Lumbar Spinal Stenosis

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Original Editors

Top Contributors - Donald John Auson, Astrid Lahousse, Stefanie Van De Vijver, Roxane Roosens, Kim Jackson, Pauline Bouten, George Prudden, Laure Lievens, Manisha Shrestha, Rosie Swift, Lucinda hampton, Sai Kripa, Shreya Pavaskar, Ahmed M Diab and Mariam Hashem  

Search Strategy

Databases Searched: Pubmed, Web of Knowledge, PEDro
Keywords: Low back pain, Spinal Stenosis, Physical therapy, Treatment, LSS, Management

Definition/Description

Lumbar spinal stenosis is a condition where the spinal canal (central stenosis) or one or more of the lumbar vertebral foramina (foraminal/lateral stenosis) becomes narrowed. If the narrowing is substantial, it can cause compression of the spinal cord or spinal nerves. Symptoms include low back pain, buttock pain, leg pain and numbness. These symptoms are typically aggravated by walking and relieved with rest. [1,3,12] Not all patients with spinal narrowing develop symptoms, so the term "spinal stenosis" refers to the symptoms of pain and not to the narrowing itself. [5]

Clinically Relevant Anatomy

Five lumbar vertebrae (L1-L5) make up the “lower back”. As demonstrated in the picture to the right, this is where the spine starts curving toward the abdomen.
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain.
This is the main pathway for information traveling from the brain to the peripheral nervous system. The length of the spinal cord is much shorter compared to the length of the bony spinal column. The spinal cord ends in the lower thoracic spine. The nerve roots from the lumbar and sacral levels continue from the bottom of the cord like a "horse's tail" (cauda equina) and then exit the spine.
There are 33 spinal cord nerve segments in a human spinal cord, and 5 lumbar segments that form 5 pairs of lumbar nerves. [7]

Epidemiology /Etiology

Some people are born with a small spinal canal. This is called "congenital stenosis”. However, spinal canal narrowing is most often due to age-related changes that take place over time. This condition is called "acquired spinal stenosis." Spinal stenosis is most common in people over 50 years of age. [14]
Acquired forms of LSS are further classified as degenerative, spondylolisthetic, iatrogenic (postsurgical), posttraumatic, or combined. [14]

Lumbar spinal stenosis can be caused by:

• osteoarthritis
• Inflammatory spondyloarthritis
• bulging of the disc
• thickening of the vertebral ligament
• tumor
• infection
• various metabolic bone disorders that cause bone growth, such as Paget's disease  [1,12,14]
  
  

Characteristics/Clinical Presentation

Patients typically present with radicular leg pain or neurogenic claudication. Neurogenic claudication is defined as pain, paresthesia and cramping in the buttocks and legs. Symptoms, which are posture-dependent, are worsened with extension of the lumbar spine or weight-bearing postures of the spine. Symptoms are decreased with flexion (sitting or bending forward) or non-weight-bearing postures of the spine. [2,8,12,14,15,16]
Patients may feel pain, cramping, weakness or numbness in the lower back and legs. [1,12] Pain may vary from a dull ache to dysesthetic or sharp and truly radicular. Symptoms may present as unilateral, but this is less common. Symptoms of spinal stenosis often start slowly and get worse over time. Pain in the legs may become so severe that walking, even short distances, is unbearable. Frequently, patients must sit or lean forward to temporarily ease pain. [1,12,15]

Differential Diagnosis

During the differential diagnosis, red-flag symptoms must be assessed. If such symptoms are present, further diagnostic workup is immediately warranted.

• cauda equina syndrome,
• fever,
• nocturnal pain,
• use of steroids,
• gait disturbance,
• structural deformity,
• history of carcinoma,
• unexplained weight loss,
• severe pain with recumbent position,
• recent trauma with suspicious fracture,
• presence of severe or progressive neurologic deficit [2]

Other pathologies/diseases that mimic lumbar spinal stenosis:

• degenerative hip joint (examination: Patrick and scour tests)[3]
• disc herniation http://www.physio-pedia.com/Disc_Herniation
• vascular claudication
• spinal cord primary or secondary tumor
• peripheral neuropathy
• osteoarthritis of hips or knees http://www.physio-pedia.com/Hip_Osteoarthritis
• osteoporotic compression fracture [2]
• myofascial pain
• rheumatoid arthritis http://www.physio-pedia.com/Rheumatoid_Arthritis
• lumbar degenerative disk disease
• lumbar facet arthropathy
• lumbar spondylolysis, spondylolisthesis and spondylodiskitis
• mechanical low back pain http://www.physio-pedia.com/Mechanical_low_back_pain

In older patients with back or leg pain, diagnostic possibilities differ from younger patients: non-mechanical causes of back pain, such as malignacy, infection or abdominal aortic aneurysm are common in elderly patients. [12]

Diagnostic Procedures

A variety of measurements can be used to assess treatment of patients with LSS. The underlying cause of LSS is identified by imaging techniques such as:

• radiography
• MRI (Magnetic Resonance Imaging)
• computerized axial tomography
• myelogram
• bone scan

For patients with LSS, the severity of the structural pathology seen on diagnostic imaging studies has been shown to correlate poorly with the severity of symptoms and limitation. [14]

Outcome Measures

• The Modified Oswestry Disability Index (MOSW). [3,13,17]
• The Satisfaction Subscale of the Spinal Stenosis Scale (SSS); this is a test for psychological well-being.
• The Swiss Spinal Stenosis Questionnaire [5,13]
• The Oxford Spinal Stenosis Score [13]
• Zurich Claudication Questionnaire [4,6]
• Visual analogue scale [14,17]
• [[ http://www.physio-pedia.com/Roland%E2%80%90Morris_Disability_Questionnaire%7CRoland-Morris Disability Questionnaire]] [14]
  

Examination

The physical examination for patients with LSS is usually normal or demonstrates non-specific findings. Patients with stenosis often have lumbar, paraspinal, or gluteal tenderness, which is usually related to underlying degenerative changes, muscle spasms, and poor posture. Some assume a characteristic “simian stance”, with their hips and knees slightly flexed and the trunk flexed forward. This flexed posture allows patients to stand or walk for longer distances, because extension is usually more limited than flexion, and may reproduce lumbar or lower extremity symptoms of pain and/or paresthesias. S Hamstring tightness is often present and may produce a false-positive straight leg-raise test. [9,12]
The neurologic examination is usually normal or reveals only subtle abnormalities such as mild weakness, sensory changes, and reflex abnormalities. Ankle reflexes are often diminished, while abnormal knee reflexes are less common. The straight leg-raise test and other neural tension signs are usually negative unless there is accompanying disc herniation.
A careful motor examination should be performed. Leg weakness is generally mild and in the distribution of the L4, L5, or S1 nerve roots. Weakness of the muscles innervated by L5 is the most common finding. The examiner should test for weakness of great toe extensors and hip abductors as well. The Trendelenburg test is used to observe for hip abductor weakness. Difficulty with walking on the toes suggests S1 root involvement. Difficulty with heel walking suggests L4 of L5 nerve dysfunction.[12] Extension in the lumbar spine may be more limited than flexion. [22]

Medical Management

Surgery
If non-operative treatment has failed, surgical treatment may be considered. The key in deciding whether or not to have surgery is the degree of physical disability and disabling pain. In most cases of advanced claudication (spinal or vascular), a decompression surgery is required to alleviate the symptoms of spinal stenosis. [18]
Decompressive posterior laminectomy is the most common type of surgery to treat spinal stenosis. The goal of this surgery is to relieve pressure on the spinal cord or spinal nerve roots. If instability is present, autogenous intertransverse bone grafting is recommended. In some cases, spinal fusion (arthrodesis) may be done at the same time to help stabilize sections of the spine treated with decompressive laminectomy.[19,20] The most common surgical complication is dural tear. [8]

Steroid injections
Nerve roots may become irritated and swollen at the area where they are pinched. Injecting a corticosteroid into the space around the compression can help reduce the inflammation and relieve some of the pressure. It is suggested that epidural steroid injections help to control severe radicular symptoms in patients with spinal stenosis. However, repeated steroid injections can weaken nearby bones and connective tissue.[12]

Non-steroidal Anti-Inflammatory Medications
Non-steroidal anti-inflammatory medications (NSAIDs) are commonly prescribed for patients with LSS, and often help relieve pain associated with spinal stenosis. By reducing inflammation, these medications can relieve some of the pressure on compressed nerves. [21]

Physical Therapy Management

Although physical therapy is often the first treatment strategy recommended for persons with spinal stenosis, few studies have closely examined the effect of specific exercise programs on functional outcomes. Physical therapy may be prescribed with the goals being to improve strength, endurance, and flexibility.[12,22]

Exercises and techniques that may help relieve symptoms of spinal stenosis and prevent progression of the condition include: [3,12,22]

• Education: To help the patient improve and maintain good posture. Frequent changes of position are recommended to avoid sustained postures that compress the spine. Patients should plan ahead to take breaks in between potentially back-stressing activities such as walking and yard work.
• Manual therapy, including massage, mobilisations to improve or maintain range of motion and tractions.
• Strengthening: Lumbar and abdominal strengthening often help manage symptoms. Lower limb strengthening may help prevent falls. Exercises that encourage lumbar flexion and flattening of the lumbar lordotic curve can be of a clinical benefit to patients suffering from lumbar spinal stenosis.
• Active exercise may help increase lumbopelvic muscular stabilization and help the patient maintain a posterior pelvic tilt. It may also help by improving cardiovascular conditioning and enhancing “soft tissue function” (strength and flexibility of muscles, ligaments, and tendons).
• Aerobic fitness training
• Stretching to reduce stress on joints
• Pelvic tilts and lower back stabilization
• Proper lifting, pushing, and pulling
• Heat therapy to improve blood circulation to the muscles and other soft tissues.
• Ice therapy to help relieve pain.
• Cycling and limited walking to promote good physical conditioning.
• Aquatic exercises to allow the body to exercise without pressure on the spine.
• Transcutaneous electrical nerve stimulation (TENS)

Stretching lumbar spine: double knee to chest. Prone trunk raises.

Pelvic tilts and lower back stabilizing. Curl up.

Key Research

Julie M Fritz, et al., A Nonsurgical Treatment Approach for Patients With Lumbar Spinal Stenosis, 1997

Resources

[1] http://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Spinal_Stenosis/

[2] http://hjd.med.nyu.edu/spine/patient-education/spine-problems/back-and-leg-pain/lumbar-spinal-stenosis
[3] https://myhealth.alberta.ca/health/pages/conditions.aspx?hwid=uh1931
[4] Nederlandse Vereniging van Neurochirurgen: http://www.nvvn.org/patienteninfo/rug-stenose.php
[5] Swiss Spinal Stenosis Questionnaire: http://www.scientificspine.com/spine-scores/swiss-spinal-stenosis-questionnaire.html
[6] http://ideas.repec.org/c/boc/bocode/s457481.html

Clinical Bottom Line

Lumbar spinal stenosis is a condition where the spinal canal (central stenosis) or one or more of the lumbar vertebral foramina (foraminal/lateral stenosis) becomes narrowed. If the narrowing is substantial, it can cause compression of the spinal cord or spinal nerves. Symptoms of spinal stenosis include low back pain, buttock pain, leg pain and numbness. These symptoms are typically aggravated by walking and relieved by resting. Interventions that may help relieve symptoms of spinal stenosis and prevent progression of the condition include: education, strenghtening, stretching, mobilization, pelvic tilts and lower back stabilization. If non-operative treatment does not relieve symptoms, surgical treatment may be appropriate. Decompressive posterior laminectomy is the most common type of surgery.

Recent Related Research (from Pubmed)

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References

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