management of lumbar spinal stenosis

Last reviewed 10/2020

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: