Management of lumbar spinal stenosis

Abstract

Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.

Fig 1

Degenerative spinal stenosis: frontal (A), sagittal (B), and axial views (C). Thickening of the tissue surrounding the dural sac is shown in purple. The axial figure depicts only a relatively minor degree of stenosis to allow visualization of the different structures. Reproduced with permission from the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center

Fig 2

Pooled results of epidural steroid injections versus placebo interventions for spinal stenosis¹⁰⁸

Fig 3

Degenerative spondylolisthesis: frontal (A) and sagittal (B) views. Forward slippage of one vertebra over the other may cause narrowing of the central canal, lateral recesses, and neuroforamina, thereby contributing to lumbar spinal stenosis. Reproduced with permission from the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center