Exploring Management of Patients with Spinal Stenosis

Original Editor- Edward Cobb Top Contributors - Nehal Shah, Edward Cobb, Khloud Shreif, Helena Dickson and Kim Jackson

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (20/5/2024)

Overview[edit | edit source]

Spinal canal is the osteo-ligamentous canal which contains the spinal cord. Spinal canal stenosis can be described as an anatomical or functional narrowing of the osteoligamentus vertebral canal and/or the intervertebral foramina causing direct compression or indirect compromise of dural sac, the caudal nerve roots and their vasculature, enough to cause symptoms or signs[1].Spinal stenosis defined as a narrowing of the spinal canal causing clinical symptoms secondary to spinal cord or radicular compromise.

Mechanical back pain can be caused due to Functional spinal canal stenosis with or without neurological affection or claudication. It is treatable[1]. A functional canal stenosis can occur either due to the decrease in size of spinal or foraminal canal ( disc bulge, osteophyte, spondylolysis/listhesis) or increase in the size of spinal cord / nerve roots (space occupying lesion). As the age advances, due to degenerative spinal changes, some adults develop progressive neurological deficit and low back pain in the latter part of their life. This is due to acquired spinal canal stenosis[1]

Briefly, lumbar spinal stenosis is characterised by compression of neural tissue either at the central canal, foramen or lateral recess, there are multiple mechanisms of which spinal stenosis can occur these include disc herniation, facet joint hypertrophy or slippage of adjacent vertebral bodies, all narrowing the space for neural tissue to pass through.

Etiology[edit | edit source]

Spine imaging of the elderly usually shows narrowing of spinal canal or foramina. But the diagnosis of spinal stenosis is made only when patient presents with symptoms like neurogenic claudication and / or cervical myelopathy. Cervical and Lumber canal stenosis may / may not co-exist. But this usually does not involve thoracic spine[2]. Cases in earlier life are more likely due to congenital causes such as achondroplasia however acquired lumbar spinal stenosis is generally due to natural degenerative changes. Rarely cancer around the spine can be the cause of spinal stenosis. Several other conditions can display similar symptomology, some common differential diagnoses include, vascular claudication, peripheral neuropathy, lumbar spondylosis and many more.

Spinal stenosis may be classified according to its etiology or anatomy. Anatomical classification describes either central canal, lateral recess or foraminal stenosis. Two types of spinal stenosis were described by Arnoldi from etiologic point of view - Congenital and Acquired. Congenital stenosis is idiopathic or may be caused by achondroplasia. Presence of short and thick pedicles are seen which lead to stenotic central canal in sagittal diameter. Acquired Spinal stenosis is mainly caused by Degenerative disc disease. Most frequently is is seen in L4-5 levels followed by L3-4, L5-S1 and L1-2.[2]

Epidemiology[edit | edit source]

Epidemiological data suggest that cervical spinal stenosis is seen is 1 out of 1,00,000 persons and lumbar spinal stenosis is seen in 5 out of 1,00,000 persons[2]. Cervical myelopathy in patients over 50 years of age is most commonly due to cervical spine stenosis. 5/1000 people over the age of 50 are projected to develop some level of spinal stenosis, only 9% of cases are ever of congenital cause highlighting how common lumbar stenosis is as a degenerative disease.

Clinical Presentation and related pathomechanics[edit | edit source]

In cervical stenosis, patients may either be asymptomatic or at times may present with symptomatic myelopathy from spinal cord compression[3]

Patients with Lumbar canal stenosis may present with back pain and radicular symptoms like pain, weakness, numbness and reduced sensations in the leg[4]. Pain and stenotic symptoms aggravate by dynamically loading the spine during standing, walking etc and are relieved on lying down[1]

Patients with spinal canal stenosis often complain increased pain during extension of the spine. Studies have found that from flexion to extension, reduction in the spinal canal diameter on an average ranged from 12 to 30%. Majority of our routine activities involve dynamic loading of spine in sagittal plane. During flexion, the laminae of the two adjacent vertebrae move apart widening the interlaminar space and lengthening and thinning of ligamentum flavum. These dynamic changes occur more markedly in the central portion of central canal than the lateral recess. Posterolateral annulus of the disc bulge cause dynamic changes in the lateral recess especially into the subarticular portion of lateral recess which is worsened by rotational forces[1].

Different types of clinical presentation of stenotic symptoms on loading are observed. Patients may have well-localized radicular signs and symptoms often involving a single root and their symptoms are produced within no time of spinal loading whereas few patients present with ill localized symptoms and are produced after prolonged walking or standing[5]

Claudication[edit | edit source]

Neurogenic Claudication means lameness or limping with symptoms of cauda equina compression simulating vascular claudication in patients with canal stenosis. Sensory symptoms predominate over motor symptoms and patients usually stop their activities before they feel weakness. Pain rarely follows a sciatic radicular course. But patient complains more of numbness, coldness burning and cramping. There is no aggravation with coughing or straining. The course of this discomfort begins from buttocks and extend upto posterior thigh and along the leg. These symptoms aggravate on walking and at times standing also with back in extension. Apart from Spinal canal stenosis, claudication is also seen in other causes of neural compression like massive central disc herniation and lateral foraminal narrowing[1][6]. Claudication is relieved with spinal flexion in spinal canal stenosis.

Grading of Lumbar Spinal Stenosis[edit | edit source]

Grading of Lumbar Spinal Stenosis was given by Hufschmidt and Bar as follows[7]

Grade I - Neurogenic intermittent claudication characterized by a reduced walking distance due to pain and short term intermittent sensory and / or motor deficits which were not remarkable at rest but worsen while walking. This is further subdivided into Grade 0 - Symptoms appear after walking 100 mts or more and Grade I - Symptoms appear after walking a distance less than 100 mts

Grade II - Intermittent paresis with persistent sensory deficits and loss of reflexes

Grade III - Persistent, progressive paresis accompanied by partual regression of pain

Diagnosis[edit | edit source]

When considering diagnosis, imaging is a powerful tool to confidently identify what is causing the patients problem, confirming a lumbar stenosis or perhaps a differential diagnosis.

  • X -ray: will show the vertebra and may show disc or facet degeneration, fractures, or calcification.
  • MRI: can offer more insight into surrounding soft tissues useful for identifying ligamental changes, neural changes or potential tumors.
  • CT: uses computer software to generate 3d images of the lumbar structures, CT is especially useful for investigating potential fractures or arthritic changes.

Note that Imaging is useful for identifying stenotic changes however does not determine whether the stenosed spine requires direct treatment. Around 21-33% of people who demonstrated radiological signs of lumbar spinal stenosis (LSS) did not have symptoms[8] One must also understand the fact that impression of LSS on MRI does not necessarily determine if LSS is the cause of pain[9].

Diagnosis of LSS is made on the basis of a wide range of clinical, electrodiagnostic, and radiological tests. But there is a lack of generally accepted "Gold Standard" technique for the classification of LSS and clinical decision making especially in borderline patients[10]

To ensure a confident diagnosis of LSS symptoms and signs should match with imaging findings, a spinal canal diameter of 10mm is characterised as an absolute stenosis and can be supported by signs such as the bicycle stress test, the patient rides a stationary bicycle in an upright position and the distance is recorded, this is repeated with a flexed forward position, if the distance is greater this time, LSS is indicated.

Electrodiagnostic testing with electromyography and nerve conduction studies are recommended in patients with atypical presentation, inconclusive imaging, presence or possibility of confounding etiologies like lumbar plexopathies, nerve impingement syndromes, vascular claudication or neuropathies of any cause[11]Electrodiagnostic testing must be combined with a thorough clinical examination.

Clinical Course of the condition[edit | edit source]

There are insufficient evidences describing natural history of LSS especially for severely advanced cases. As per the data of North American Spine Society, natural history of mild to moderate symptomatic cases of LSS show a favorable result in upto 50%cases. They have also mentioned that rapid or catastrophic neurologic progression is rare[12] . Various studies have found that symptoms were unchanged in about 30-70% cases, improvement in 15-30% cases and worsening in 15-30% cases[13]

Management[edit | edit source]

It is of utmost importance that the healthcare professional is aware about the natural history of the disease as that will help in deciding most appropriate management course. This is a progressive condition and hence significant spontaneous improvement may not be expected. Unbearable symptoms warrant more aggressive treatment approach[14]The primary goal of management is to prevent progression of the condition and relief of symptoms,

Spinal canal stenosis can be treated conservatively and surgically. Conservatively, patients can be treated with exercises, manual therapy, nonsteroidal anti inflammatory medicines, epidural steroid injections and opioid analgesics. Failure of conservative treatment options to improve patient's symptoms point towards surgical procedures[15]

Pros and cons of each approach differ, conservative treatment is preferred in early stages as this prevents the need to recover from a large operation, operations that carry risks like infections, decreased function post op and mental health challenges pre and post op. Some cons of the conservative approach are as follows, recovery time is generally longer as you are facilitating the natural healing process, problems from larger issues are unlikely to resolve completely without surgery and certain medical conditions will need to be considered prior to treatment and acted on accordingly by the MDT such as diabetes.

On the other hand surgery can resolve pain quicker as the route cause is dealt with, however spinal surgery is somewhat traumatic to the body so naturally a post op rehabilitation plan is needed which can be lengthy.

Surgical Management[edit | edit source]

Depending upon the anatomical level and type of narrowing, laminectomy, foraminotomy, discectomy, corpectomy are performed for decompression. Additionally if spinal stability and sagittal balance are found affected, additional instrumentation is performed. There is class 1b evidence that surgery is of benefit for lumbar stenosis at least in the short term.[2]

For cervical spine stenosis the main objective of surgery is to halt disease progression.

Decompression by laminectomy can be used if the central canal is compromised by ligament changes for example, removal of spinal laminae and spinous process and/or soft tissues can relieve pressure on neural tissue

Spondylosyndesis is a type of spinal fusion which is commonly completed post decompression when instability of the spine is suspected. This type of fusion is followed by implants of a metal brace to support the two vertebra together.

Discectomy and fusion – if a disc herniates or degrades it may reduce the compress the central canal or the foraminal space, if the disc is sufficiently degraded it may be removed and the adjacent vertebra fused

Foraminotomy – in cases where the foraminal space is compromised by bony spur or disc herniation, etc, intrusive material will be removed widening the foraminal space to relieve symptoms.

Finally if disc degeneration is severe enough, a disc arthroplasty may be suitable, the damaged intervertebral disc is completely removed, an artificial disc is then place as substitution.

Conservative management[edit | edit source]

Conservative management is usually the first line of treatment to patients with spinal stenosis who present with mild to moderate symptoms. The treatment options are vast, ranging from strengthening and stretching, non-steroidal anti-inflammatory drugs, epidural steroid injections, pelvic traction, hydrotherapy or aquatic therapy to flexion exercises and more, however, these options are commonly recommended[16]Some of the many benefits of conservative treatment options for LSS include; reduced risk of infection in comparison to surgical interventions, minimizes invasive interventions and the patients generally report better outcome measures.

MEDICATIONS

Non-steroidal anti-inflammatory drugs (NSAISs) are the first choice of drugs given for short- term to give symptomatic pain relief and enable the patients to go for initial Physiotherapy[11]. Evidences regarding the use of any one type of NSAIDs are insufficient[17][18]Opoids and muscle relaxants have not been found superior to NSAIDs or acetaminophen. Role of prostaglandins, gabapentin, Vitamin B12 and Calcitonin is also unclear[19]

EPIDURAL / STEROIDAL INJECTIONS

These are anaesthetic or steroid injections given within the epidural space around the spinal nerves to relieve symptoms of pain and radiculopathy. These injections can be Interlaminar ESI, Transforaminal ESI, Caudal ESI. Compared to surgical interventions, ESIs are safer and less invasive. They provide short-tern symptom relief in patients with neurogenic claudication or radiculopathy[12]Injections also coincide with an increased risk of infection due to the needle breaking the protective skin barrier. Epidural or steroid injections also come with further risks to patients with diabetes and/or glaucoma, these need to be taken into consideration for patients considering this line of treatment

PHYSIOTHERAPY MANAGEMENT

Though the evidence behind improvement in pain and function following Physiotherapy management is of low-quality[20], Physiotherapy interventions are clinically found to be effective and should be considered as part of initial management. Physiotherapy management involves a combination of flexibility and stability in the form of flexibility training, core strengthening, and stability exercises[11].

  • Lumbar flexion prescription - Lumbar flexion is promoted by several authors rather than lumber extension exercises due to the neuroforaminal narrowing and the narrowing of the spinal canal that is produced in lumbar extension. In ‘normal’ spines, during lumbar extension the cross-sectional area of the lumbar spinal canal and lateral recesses reduces by 9%, with lumbar stenotic patients, this reduction increases to 67%. This reduction in the area of space the spinal cord and exiting nerve roots can move around would likely reproduce the patients symptoms and risk further nerve damage.[21]
  • Hydrotherapy - Aquatic treatments have proven to provide benefits to patients such as increasing muscle strength (paraspinal, trunk, glutes and other lower limb muscles), improving flexibility and also the balance of the patients, with the natural buoyancy of the water if a patient slips who has fear of falling it has been observed to reduce their fear. Along with the warmth of the water providing further pain relief effects.
  • Pelvic/lumbar manual traction - This is used to stretch the para-spinal muscles, reducing the pressure they exert on the nerve roots and also to temporarily widen the joint space to alleviate the patient's symptoms which has been proven to be beneficial with lumbar stenotic patients.[22]
  • Stretching and strengthening exercises - Having been used for several years in the lines of management for back pain, stretching exercises to lengthen muscles have been proven to temporarily alleviate patients' symptoms by relaxing the muscles and reducing the pressure exerted onto the exiting nerve roots and increasing the central canal space encasing the spinal cord. Strengthening exercises have also been proven to reduce the patients' pain levels and decrease disability levels [23]
  • Joint Mobilization - Joint mobilization / distraction techniques for spine, sacroiliac joint and hip joint are found to be effective in treating Lumbar stenosis[24]
  • Neural Tissue Mobilization - Neural mobilization techniques are found to be effective in the treatment of radiculopathy[25] following Spinal stenosis. Treatment aims at improving nutrition to the compressed nerve root, improve the gliding of the nerve and thereby relieving radicular symptoms. Though good level evidences are missing in this area, clinical improvement has been found in patients.

Surgery - Exploring the Literature[edit | edit source]

There are various surgical interventions available that can be used to treat lumbar spinal stenosis. The most common surgery is spinal decompression but these vary mostly due to location and type of deformity of the stenosis as well presence of instability. Surgical options are only considered for patients who do not improve with conservative management[19]. Patients with lumbar stenosis and predominant leg pain have better surgical outcomes as surgery is particularly effective in decompressing the nerve[26] fusion of vertebra may also be considered if instability is also suspected as a cause of pain[27]. Spinal stenosis is now one of the most common indications for spinal surgery in those older than 65 years, with an overall increasing rate of these surgeries being linked to an increasingly aging population [28]. Regarding age, surgery still provided a significant benefit for patients 80 or over with no significant differences in complications or mortality rates compared to younger patients, so surgery is still a viable option. However, studies have observed that pain levels were not as reduced as much compared to the younger population[29]

When is surgery considered?[edit | edit source]

Spinal decompression surgery gives better patient outcomes compared to conservative management with improvement in pain, function and quality of life [30] However, it is important to consider that this study grouped patients that are already candidates for surgery and who had found no improvements with three to six months of conservative treatment. Therefore, non-conservative management should be trialed first in order to assess whether surgery is or is not required, as surgery is a high cost intervention with potential risks such as infection, hemorrhage and associated anesthetic risks. [31] Studies have proposed that surgery should be considered if conservative treatment has failed for 3-6 months. Additionally studies have also put in the fact that the effects of longer term conservative treatment is unclear. Progressing neurological symptoms and their severity are taken into consideration while planning the surgery but there are no consensus in terms of guidelines as to when should surgery be considered for each patient[32]. It is important to note that it has been reported that only 60-70% of patients were satisfied with their symptoms following surgery[33] . Therefore, it is important for patients to understand that surgery may not alleviate all symptoms and that a discussion around what non-conservative treatment can do compared to surgery is required. Additionally, a study that looked at longer term outcomes of surgery at eight years after operation concluded that there is evidence to suggest that the surgical group had diminishing benefits of their surgery. This should be considered but could also indicate the importance of long term self-management / rehabilitation following surgery[34] .

How effective is rehabilitation following surgery for spinal stenosis?[edit | edit source]

A Cochrane review comparing active rehabilitation to usual care in patients following surgery for spinal stenosis concluded that there were moderate-quality evidences that indicated that active rehabilitation is more effective in both short and long term functional status. Active Rehabilitation included all forms of active rehabilitation that aimed to restore or improve function, including exercise or stabilization training involving strength training, flexibility training as well as education and encouraging activity. This review suggested that active rehabilitation was more effective for short-term ( within six months post operatively) in improving low back pain and for long-tern (12 months post operatively) in improving low back pain and leg pain. The review also showed 20% improvement in functional status and 16% improvement in low back pain for short-term following active rehabilitation[35]

What makes an effective postoperative rehabilitation program?[edit | edit source]

Early Postoperative Rehabilitation:

Intensive physiotherapy is not recommended until the surgical wound following decompression surgery has completely healed. This will take approximately three weeks and building up exercise gradually is encouraged (Cambridge University Hospitals, 2023). Therefore, rehabilitation from the studies in the Cochrane review started from six weeks (at the earliest) and three months (at the latest), this active rehabilitation will be explored later. Immediately post-operation, an NHS exercise program recommends 7 simple exercises that focus on moving the joints and neural tissue of the lumbar spine. These exercises are as follows (Cambridge University Hospitals, 2022):

Plantar and dorsiflexion to help improve circulation, reducing chances of DVTs and to help glide the nerves.

Knee rolls, this exercise aims to increase movement in the hips and encourages the small rotational abilities of the lumbar spine .

Hip and knee bends, helps to gently glide the nerves and encourages slight lumbar flexion in a comfortable position.

Back arches on all fours, lengthens the spinal erectors preventing tightness and lumbar restriction.

Lumbar side flexion, the last exercise targeting the different range of motion at the lumbar spine.

Bent Knee dropout, more of a focus on strengthening the hips in a comfortable lying position.

Bridging, strengthening mainly the glutes but also stabilizing and strengthening the muscles surrounding the lumbar spine.

Patients are encouraged to move regularly, with walks recommended as a great way to increase activity level. Sitting for long periods may be uncomfortable so if this occurs movement is needed. Returning to hobbies and sport is recommended to be gradual and guided by levels of pain (Cambridge University Hospitals, 2022).

One study found that patients with more fear avoidance behaviours and reduced physical activity had higher levels of pain and disability[36] . It is also found that many patients engage in very low levels of physical activity during the early postoperative periods. Even with physiotherapy input and general physical improvements, activity levels did not change from six weeks to six months[37] . This suggests that a priority of rehabilitation should be to encourage movement and reduce fear avoidance, particularly in the early stages.

Later Stage Postoperative Rehabilitation[edit | edit source]

It is established that postoperative rehabilitation provides better outcomes than no active rehabilitation. However, studies that look at the effect rehabilitation has, often provide only a limited discussion of the actual rehabilitation process. This makes it hard to identify what is most effective from a rehabilitation program. There have been various studies that have tried to explore most effective rehabilitation program. Treatment protocols of various studies ranged from strengthening exercises 3-5 times a week with stretching exercises everyday[38], attending one hour classes of general aerobic fitness, stretching, stability exercises, strengthening and endurance training given twice a week with advice on lifting, setting targets and self-motivation[39], spine stabilization exercises[40]. Practically all the studies have incorporated strengthening exercises. Few studies have focussed on core stabilization and stretching. But there is a scarce literature exploring individual effect of each of these intervention, Therefore, there is a need for more research to look at what specific rehabilitation principles are most effective post operatively.

Postural Control[edit | edit source]

Worsened postural control and timing of postural reactions is observed in spinal stenosis patients potentially due to stenosis caused afferent dysfunctions. Post surgery, patients still showed postural alterations, but these were significantly improved compared to the control group. Therefore, post-surgical rehabilitation should include a form of balance and proprioception training. Proprioception training should progress on unstable surfaces with a component of reduced visual input[41]. These exercises also address the fact that core stabilization is important for rehabilitation of these patients, though there is a lack of research exploring effect of these exercises on pain relief and improvement in disability.

Example Exercises and Ideas[edit | edit source]

Walking – aerobic exercise that is an easy way to increase overall activity levels. Any exercise that patients enjoy should be promoted

Sit to Stand Training – Strengthens the lower limb and can be adjusted to bias one leg, useful if leg strength is unequal due to radicular leg symptoms.

Deadlifts – Isometrically strengthening the spinal erectors which may be weaker after surgery this exercise also helps to build overall strength.

Woodchops/exercises involving spinal movement – This strengthens the ‘core’ muscles but incorporating spinal movement also helps to potentially reduce any fear avoidance.

Wobble Board Training – This could involve balancing with or without eyes closed or incorporating strength and functional movements such as a squat. This is to train postural control and stability.

Suitcase Marches – Core stability and balance for late-stage rehabilitation. We can use the Cochrane recommended outcome measures for our patients to assess if improvements are being made.

Conclusion/Key Learning Points[edit | edit source]

  • Surgery is effective for reducing pain, increasing function and improving quality of life.
  • Surgery is particularly effective at reducing leg symptoms, however it is not guaranteed to reduce all symptoms experienced.  
  • Patients are encouraged to do what pain allows following surgery, reducing inactivity is important.
  • At around 2 months following surgery, more intensive physiotherapy can start.
  • There is limited evidence about the most effective form of rehabilitation post operation but evidence that shows the benefits of rehabilitation revolve around strength training.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Gopinathan P. Lumbar spinal canal stenosis-special features. Journal of orthopaedics. 2015 Sep 1;12(3):123-5.
  2. ↑ 2.0 2.1 2.2 2.3 Melancia JL, Francisco AF, Antunes JL. Spinal stenosis. Handbook of clinical neurology. 2014 Jan 1;119:541-9.
  3. ↑ Caron TH, Bell GR. Combined (tandem) lumbar and cervical stenosis. InSeminars in Spine Surgery 2007 Mar 1 (Vol. 19, No. 1, pp. 44-46). WB Saunders.
  4. ↑ Azimi P, Azhari S, Benzel EC, Khayat Kashany H, Nayeb Aghaei H, Mohammadi HR, Ebrahimi M. Outcomes of surgery in patients with lumbar spinal canal stenosis: comparison of three types of stenosis on MRI. PLoS One. 2016 Jun 22;11(6):e0158041.
  5. ↑ Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. The Journal of Bone & Joint Surgery British Volume. 1954 May 1;36(2):230-7.
  6. ↑ Spanos NC, Andrew J. Intermittent claudication and lateral lumbar disc protrusions. Journal of Neurology, Neurosurgery, and Psychiatry. 1966 Jun;29(3):273.
  7. ↑ Hufschmidt A, Rauer S, Glocker FX, editors. Neurologie compact: für Klinik und Praxis. Georg Thieme Verlag; 2022 Mar 9.
  8. ↑ Jensen RK, Jensen TS, Koes B, Hartvigsen J. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. European spine journal. 2020 Sep;29:2143-63.
  9. ↑ Haig AJ, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, Chiodo A, Miner JA, Choksi VR, Geisser ME, Parres CM. Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. Archives of physical medicine and rehabilitation. 2006 Jul 1;87(7):897-903.
  10. ↑ De Schepper EI, Overdevest GM, Suri P, Peul WC, Oei EH, Koes BW, Bierma-Zeinstra SM, Luijsterburg PA. Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests. Spine. 2013 Apr 15;38(8):E469-81.
  11. ↑ 11.0 11.1 11.2 Bagley C, MacAllister M, Dosselman L, Moreno J, Aoun SG, El Ahmadieh TY. Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Research. 2019;8.
  12. ↑ 12.0 12.1 Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, Hwang SW, Mendel RC, Reitman CA. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). The Spine Journal. 2013 Jul 1;13(7):734-43.
  13. ↑ Minamide A, Yoshida M, Maio K. The natural clinical course of lumbar spinal stenosis: a longitudinal cohort study over a minimum of 10 years. Journal of Orthopaedic Science. 2013 Sep;18:693-8.
  14. ↑ Fouyas IP, Statham PF, Sandercock PA. Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy. Spine. 2002 Apr 1;27(7):736-47.
  15. ↑ Anderson DB, De Luca K, Jensen RK, Eyles JP, Van Gelder JM, Friedly JL, Maher CG, Ferreira ML. A critical appraisal of clinical practice guidelines for the treatment of lumbar spinal stenosis. The Spine Journal. 2021 Mar 1;21(3):455-64.
  16. ↑ Gunzburg R, Szpalski M. The conservative surgical treatment of lumbar spinal stenosis in the elderly. The Aging Spine. 2005:94-8.
  17. ↑ Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CW, Day RO, McLachlan AJ, Ferreira ML. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. bmj. 2015 Mar 31;350.
  18. ↑ Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Non‐steroidal anti‐inflammatory drugs for low back pain. Cochrane database of systematic reviews. 2008(1).
  19. ↑ 19.0 19.1 Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. Bmj. 2016 Jan 4;352.
  20. ↑ Ammendolia C, Stuber K, de Bruin LK, Furlan AD, Kennedy CA, Rampersaud YR, Steenstra IA, Pennick V. Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review. Spine. 2012 May 1;37(10):E609-16.
  21. ↑ Penning L. Functional pathology of lumbar spinal stenosis. Clinical Biomechanics. 1992 Feb 1;7(1):3-17.
  22. ↑ Schneider MJ, Ammendolia C, Murphy DR, Glick RM, Hile E, Tudorascu DL, Morton SC, Smith C, Patterson CG, Piva SR. Comparative clinical effectiveness of nonsurgical treatment methods in patients with lumbar spinal stenosis: a randomized clinical trial. JAMA network open. 2019 Jan 4;2(1):e186828-.
  23. ↑ Slater J, Kolber MJ, Schellhase KC, Patel CK, Rothschild CE, Liu X, Hanney WJ. The influence of exercise on perceived pain and disability in patients with lumbar spinal stenosis: a systematic review of randomized controlled trials. American Journal of Lifestyle Medicine. 2016 Mar;10(2):136-47.
  24. ↑ Schneider MJ, Ammendolia C, Murphy DR, Glick RM, Hile E, Tudorascu DL, Morton SC, Smith C, Patterson CG, Piva SR. Comparative clinical effectiveness of nonsurgical treatment methods in patients with lumbar spinal stenosis: a randomized clinical trial. JAMA network open. 2019 Jan 4;2(1):e186828-.
  25. ↑ Efstathiou MA, Stefanakis M, Savva C, Giakas G. Effectiveness of neural mobilization in patients with spinal radiculopathy: a critical review. Journal of bodywork and movement therapies. 2015 Apr 1;19(2):205-12.
  26. ↑ Pearson A, Blood E, Lurie J, Abdu W, Sengupta D, Frymoyer JF, Weinstein J. Predominant leg pain is associated with better surgical outcomes in degenerative spondylolisthesis and spinal stenosis: results from the Spine Patient Outcomes Research Trial (SPORT). Spine. 2011 Feb 1;36(3):219-29.
  27. ↑ Katz JN, Zimmerman ZE, Mass H, Makhni MC. Diagnosis and management of lumbar spinal stenosis: a review. Jama. 2022 May 3;327(17):1688-99.
  28. ↑ Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. Jama. 2010 Apr 7;303(13):1259-65.
  29. ↑ Rihn JA, Hilibrand AS, Zhao W, Lurie JD, Vaccaro AR, Albert TJ, Weinstein J. Effectiveness of surgery for lumbar stenosis and degenerative spondylolisthesis in the octogenarian population: analysis of the Spine Patient Outcomes Research Trial (SPORT) data. JBJS. 2015 Feb 4;97(3):177-85.
  30. ↑ Kovacs FM, Urrútia G, Alarcón JD. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine. 2011 Sep 15;36(20):E1335-51.
  31. ↑ Ogihara S, Yamazaki T, Inanami H, Oka H, Maruyama T, Miyoshi K, Takano Y, Chikuda H, Azuma S, Kawamura N, Yamakawa K. Risk factors for surgical site infection after lumbar laminectomy and/or discectomy for degenerative diseases in adults: a prospective multicenter surveillance study with registry of 4027 cases. PLoS One. 2018 Oct 16;13(10):e0205539.
  32. ↑ Liang J, Lian L, Liang S, Zhao H, Shu G, Chao J, Yuan C, Zhai M. Efficacy and complications of unilateral biportal endoscopic spinal surgery for lumbar spinal stenosis: a meta-analysis and systematic review. World neurosurgery. 2022 Mar 1;159:e91-102.
  33. ↑ Weinstein JN, Tosteson TD, Lurie JD, Tosteson A, Blood E, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial.
  34. ↑ Lurie JD, Tosteson TD, Tosteson A, Abdu WA, Zhao W, Morgan TS, Weinstein JN. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT).
  35. ↑ McGregor AH, Doré CJ, Morris TP, Morris S, Jamrozik K. Function after spinal treatment, exercise and rehabilitation (FASTER): improving the functional outcome of spinal surgery. BMC Musculoskeletal Disorders. 2010 Dec;11:1-8.
  36. ↑ Donnarumma P, Presaghi F, Tarantino R, Fragale M, Rullo M, Delfini R. The impact of pelvic balance, physical activity, and fear-avoidance on the outcome after decompression and instrumented fusion for degenerative lumbar stenosis. European Spine Journal. 2017 Feb;26:428-33.
  37. ↑ Coronado RA, Master H, White DK, Pennings JS, Bird ML, Devin CJ, Buchowski MS, Mathis SL, McGirt MJ, Cheng JS, Aaronson OS. Early postoperative physical activity and function: a descriptive case series study of 53 patients after lumbar spine surgery. BMC musculoskeletal disorders. 2020 Dec;21:1-0.
  38. ↑ Aalto TJ, Leinonen V, Herno A, Alen M, Kröger H, Turunen V, Savolainen S, Saari T, Airaksinen O. Postoperative rehabilitation does not improve functional outcome in lumbar spinal stenosis: a prospective study with 2-year postoperative follow-up. European Spine Journal. 2011 Aug;20:1331-40.
  39. ↑ McGregor AH, Doré CJ, Morris TP, Morris S, Jamrozik K. Function after spinal treatment, exercise and rehabilitation (FASTER): improving the functional outcome of spinal surgery. BMC Musculoskeletal Disorders. 2010 Dec;11:1-8.
  40. ↑ Mannion AF, Denzler R, Dvorak J, Müntener M, Grob D. A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. European Spine Journal. 2007 Aug;16:1101-17.
  41. ↑ Kneis S, Bruetsch V, Dalin D, Hubbe U, Maurer C. Altered postural timing and abnormally low use of proprioception in lumbar spinal stenosis pre-and post-surgical decompression. BMC Musculoskeletal Disorders. 2019 Dec;20:1-3.
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