Lumbar Spinal Stenosis: Updated Research.
“If you go to out to do some grocery shopping, are you always leaning on the shopping trolley or looking for a seat?”
If the answer is yes (especially if you’re over 60 years of age) -> chances are you might be struggling with some form of lumbar stenosis.
So what is Stenosis of the Lumber Spine?
Lumbar spinal stenosis is a narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs. While it may affect younger people, due to developmental causes, it is more often a degenerative condition that affects people who are typically age 60 and older. These changes leads to pain in the legs and back, as well as impaired ambulation and other disabilities.
With this in mind, let’s look at some commonly proposed methods of treatment. The list below is numbered in descending order of the results when we google “lumbar spinal stenosis”:
Decompression laminectomy
Oral medication: pregabalin (lyrica) or gabbapentin (paracetomol)
Conservative treatment (Physiotherapy)
I will now provide you an update for the validity of all 3 treatment strategies.
1. Decompression laminectomy
Nowadays technology is so prevalent, information is so easy to access, it’s common that we usually would prioritize what’s in the first page of a google search, and within the first page, we’d go for the link with the “Big Bold Font”.
Now, if I go right now to google and search “spinal stenosis” or “lumbar spinal stenosis” within the top 3 search results I see:
Lets break down what a laminectomy is one step at a time.
Step 1. Watch this video:
Laminectomy procedure video: https://www.youtube.com/watch?v=nstyX0Fo2yc
Step 2. If you’ve watched this video, you now understand 3 things:
During the procedure the spine is exposed via incision
They CUT OUT part of your spine to relieve the nerve pressure
It is proposed that the pressures gone from the spine and you will feel no more pain from the nerve compression.
Makes sense right? When you want to make more room, you throw things out. But is it really that simple for everyone? I mean for such an invasive procedure, I think having a strong understanding of the effectiveness through historical data is really important.
So, let’s see how promising this procedure actually is according to the most up to date literature.
In a 2022 systematic review,15000 titles and abstracts were screened, they checked out 156 articles, ended up with under 3600 participants, male and female were split just equally, mean age were 63 years old.
Duration of lumbar spinal stenosis symptoms were between 12 weeks to 15 years
The analysis showed that Laminectomy showed improved outcomes only at the 2 year follow up compared with conservative care. One of the studies shows that there's no difference in outcomes after 8 years (1).
Pretty wild to think isn’t it?
They took the spine out, cut the bones, the patient’s under general anesthesia, they probably billed out 10,000-15,000 dollars for the procedure that’ll probably take 1 hour, and there is NO DIFFERENCE in outcomes after until after 2 years and one of them showed NO DIFFERENCE in outcomes after 8 years!
This is a BIG deal, because most people in the community think that surgery is a fix. In cases of red flags, surgery is important and it can be life saving, but it is certainly NOT a guaranteed fix for a lot of these chronic conditions as people believe them to be.
2. Oral Medication/Steroid Injection
The article found that oral pain meds to not improve pain, distance walked, functional or global health status compared with placebo. Additionally adverse events were reported in 64% in the lyrica (pregabalin) group.
If you’re taking lyrica, you might want to confirm with your doctor if its the best medication for you.
Another study found that oral corticosteroids did not improve the outcomes in the short term compared to placebo
and there just very low quality evidence that paracetomol (gabbapentin) can improve distance walked or pain compared to placebo
Medication is just not a very good treatment strategy if we just get down to it.
2 studies shows that trans laminar or caudal steroid injections were no better than placebo.
Loading up on steroids is quite frankly going to deteriorate cartilage, it promotes degenerative changes of a joint, in a pinch they can help don't get me wrong…But, overwhelming majority of the time, you’re 3 shots a year for life, as many people try to quote on quote “AvOiD SuRgeRy'' by getting 3 injections a year, they’re actually pushing themselves towards surgery. Again, to further understand the long term effects of steroid injections, please read my corticosteroid blog.
A recent clinical update published in the Brittish Medical Journal recommended supervised exercise and manual therapy as the FIRST LINE TREATMENT and recommended against the use of steroids.
The article -> https://www.bmj.com/content/373/bmj.n1581
3. Conservative Treatment
There is moderate quality evidence from a trial that manual therapy and exercise provides superior and clinically important short to long improvements in symptoms and function compared with medical care. Moderate quality evidence was also found in a multi-model 6 week program consisting of manual therapy and exercise is an effective approach.
What am I thinking when I’m interpreting this data? It is that conservative treatment coupled with a movement based approach is:
Safer than surgery - Think about post operative complications…They do exist, especially when a portion of the spine is literally cut off
More cost effective than surgery
Proven to have equal functional outcomes to surgery after 2 years and also 8 years follow up
What they also found is that vitamin B12 + conservative treatment improves walking distance in the intermediate and long term, compared to conservative treatment alone. B-vitamins can be helpful in many different cases, but interesting to know that B-vitamins can be helpful for neural claudication.
Small trial with low quality evidence that presurgical exercise will improve post surgical outcomes. So is prehab a wise idea? Yes, this means that even if you need to go to surgery, prehabilitation is important to make sure that your post surgical outcomes are better.
My Suggestion is: Always try conservative treatment if presented with the opportunity. Give it your all. Trust the process, and be proactive with treatment and rehab. It’s not uncommon for people that have booked for a surgery to pull out during the prehabilitation process because they found significant improvements through movement based conservative treatment with their therapist.
Final Thoughts
You might gather information other health care providers. But, it’s important to tell the story from my perspective, in a way that you understand, so that you can compare apples to apples, and to me that's one of the most important things that I can do as a physiotherapist.
So in summary, there have been recent guidelines for lumbar stenosis which is a multi-model care consisting of education, exercise, manual therapy. The research is saying that a multi-model approach would appear to be the more rational approach, given the complexity of the symptoms and a lot of these factors are:
Physical
Functional
or Psychosocial
These guidlelines recommend against the use of epidural steroid injections. Epidural steroid injections are one of the most common things that are done millions of times per year for this, and they are billed out hundreds if not thousands of dollars, and there’s no evidence to support it.
There is no evidence to support the usage of oral pain medication to treat lumbar spinal stenosis, and was also reported 64% incidence in adverse effects from the usage of lyrica.
Based on what research says and what I’ve been seeing from my patients, movement based care is where it's at. Without a red flag (ie. tumours, infection, fractures, incontinence, severely progressing neurological deficit), movement based care is probably the safest and most cost effective way to manage lumbar spinal stenosis.
Hope this helps.
Your friendly neighbourhood physio,
Tony
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Resources:
Ammendolia, C., Hofkirchner, C., Plener, J., Bussieres, A., Schneider, M., Young, J., Furlan, A., Stuber, K., Ahmed, A., Cancelliere, C., Adeboyejo, A., Ornelas, J. Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review (2022).
Retrieved from: https://pubmed.ncbi.nlm.nih.gov/35046008/
Macedo, L., Hum, A., Kuleba, L., Mo, J., Troung, L., Yeung, M., Battie, M. Physical Therapy Interventions for Degenerative Lumbar Spinal Stenosis: A Systematic Review (2013). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3870489/
Jenson, R., Harhangi, B (neurosurgeon)., Huygen, F., Koes, B. (2021). Lumbar Spinal Stenosis.
Retrieved from: https://www.bmj.com/content/373/bmj.n1581
Rajsekaran, S., Raja, S., Pushpa, B., Ananda, K., Prasad, S., Rishi, M. (2021).The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials
Retrieved from: https://link.springer.com/article/10.1007/s00586-021-06809-0
Shipton, E. (2018). Physical Therapy Approaches in the Treatment of Low Back Pain
Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6251828/
Franz, W., Bentley, N., Yee, P., Chang, W., Kendall-Thomas, J., Park, P., Yang, J. (2015).Patient misconceptions concerning lumbar spondylosis diagnosis and treatment
Retrieved from: https://thejns.org/spine/view/journals/j-neurosurg-spine/22/5/article-p496.xml
Bussieres, A., Cancelliere, C., Ammendolia, C., … Stubler, K., Yee, A., Ornelas, J. (2021). Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline
Retrieved from: https://www.jpain.org/article/S1526-5900(21)00188-7/fulltext
