): 1646–1660
  26. David Kubosch, Marco Vicari, Alexander Siller, Peter C. Strohm, Eva J. Kubosch, Stefan Knöller, Jürgen Hennig,Norbert P. Südkamp, and Kaywan Izadpanah.  The Lumbar Spine as a Dynamic Structure Depicted in Upright MRI. Medicine (Baltimore). 2015 Aug; 94(32). Published online.
  27. James N. Weinstein, DO, MS, Tor D. Tosteson, ScD, Jon D. Lurie, MD, MS, et al.  Surgical Versus Nonoperative Treatment for Lumbar Spinal Stenosis Four-Year Results of the Spine Patient Outcomes Research Trial. Spine • Volume 35 • Number 14 • 2010

 

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