Spinal stenosis

Significant, acute neurological deficit is uncommon in spinal stenosis. Cauda equina syndrome can occur with an acute disc herniation superimposed on pre-existing stenosis. This represents a surgical emergency and should be treated with urgent decompression.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the preferred option for most patients. COX-2 inhibitors (e.g., celecoxib) are selective NSAIDs, which may be safer than non-selective NSAIDs in patients with a history of gastrointestinal bleeding or comorbid medical conditions. The lowest possible dose or an intermittent dose is used to minimise side effects.

In patients with documented hypersensitivity to NSAIDs, upper gastrointestinal disease, or who are taking oral anticoagulants, paracetamol is preferred.

Additional treatment recommended for SOME patients in selected patient group

Short-term (<4 days) bed rest may be effective in reducing the movements that are perceived as painful by the patient, but it is generally not recommended. Prolonged bed rest may produce stiffness, weakness, and increased pain. Patients should be careful to avoid repetitive bending, lifting, or twisting movements until the pain subsides.

Additional treatment recommended for SOME patients in selected patient group

If non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol do not adequately control acute symptoms, a 5- to 7-day course of systemic corticosteroids is indicated, except in patients in whom such medicines would introduce serious medical risk, such as those with inadequately controlled diabetes mellitus. Corticosteroids can also help to control acute exacerbations of painful symptoms.

Caution is advised if oral corticosteroids and NSAIDs are used together, especially in patients with a prior history of peptic ulcer disease or gastrointestinal bleeding and in older and debilitated patients. Concomitant therapy should be avoided if possible. If concomitant therapy is unavoidable, patients should be advised to take the medications with food and to immediately report signs and symptoms of gastrointestinal ulceration and bleeding. The selective use of prophylactic anti-ulcer therapy (e.g., antacids, H2-antagonists) may be considered.

Epidural corticosteroid injection, performed under image guidance, can be considered for acute exacerbations in patients with symptoms of radicular pain when oral medicine or physiotherapy is inadequate, or for patients who are not candidates for surgery.

The corticosteroid decreases nerve root oedema that occurs because of mechanical compression. In one randomised controlled trial, epidural injection of a corticosteroid plus lidocaine provided no significant benefit over epidural lidocaine alone at 6 weeks.[31]Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014 Jul 3;371(1):11-21. https://www.nejm.org/doi/10.1056/NEJMoa1313265 http://www.ncbi.nlm.nih.gov/pubmed/24988555?tool=bestpractice.com The response in chronic back pain caused by lumbar stenosis is poor, and efficacy is questionable.[74]Fukusaki M, Kobayashi I, Hara T, et al. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998 Jun;14(2):148-51. http://www.ncbi.nlm.nih.gov/pubmed/9647457?tool=bestpractice.com [75]Staal JB, de Bie R, de Vet HCW, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database of Syst Rev. 2008; (3):CD001824. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001824.pub3/full Transforaminal injections are likely to be more effective than interlaminar injections.[26]Roberts ST, Willick SE, Rho ME, et al. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PM R. 2009 Jul;1(7):657-68. http://www.ncbi.nlm.nih.gov/pubmed/19627959?tool=bestpractice.com One systematic review suggests that epidural corticosteroid injections may have slightly reduced leg pain and disability at short term follow-up in patients with lumbosacral radicular pain.[27]Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database of Syst Rev. 2020 Apr 09;(4): CD013577. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013577/full [ ] What are the benefits and harms of epidural corticosteroid injections for adults with lumbosacral radicular pain?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.3172/fullShow me the answer

Reported complications include dural puncture, intrathecal injection, epidural haematoma, epidural abscess, and epidural lipomatosis.[32]Rydevik BL, Cohen DB, Kostuik JP. Spine epidural steroids for patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 1997 Oct 1;22(19):2313-7. http://www.ncbi.nlm.nih.gov/pubmed/9346155?tool=bestpractice.com [33]Chan ST, Leung S. Spinal epidural abscess following steroid injection for sciatica: case report. Spine (Phila Pa 1976). 1989 Jan;14(1):106-8. http://www.ncbi.nlm.nih.gov/pubmed/2913653?tool=bestpractice.com

Caution is advised if oral corticosteroids and non-steroidal anti-inflammatory drugs are used together, especially in patients with a prior history of peptic ulcer disease or gastrointestinal bleeding and in older and debilitated patients. Concomitant therapy should be avoided if possible.

If concomitant therapy is unavoidable, patients should be advised to take the medications with food and to immediately report signs and symptoms of gastrointestinal ulceration and bleeding. The selective use of prophylactic anti-ulcer therapy (e.g., antacids, H2-antagonists) may be considered.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the preferred option for most patients. COX-2 inhibitors (e.g., celecoxib) are selective NSAIDs, which may be safer than non-selective NSAIDs in patients with a history of gastrointestinal bleeding or comorbid medical conditions. The lowest possible dose or an intermittent dose is used to minimise side effects.

In patients with documented hypersensitivity to NSAIDs, upper gastrointestinal disease, or who are taking oral anticoagulants, paracetamol is preferred.

Additional treatment recommended for SOME patients in selected patient group

Activity modification: goal is to achieve a tolerable level of discomfort while minimising disruption of daily activities; patients should limit heavy lifting, and avoid prolonged sitting and repetitive bending or twisting of the back.

Deep heat therapy and massage may relieve some of the muscle spasm associated with pain; however, benefit is insufficiently proven.

Lumbar corset or brace serves as a short-term measure before surgical treatment or long-term supportive therapy when surgery is contraindicated.

Walker allows the patient to move while maintaining spinal flexion and may decrease pain and increase exercise tolerance. Prophylactic use is controversial.

Physiotherapy and exercise: patients should use exercises that minimally stress the back, such as walking, swimming, or bicycling. Exercise may help to strengthen the paraspinal muscles. Conditioning exercises for trunk muscles may be helpful but can aggravate symptoms. Gradually escalated exercise results in a better outcome.

Spinal manipulation therapy should not be used in patients with severe or progressive neurological deficit or with radiculopathy. Transcutaneous electrical stimulation and traction have not been shown to be effective.

Additional treatment recommended for SOME patients in selected patient group

These agents may be used when pain is not controlled on non-steroidal anti-inflammatory drugs and/or paracetamol.

More effective for neuropathic pain, such as that seen in neuropathy from diabetes mellitus, than for direct nerve compression, as seen in spinal stenosis.

Patients stay on these alternative medicines as long as they are beneficial. There are no good-quality trials supporting their use in spinal stenosis.[38]Coronado-Zarco R, Cruz-Medina E, Arellano-Hernández A, et al. Effectiveness of calcitonin in intermittent claudication treatment of patients with lumbar spinal stenosis: a systematic review. Spine (Phila Pa 1976). 2009 Oct 15;34(22):E818-22. http://www.ncbi.nlm.nih.gov/pubmed/19829246?tool=bestpractice.com [39]Podichetty VK, Varley ES, Lieberman I. Calcitonin treatment in lumbar spinal stenosis: a meta-analysis. Spine (Phila Pa 1976). 2011 Mar 1;36(5):E357-64. http://www.ncbi.nlm.nih.gov/pubmed/21325931?tool=bestpractice.com Amitriptyline has known anticholinergic side effects and has been associated with arrhythmias in older patients.

Additional treatment recommended for SOME patients in selected patient group

Surgery is usually not considered unless symptoms have persisted despite 3 months of medical treatment.[42]Kovacs FM, Urrutia G, Alarcon JD. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine (Phila Pa 1976). 2011 Sep 15;36(20):E1335-51. http://www.ncbi.nlm.nih.gov/pubmed/21311394?tool=bestpractice.com

Decompressive laminectomy is the traditional technique; it has been shown to be more effective than non-operative treatment.

Fusion is added to decompression in the case of degenerative spondylolisthesis, though the role of fusion and specific fusion techniques continues to be debated.

Common complications include incidental durotomy, infection, haematoma, and medical complications.

Interspinous devices have been developed to minimise the morbidity associated with surgery; however, their long-term effectiveness remains unknown.