Approach
The main goals of treatment are to relieve back and leg pain, improve the patient's functional ability, restore spinal stability, and to reverse or prevent progression of neurologic deficits.
Acute episodes
Nonpharmaceutical measures:
Temporary reduction in physical activity is recommended; patients should be careful to avoid bending, lifting, or twisting movements until the pain subsides.
Bed rest is not recommended.
Prolonged bed rest (>4 days) is contraindicated, especially in older patients as it may lead to rapid deconditioning and increased risk of deep vein thrombosis (DVT).
Pharmaceutical measures:
A course of several weeks of nonsteroidal anti-inflammatory drug (NSAID) therapy is used to control pain and reduce inflammatory changes as first-line therapy in all patients presenting acutely unless they have contraindications to NSAIDs.
Acetaminophen may provide some pain relief, but provides no anti-inflammatory effect and is generally less effective than either conventional NSAIDs or COX-2 inhibitor therapy. It can be used alone first-line in patients with contraindications to NSAIDs. Acetaminophen can also be added to NSAIDs for supplemental pain relief.
If NSAIDs are not adequately controlling acute symptoms, a 5- to 7-day course of systemic corticosteroids can be considered, except in patients in whom such medications would introduce serious medical risk, such as those with inadequately controlled diabetes mellitus. However, placebo-controlled trials have demonstrated no benefit of systemic corticosteroids for radicular pain.[26] Caution is advised if oral corticosteroids and NSAIDs are used together, especially in patients with a prior history of peptic ulcer disease or gastrointestinal (GI) 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 GI ulceration and bleeding, such as severe abdominal pain, dizziness, lightheadedness, and the appearance of black, tarry stools. The selective use of prophylactic anti-ulcer therapy (e.g., antacids, H2-antagonists) may be considered.
Epidural corticosteroid injections performed under image guidance may be effective at treating an acute episode of symptoms and are indicated in patients with symptoms of radicular pain when oral medication or physical therapy is inadequate, or for patients who are not candidates for surgery. Transforaminal injections are likely more effective than interlaminar injections.[27] One systematic review suggested that epidural corticosteroid injections may slightly reduce leg pain and disability at short term follow-up in patients with lumbosacral radicular pain.[28] [
]
Prolonged use is controversial because of questions regarding efficacy and safety.[29][30] The beneficial effect of epidural corticosteroid injections may be short-lived and the injections are contraindicated for managing chronic symptoms. Repeated series of injections have not been found to be of benefit.[31] In one randomized controlled trial of patients with spinal stenosis, epidural injection of a corticosteroid plus lidocaine provided no significant benefit over epidural lidocaine alone at 6 weeks, although there were some small advantages at 3 weeks.[32] Improvement in both groups was modest.[32] Reported complications of epidural corticosteroid injection include dural puncture, intrathecal injection, epidural hematoma, epidural abscess, and epidural lipomatosis.[33][34] Caution is advised if oral corticosteroids and NSAIDs are used together, especially in patients with a prior history of peptic ulcer disease or GI 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 oral medications with food and to immediately report signs and symptoms of GI ulceration and bleeding such as severe abdominal pain, dizziness, lightheadedness, and the appearance of black, tarry stools. The selective use of prophylactic anti-ulcer therapy (e.g., antacids, H2-antagonists) may be considered.
Surgery:
Surgery is rarely performed for acute symptom episodes unless a neurologic deficit appears, such as cauda equina syndrome.
Nonsurgical maintenance therapy
Nonpharmaceutical measures can be used in conjunction with medication to alleviate lower back pain:[35]
Activity modification
Use of physical aids (e.g., a walker)
Exercise
Spinal manipulation
Heat treatments
Massage
Short-term use of a lumbar corset or a lumbar brace: may reduce pain, particularly in the presence of spondylolisthesis and spinal instability. It is used as a short-term measure before surgical treatment or as long-term supportive therapy when surgery is contraindicated.
Manual therapy combined with an individualized exercise regimen has been demonstrated to provide greater short term benefit than group exercise or medical care.[38]
Pharmaceutical measures:
NSAIDs are the primary medications used to manage long-term symptoms of lumbar spinal stenosis. As is the case when using NSAIDs to treat symptoms of osteoarthritis, a practitioner must, for each patient, weigh concerns regarding cardiac complications of continuous use.
Acetaminophen may provide some pain relief, but provides no anti-inflammatory effect and is generally less effective than either conventional NSAIDs or COX-2 inhibitor therapy. It can be used in addition to NSAIDs as supplemental analgesia or alone in patients unable to tolerate NSAIDs.
A variety of chronic pain medications (gabapentin, amitriptyline, duloxetine, and calcitonin) are used second-line in patients with unsatisfactory remission despite NSAIDs and/or acetaminophen to lessen symptoms of back and leg pain. They are generally not effective in limiting symptoms of neurogenic claudication and improving the ability to walk distances. There are no good-quality trials supporting their use in spinal stenosis.[39][40][41]
One systematic review found a lack of good-quality evidence for nonsurgical treatment.[42] Further studies are needed to guide recommendations for clinical practice.
Surgery
If symptom relief or improved functional ability is not seen after 3 to 6 months of medical management, surgery is the recommended next option and has been shown to lead to more improvement than nonoperative care by multiple studies.[43] Treatment options should be explored with the patient using a process of shared decision making to ensure that the treatment is aligned with the patient’s preferences. A range of decision aids can be used to educate and inform the patient about interventions and their expected outcomes. A combination of reading and video material is preferred, with additional coaching to address any remaining uncertainties or anxieties. This approach improves the patient's knowledge base, helps moderate unrealistic patient expectations, and elicits the patient's priorities and values.[44][45][46]
The Spine Patient Outcomes Research Trial (SPORT) showed that decompressive surgery for spinal stenosis patients with neurogenic claudication or radicular symptoms lasting at least 12 weeks led to superior outcomes for up to 8 years compared with nonoperative treatment, although the benefit of surgery diminished from year 4 to year 8 after enrollment.[47][48]
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Surgery is most effective in patients whose primary complaint is leg pain rather than back pain, and it improves walking tolerance.[49][50][51][52] While surgical outcomes varied based on many patient characteristics, surgery led to better results than nonoperative treatment in all examined subgroups other than smokers.[53] The surgery involves a midline posterior approach to the lumbar vertebrae with a bilateral laminectomy of the involved segments (as the stenosis is usually bilateral). A full decompression of the central spinal canal, lateral recess, and neuroforamina at all involved levels is commonly performed: this involves removal of bone, ligamentum flavum, and facet capsular tissue, as indicated by the preoperative imaging studies and intraoperative findings. Preservation of the pars interarticularis and facets is critical to maintaining the stability of the segment. Limited procedures, such as unilateral procedures involving hemilaminectomies or laminotomies, can be performed when the pathology is limited, for example when there is focal foraminal or lateral recess stenosis, or when a facet synovial cyst is present. Exposure by open or by tubular retraction systems (for limited procedures) provides similar exposure and results. Interspinous process devices have been reported to provide improvement compared with nonoperative treatment for up to 2 years in industry-sponsored trials.[54] Some authors, however, have noted a high failure rate and less than anticipated improvement and have recommended against the devices.[55][56][57] Interspinous process devices have been shown not to be cost-effective compared with laminectomy.[58] There has been no randomized trial comparing interspinous devices and laminectomy. While one device (X-STOP) has been Food and Drug Administration approved and multiple devices are under study, the long term results remain unknown.
There is also controversy regarding the surgical treatment of spinal stenosis patients with degenerative spondylolisthesis. In the SPORT trial on degenerative spondylolisthesis, patients treated with decompression and fusion improved more than those treated nonoperatively for up to 8 years.[59][60][61] The role of fusion in addition to decompression has been debated. One older study demonstrated superior clinical outcomes in patients with degenerative spondylolisthesis undergoing fusion in addition to laminectomy compared with outcomes in patients treated with laminectomy alone.[62] Two more recent randomized controlled trials came to opposite conclusions regarding the role of fusion. A Swedish study found that the addition of fusion did not improve clinical outcomes or reoperation rate compared with laminectomy alone.[63] However, a US study found significantly better clinical outcomes and a lower reoperation rate for patients undergoing laminectomy and fusion.[64] Spinal instrumentation during fusion is common as it provides immediate stability and improves the rate of successful arthrodesis, but spinal instrumentation may not contribute to additional functional improvement.[65][66] In addition, there is no evidence that the fusion method influences outcome up to 8 years from surgery.[67] Fusion success may be augmented by the use of bone morphogenic proteins including both BMP-2 and rhBMP-7, although it is unclear whether this leads to better clinical outcomes.[68][69] Surgery for degenerative spondylolisthesis with stenosis leads to better outcomes than nonsurgical treatment, though the role of fusion and specific fusion techniques continues to be debated.
Complications from surgical decompression include incidental durotomy (0.3% to 13% may lead to leak of cerebrospinal fluid or pseudomeningocele), deep infection (0.5% to 3%), superficial infection (0.9% to 5%), and DVT with risk of pulmonary embolism (0.1%).[70][71][72][73][74] Less common complications include increased motor deficit (most are transient), direct injury to neural structures, spinal epidural hematoma (often causing cauda equina syndrome), arachnoiditis, and meningitis. Overall risk of mortality in the hospital is 0.32% to 1%, most often because of septicemia, myocardial infarction, or pulmonary embolism.[70][73]
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