Management of lumbar spinal stenosis

Management of lumbar spinal stenosis can be divided into:

• non surgical options
  • usually recommended before surgical options
    • due to the lack of consensus, a specific type of non-surgical treatment cannot be recommended for LSS
      
      
  • main categories include:
    • drugs
      • several drugs are used for the treatment of LSS, their efficacy remains unclear
      • e.g. -,
        • NSAIDs
        • prostaglandins E1, gabapentin, and vitamin B1 - has been shown to improve pain and walking distance
        • corticosteroids
        • antidepressant
          
          
    • physiotherapy
      • is an accepted treatment for LSS
      • e.g. -
        • exercise (aerobic, strength, flexibility)
        • specific exercises in lumbar flexion (cycling)
        • body weight supported treadmill walking
        • muscle coordination training
        • balance training
        • lumbar semi-rigid orthosis
        • braces and corsets
        • spinal manipulation
          
          
    • injections
      • evidence shows that epidural steroid injections helps in providing  limited short term and long term improvement in pain and walking distance in patients with LSS
      • another systemic review concluded that epidural injections with local anesthetic alone, or local anesthetic with steroids provide some relief of low back pain and lower extremity pain for central LSS
        
        
    • others
      • although there is lack of evidence, alternative treatment methods have been used by patients with LSS
      • e.g. - flexion distraction manipulation, acupuncture
        
        
• surgical options
  • carried out when bothersome symptoms persists despite treatment with less invasive methods
  • helpful in relieving the leg symptoms (claudication or radiculopathy) associated with LSS than improving any accompanying back pain.
  • decompression
    • main aim is to decompress the neural structures to relieve symptoms and improve function
    • options include traditional laminectomy, bilateral laminotomies, bilateral decompression through unilateral laminotomy, and different forms of laminoplasty
    • postoperative active rehabilitation after decompression surgery helps in improving both short term and long term (back related) functional status
  • interspinous spacer devices
    • a device inserted between the spinous processes to separate the spinous processes at the stenotic levels
    • may provide some benefit with fewer major medical complications than decompression surgery, but is associated with higher rates of re-operation (1)

Notes:

• when comparing surgical or nonoperative treatment for lumbar spinal stenosis:
  • relative benefit of initial surgical treatment diminished over time, but outcomes of surgery remained favorable at 2 years in comparison to nonoperative treatment (2)
• a systematic review concluded (3):
  • surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials

Reference:

• (1) Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016;352:h6234
• (2) Malmivaara A et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial.1: Spine. 2007 Jan 1;32(1):1-8.
• (3) Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD.Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1094-109.