Unless debilitating medical conditions prohibit surgery under general anesthesia, medical or nonsurgical management of lumbar stenosis is not a practical option if symptoms are incapacitating. Nonsurgical management of this condition may be attempted initially in patients with mild symptoms of short duration.
Morbidly obese patients with symptoms of neurogenic claudication may improve following institution of a weight loss program. Back strengthening exercises, strict physical therapy regimens and symptomatic management with nonsteroidal analgesics also may benefit some patients initially but, in contrast to patients with herniated intervertebral discs who often respond favorably to nonsurgical management , patients with lumbar stenosis often show no improvement on long-term follow-up.
Their symptoms rapidly return with the resumption of activity. Since many of these persons are severely limited by pain, early surgery is the best way to return them to full activity and independent living. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Russell H.
Hardy, Jr. Reprints are not available from the authors. Weinstein PR. Lumbar stenosis. In: Hardy RW Jr, ed. Lumbar disc disease. New York: Raven, — Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg.
Roberts MP. Complications of lumbar disc surgery. New York: Raven, —9. Anatomy of the lumbar spine. Verbiest H. Lumbar spine stenosis. In: Youmans JR, ed. Neurological surgery: a comprehensive reference guide to the diagnosis and management of neurosurgical problems. Philadelphia: Saunders, — Results of surgical treatment of idiopathic developmental stenosis of the lumbar vertebral canal. A review of twenty-seven years' experience. J Bone Joint Surg [Br]. Acquired lumbar spinal stenosis.
In: Clinical neurosurgery. Wilson CB. Significance of the small lumbar spinal canal: cauda equina compression syndromes due to spondylosis. Mathew P, Todd NV. Intradural conus and cauda equina tumours: a retrospective review of presentation, diagnosis and early outcome.
J Neurol Neurosurg Psychiatry. Outcome after laminectomy for lumbar spinal stenosis. Part I: clinical correlations. Neurological surgery. Philadelphia: Saunders, ;—7. Part II: radiographic changes and clinical correlations. Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
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Get Permissions. Read the Issue. Sign Up Now. Next: Exercise During Pregnancy. Apr 15, Issue. Neurogenic vs. Read the full article. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys.
Updating… Please wait. Unable to process the form. Check for errors and try again. Thank you for updating your details. Log In. Sign Up. Become a Gold Supporter and see no ads. Log in Sign up. Articles Cases Courses Quiz. About Recent Edits Go ad-free. Computed tomography is a very important advance in the diagnosis of vertebral stenosis, because it shows important bone details, including the central canal, the lateral recess, the foramen, the joint facets, and their degree of degeneration [ 34 ].
MRI provides images of soft tissue with excellent quality, including ligaments, neural tissue, and the intervertebral discs. It is more sensitive for diagnosing lumbar stenosis than tomography. MRI findings include signal weakening at T2, with dehydration and rupture of the annulus in multiple discs; changes in terminal plates; void signal; enlarged yellow ligaments; and reduced vertebral canal [ 35 ]. Myelography is an invasive exam, although it shows the dimensions of the dural sac and the neural roots in detail.
Myelography findings include the partial or total interruption of contrast flow, and the dynamic examination may reveal a dynamic compression of neural structures [ 36 ]. That is, Hamanishi considers a diameter of less than mm 2 to define stenosis in patients with clinical symptoms and characteristic images [ 39 ]. The treatment of lumbar canal stenosis may be divided into two main types: clinical or conservative and surgical [ 40 ], each of them comprising several different modalities.
When a thorough clinical examination has been performed and there is confirmation from imaging exams, electrodiagnosis is not needed, as results are often inconclusive and, when positive, do not have an influence on either the clinical or the surgical treatment [ 41 ].
However, a small fraction suffers a more severe progression, with more unfavorable natural history and serious, limiting symptoms [ 43 ]. Many lumbar canal stenosis patients have symptoms of unilateral radiculopathy. In such cases, the most likely cause is herniation, which may affect a root in an already stenotic canal. When this happens, treatment should be more focused on the disc herniation. Despite the large number of articles in the literature, there is no consensus about when to operate such patients and, if surgery is performed, what the best technique would be [ 44 ].
Drug treatment does not offer many possibilities. The indiscriminate and frequent use of anti-inflammatory medications for chronic lumbar pain does not have a proven satisfactory response [ 45 ] and may be associated with gastrointestinal and renal complications. Its use should be very restricted and avoided in elderly patients with narrow lumbar spinal canal syndrome [ 45 ].
Simple painkillers, muscle relaxants, and opioids may be of value. They are indicated for treating and controlling the pain but have no effect on the treatment of neurogenic claudication [ 45 ]. Gabapentin has been shown to be a safe medication; it may be taken orally and has a positive effect on patients with neurogenic claudication and the sensory alterations, which are very common in these patients [ 46 ].
Corticosteroids are also used indiscriminately. Physiotherapy, or more broadly rehabilitation, is a second non-surgical approach. Manual therapy, stretching, and muscular strengthening play an important role, in addition to the exercises. Patients who suffer from canal stenosis have, in addition to pain, a significant muscle loss, which severely limits their activities and progressively worsens their clinical condition, which leads to further impairments [ 48 , 49 ].
The recommended activities include manual therapy, strengthening, and walking training, as well as exercises that improves proprioception. In addition, weight loss is important, because obese patients have been described to have a worse prognosis [ 47 ]. Cycling is a very much recommended activity, not only because patients tolerate it well, but it also allows them to improve their conditioning and does not impact other joints that may also be degenerated, such as the hip and the knee [ 50 ].
Zarife et al. Peridural corticosteroids are another type of non-surgical treatment for narrow lumbar spinal canal syndrome, as opposed to oral corticosteroids, which were shown to be ineffective for this condition [ 47 ]. Peridural corticosteroids have some advantages, which are discussed below. There are several possibilities for their administration, with or without radioscopy, as well as several techniques: interlaminar, caudal, and transforaminal.
Despite their limited benefits, their use may have lasting efficacy in many patients [ 52 ]. Cosgrove et al. Although Cosgrove et al. Similarly to the above-mentioned article, Charles et al. However, we also found some articles in which the use of peridural corticosteroids did not deliver the expected satisfaction, in addition to causing complications such as meningitis, arachnoiditis, aseptic meningitis, and increased serum corticosteroids [ 55 ].
Fukusaki et al. Surgical treatment is considered the last resort for patients with treating lumbar canal stenosis. Because surgery is performed in patients over 65 years of age, there is significant morbidity and mortality, which increase with associated diseases and patient age, making it mandatory to assess the risks and benefit of the surgery [ 57 ].
That reduction was even greater in older patients. There are articles that report surgical results, with conflicting results. Hurri et al. No differences in neurologic recovery in patients without cord changes and high T2 only. Padadopoulos 42 patients treated by decompression, focal high T2 changes had better recovery than multi-segmental high T2.
Patients with focal high T2 had same recovery as those without cord changes. Is low T1-high T2 cord changes an indication for surgery? This represents potentially irreversible histopathologic changes in the cord that correlates with severity of myelopathy. Surgical outcomes are better if these changes not present. Yes it is an indication for surgery but ideally operate before these changes occur. Is High T2 cord changes an indication for surgery?
Yes, High T2 represents potentially reversible cord changes. It may respond to conservative care. Surgical outcomes no different in high T2 signal than no cord changes. This is a controversial indication for surgery.
Lumbar stenosis treatment -What can I do to relieve the pain and numbness? Once you know you have lumbar spinal canal stenosis, you have several choices for treatment. Your treatment will depend on how bad your symptoms are. If your pain is mild and you haven't had it long, you can try an exercise program or a physical therapy program. This can strengthen your back muscles and improve your posture. Your doctor may also prescribe medicine to help reduce inflammation soreness and swelling in your spine.
If you have more severe symptoms, you may need to see a spine surgeon. The surgeon may recommend surgery to take the pressure off the nerves in your lower spine. This surgery works well for many people. An initial course of non-surgical therapy is recommended. Pain reduction with activity modification and relative rest.
Strict bed rest no longer advocated. Patients become active as soon possible. Avoid heavy lifting and trunk extension. An elastic lumbar binder for a short period of time. Medications include Nonsteroidal anti inflammatory drugs, Muscle relaxants occasionally, Gabapentin and tricyclic antidepressants for neuropathic pain, Oral corticosteroids for acute flare-ups used briefly.
Narcotics prescribed sparingly, cause constipation and habit forming. Therapy modalities and chiropractic treatment have no prospective randomized studies proving their benefit.
Chiropractic manipulation is useful when the symptoms are posture dependent. Usually not recommended, but if desired, avoid extension manipulation. Epidural steroid injections reduce the radicular pain with analgesic and anti-inflammatory effects, and may facilitate progression to physical therapy.
Acute radicular pain is best treated with a nerve-root block NRB. Physical therapy is mainly flexion-based exercises, including exercises on a stationary bicycle and inclined treadmill, aquatic therapy, stretching and strengthening, and patient education on posture and daily activities.
Non-surgical treatment can minimize the progression of symptoms but is unlikely to affect the underlying pathology. Although conservative measures may be of little long-term benefit, nonsurgical is the first line of treatment for lumbar stenosis, reserving surgery for intolerable pain, a progressive neurologic deficit, cauda equina syndrome which is rare , and patients for whom conservative measures have failed.
Conservative Treatment Cervical Stenosis. Most often, early cervical stenosis can be treated with stretching and strengthening exercises, over the counter medications, and lifestyle modifications.
Acute neck pain may be treated with a cervical collar for weeks. Physical therapy such as modalities and electrical stimulation followed by isometric exercises may be added. Sometimes, acute flare-ups may be treated with a brief course of medications, including Nonsteroidal antiinflammatory drugs, Muscle relaxants occasionally, and Gabapentin or tricyclic antidepressants for neuropathic pain, Oral corticosteroids for acute flare-ups may be used briefly.
Narcotics prescribed sparingly, cause constipation and habit-forming. Traction is contra-indicated in myelopathy. Physical therapy is mainly stretching and strengthening, and patient education on posture and daily activities. In patients with myelopathy, non-surgical treatment can minimize the progression of radicular symptoms in the arms but is unlikely to affect the underlying pathology. Although conservative measures may be of little long-term benefit, conservative options are the first line of treatment for cervical stenosis, reserving surgery for intolerable pain, a progressive neurologic deficit and patients for whom conservative measures have failed.
As a 61 year old real estate agent Mrs. She began experiencing myelopathic symptoms. Occasionally, she wears a soft cervical collar to calm her neck spasms. In the past two months, however, she finds that her fingers are becoming clumsy, and she has to take frequent breaks.
In addition, Mrs. She is not complaining of any pain in the arms or legs. Interestingly, her legs are a bit wobbly, but she attributes that to some arthritis that has set in over the years. Examination showed diminished reflexes in the arms and hyper-active reflexes in the legs. The MRI scan clearly showed that she suffered from multifocal cervical stenosis.
Treatment may include physical therapy, medication, pain-blocking injections, or surgery. She elected surgery that thankfully was without problem. After three months, she felt that her fingers were working better and she no longer felt wobbly in the legs. She returned to knitting, producing a blue baby bonnet for her newborn grandson. Risk Factors for Spinal Stenosis. Is lumbar spinal canal stenosis the same as a ruptured disk? Lumbar spinal canal stenosis is not the same as a ruptured disk.
A ruptured also called "herniated" disk usually pinches 1 or 2 nerves at a time. The pain caused by a ruptured disk in the lumbar spine is usually easy to diagnose. This pain has a special name: "sciatica. This pain can happen any time, not just when you stand up or start walking. Spinal Stenosis Surgical Results. Lumbar decompression. Minimally invasive decompression through a narrow tubular retractor, by means of laminotomy and medial facetectomy.
Under-cutting of the facet joint may relieve the nerve root pressure and maintain stability of the facet joints. In most cases, disc bulging or a small herniation, plays a role in the compression of the neural structures. Most common is severe arthritic facets causing compression in the lateral recess. Surgical decompression of the nerve root emerging from the thecal sac along its entire course distal to the pedicle by under-cutting the facet joints.
Jerry thought he would never play golf again at first the numbness in Jerry's right leg only lasted a few minutes. A year later, Jerry was told not to play golf and to see a spinal specialist as soon as possible.
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