Non-surgical treatment options for lumbar spinal stenosis

David N. Woznica, MD 

In this article, we will examine the challenges and findings of researchers looking for the optimal treatment for lumbar spinal stenosis.

Your lumbar spinal stenosis – from diagnosis to surgery following the traditional “conservative care approach”

Your lumbar stenosis journey typically began one day when your back pain became significant enough that you could no longer self-manage it on a daily basis. You may have been self-medicating with over-the-counter medications and anti-inflammatories, you may have even gone on line for yoga or back stretching exercises to help you. But now the pain is worse and it is now moving down your hip and into your legs.

First stop the X-ray or MRI

You may have decided first to go to a chiropractor or physical therapist to deal with your back pain. Perhaps your insurance plan insisted that you see a doctor first. It is likely that you whoever you saw, you were getting an X-ray and then you were moved onto MRI to confirm the diagnosis of stenosis.

The MRI came back: Your doctor read the report to you

  • Degenerative disc disease causing pressure on the spinal nerves
  • You have spinal arthritis
  • You have bone spurs on the vertebrae closing the spinal canals through which nerves pass through
  • You have a problems with the ligamentum flavum. The big ligament that holds your spine together.

We will discuss the problems of ligaments below. For now we will only state that the problems of spinal ligaments in lumbar stenosis is often overlooked or not even looked for. One reasons? You cannot fix the problems of spinal ligaments with surgery.

Conservative Care before surgery

Doctors are not convinced that conservative care options can help.


In the British Medical Journal, doctors looked at the options in conservative care. This is what they found:

“The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment.”(1)

In the medical journal Best practice and research. Clinical rheumatology, doctors wrote:

“Analgesics (pain killers), NSAIDs, muscle relaxants and opioid are commonly used in patients with lumbar spinal stenosis although their use is extrapolated (taken) from studies of patients with non-specific low back pain. Each of these medication classes poses risks to patients, especially among older individuals.”(2)

The bone is closing in all around the nerves. Understanding what causes spinal stenosis and the “narrowing of the spine” may help you avoid surgery.  Spinal Stenosis Infographic

Bone spurs form as a result of microinstability of the spine. Bone spurs are an “inner cast” which the body forms to help hold the spine in its correct position. Unfortunately bone overgrowth also causes problems of reduced mobility and eventual nerve compression.

Spinal stenosis is defined as a specific type and amount of narrowing of the spinal canal, nerve root canals, or intervertebral foramina and can be either congenital or developmental or be acquired from degenerative changes.

  • Some evidence suggests that disc degeneration, narrowing of the spinal canal, and degenerative changes in the facets and spinal ligaments all contribute to spinal stenosis.
  • The hallmark symptom of spinal stenosis is neurogenic claudication, which is neurologically-based pain that occurs upon walking; other common symptoms include:
    • sensory disturbances in the legs,
    • low back pain,
    • weakness, and
    • pain relief upon bending forward.
  • No association has been found between the severity of pain and the degree of stenosis, although patients who are symptomatic tend to have narrower spine openings than asymptomatic patients.
  • Making a diagnosis of spinal stenosis based on the absolute size of the spinal canal also has its drawbacks since it does not indicate whether or not there is impingement or distortion of either the spinal cord or nerve roots. Impingement or encroachment of the spinal cord by bone is called myelomalacia; impingement of the spinal nerve roots is called radiculopathy.

In treating lumbar stenosis doctors are looking to alleviate pain from the nerves of a narrowed spinal canal. But is that where they should be looking?

To quote from an article in the Journal of the American Academy of Orthopaedic Surgeons:

“Degenerative lumbar spinal stenosis is caused by mechanical factors and/or biochemical alterations within the intervertebral disc that lead to disc space collapse, facet joint hypertrophy, soft-tissue infolding, and osteophyte formation (bone overgrowth), which narrows the space available for the exiting nerve roots.

  • The clinical consequence of this compression is neurogenic claudication (pain from nerves) and varying degrees of leg and back pain. The natural history of this condition varies; however, it has not been shown to worsen progressively.

Nonsurgical management consists of pain medication and/or nonsteroidal anti-inflammatory drugs, physical therapy, and epidural steroid injections. If nonsurgical management is unsuccessful and neurologic decline persists or progresses, surgical treatment, most commonly laminectomy is indicated.”(1)

  • In decompressive laminectomy, doctors will seek to remove damaged parts of your spine to enlarge the spinal canal and relieve pressure on the nerves. This may reduce pain, numbness, and weakness in your legs. Sometimes a spinal fusion will be performed at the same time to stabilize the spine.

Studies: No clear benefits were observed with surgery versus non-surgical treatment in patients with lumbar stenosis

Doctors at the Italian Scientific Spine Institute published their research in the Cochrane database of systematic reviews which gave this warning to patients considering surgery for spinal stenosis.

  • We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. No clear benefits were observed with surgery versus non-surgical treatment.
  • However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment.
  • These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects.(2)

In the medical journal Current opinion in anaesthesiology, doctors discuss the latest trends in lumbar spinal stenosis treatments, this includes a run down of the conservative non-surgical treatments.

Here is what the researchers said: Our review of current literature within the past 12–24 months for the treatment of lumbar spinal stenosis serves to update providers on recent advances and comparisons regarding therapy spanning lifestyle modification, pharmacologic therapy, minimally invasive interventions, and surgical interventions.

  • Current literature supporting the inclusion of physical therapy and gabapentin/pregabalin (anti-seizure medications used for nerve pain) within an initial treatment regimen has been positive.
  • A recent randomized, double-blinded clinical trial of adding calcitonin (a protein hormone) to epidural steroid injections have shown improvement in pain and function up to 1 year.
  • The minimally invasive lumbar decompression (mild) procedure is showing ongoing beneficial results in pain and function.
  • Spinal cord stimulation (SCS) may have a role for select patients with lumbar spinal stenosis.

Finally,

  • the benefits of surgical treatment versus nonsurgical treatment for lumbar spinal stenosis is ultimately inconclusive because of the nature of data collection, inconsistencies with the clinical definition of lumbar spinal stenosis, and a lack of standardized treatment guidelines.
  • long-term research with validated, objective measurements for the aforementioned treatments are needed to draw any definitive conclusions for clinical practice.(3)

In their study, surgeons from the Rothman Institute at Thomas Jefferson University wrote of the problem of correctly classifying patients with lumbar stenosis for the purpose of increasing effectiveness of treatments.

According to the researchers:

  • 9% of patients suffer from lumbar stenosis,
  • it most commonly affects patients in their 50s-70s.
  • Patients often have pain, cramping, and weakness in their legs that is worsened with standing and walking.

While surgery may be effective for some, the surgical techniques vary widely from a decompression procedure to a spinal fusion procedure. This variation in technique and what the researchers call the “lack of an accepted classification system,” can lead to problems for patients with complications.(3)

We describe many spinal surgery techniques and their independent medical reviews in supportive research on this website including our articles:

Surgical procedures for spinal stenosis: Here is new research on minimally invasive lumbar surgeries:

Nancy Epstein of Winthrop University Hospital wrote in the medical journal Surgical neurology international.

The incidence of nerve root injuries following any of the multiple MIS lumbar surgical techniques transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusions (ALIF), extreme lumbar interbody fusions (XLIF) resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques

“Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients?”(5)

Types of Spinal Stenosis

 

Research findings warn doctors to stop doing certain spinal surgeries

Diagnosing stenosis as the cause of a patient’s pain is very problematic. We are going to the following problems that may lead to failed back surgery due to surgery not addressing the true cause of the patient’s pain.

  • No association has been found between the severity of pain and the degree of stenosis, although patients who are symptomatic tend to have narrower spines than asymptomatic patients.
  • Studies have found that diagnosing spinal stenosis with 10 mm as the sagittal diameter (the amount of space) alone produces false positive rates approaching 50%.
  • Making a diagnosis of spinal stenosis based on the absolute size of the spinal canal also has its drawbacks since it does not indicate whether or not there is impingement or distortion of either the spinal cord or nerve roots. Impingement or encroachment of the spinal cord by bone is called myelomalacia; impingement of the spinal nerve roots is called radiculopathy.

There seems then to be confusion if the patient is not complaining of back pain, but the MRI says it is stenosis, does the patient have a problem that needs to be operated on?

Published in the medical journal Osteoarthritis and Cartilage researchers in Japan discovered something unsettling for the diagnosed stenosis patient. It seems that many asymptomatic individuals (patients with no complaints or symptoms) have radiographic lumbar spinal stenosis.

  • There seems then to be confusion if the patient is not complaining of back pain, but the MRI says it is stenosis, does the patient has a problem that needs to be operated on?

So in 938 patients with an average age of about 66, they found when they did an MRI, Lumbar Spinal Stenosis was very prevalent. But when they asked the patient if they had back pain or other spinal problems, spinal stenosis complaint was uncommon.(6) See our article Failed Back Surgery Risk Factors | Too many inappropriate MRIs

YET

More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms”(7This according to research in the Journal of Neurosurgery

Add to this: In recent research, doctors in Mexico publishing in the Spanish language medical journal Cirugía y Cirujanos (Surgeons and surgery) say that spinal surgery failure for spinal stenosis patients is due mainly (61%) to surgical error and nearly 55% from misdiagnosis.(8)

Spinal Stenosis Injection Treatments

We often see patients who want to try to avoid a surgery for their lumbar spinal stenosis. They come to our clinics looking for the possibility that simple dextrose injections (Prolotherapy) will help them achieve their goal. Many times a patient will find it hard to believe that dextrose injections, sometimes dextrose injections plus concentrated blood platelet healing factors (Platelet Rich Plasma therapy) will help them when his/her doctor told them only a surgery can help. These patients also find it hard to believe after Prolotherapy treatments that they do not have to go to surgery.

Patients receiving epidural steroid injections for lumbar spinal stenosis had less improvement and greater need for surgery

  • What should a patient expect from epidural steroid injections for lumbar spinal stenosis?
  • New research says little improvement, more complicated surgeries, and longer hospital stays, especially if you are over 60.

Researchers are very much like patients in that they assume a treatment that they are using is going to work to help patients with lumbar spinal stenosis. The same can be said for epidural steroid injections. Read our most recent article on the updated research on epidural steroid injections. These new studies agree with research published in the December 12, 2012 edition of Spine, suggesting the injections were associated with significantly less improvement at four years among all patients with spinal stenosis…Furthermore, epidural steroid injections were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically.”(10)

  • Something has to be responsible for the back pain or leg pain in diagnosed cases of spinal stenosis. Most people will refer to some motion, often one of combined flexion and rotation that they performed before developing certain positional symptoms. For instance, symptoms that are worse with one position or motion (eg, walking or standing) then improve with spinal flexion (eg, sitting). This indicates that the spinal ligaments are loose and causing symptoms based on the patient’s position. This is why giving Comprehensive Prolotherapy to stabilize the ligaments is often the ideal treatment, even in patients who have been diagnosed with spinal stenosis.

Spinal Stenosis Prolotherapy

In comparison, Prolotherapy research in patients who failed traditional conservative management: Researchers in the UK explored the use of Prolotherapy in patients who had failed to respond to conservative approaches including spinal manipulation and physiotherapy. These patients had longstanding and often severe pain and disability. Utilizing only treatments that included 3 injections over a 3 to 5 week period, they confirmed that 91% of respondents were better or not worse off after 12 months.11

For some this concept of Prolotherapy helping spinal stenosis is difficult to grasp. Many patients cannot believe Prolotherapy will work when they have been convinced that drilling out more space is needed. Prolotherapy is not drilling.

We can think of spinal stenosis as two different disorders, one needs surgery and the other Prolotherapy. There is SSAR and SSWA which stand for Spinal Stenosis At Rest and then Spinal Stenosis With Activity. (See Figure)

Spinal Stenosis at Rest and with Movement

Surgery is needed for Spinal Stenosis At Rest but Prolotherapy resolves Spinal Stenosis With Activity. They are differentiated on symptoms and a test called electromyography/nerve conduction studies (EMG/ NCV). The patient who has severe pain, especially nerve irritation down the leg at rest has a narrowing of the space for the nerves that is not affected by activity. It means that there just is never enough room for the nerve, even at rest. In these instances, a lot of nerve damage or irritation is present on an EMG/NCV test. This patient would be referred for a surgical decompressive surgery, where the surgeon makes more room for the nerve. Any residual pain after the surgery can then be treated with Prolotherapy.

However, almost all the cases of spinal stenosis fall into the second category, Spinal Stenosis With Activity.

These are patients who have no symptoms when they are sitting and laying recumbent and resting. But upon standing or walking for too long, they develop back pain, buttock pain and pain down the leg. In other words, the symptoms are only precipitated by movement or change in position. This means that the nerves have enough room at rest, but the room for the nerve is decreased with standing or walking. The symptoms are dependent on position. Positional pain is a hallmark feature of conditions that respond to Prolotherapy, in the spine and any joint of the body!

Something has to be responsible for the back pain or leg pain in diagnosed cases of spinal stenosis.

Most people will refer to some motion, often one of combined flexion and rotation that they performed before developing certain positional symptoms. For instance, symptoms that are worse with one position or motion (eg, walking or standing) then improve with spinal flexion (eg, sitting). This indicates that the spinal ligaments are loose and causing symptoms based on the patient’s position. This is why giving Comprehensive Prolotherapy to stabilize the ligaments is often the ideal treatment, even in patients who have been diagnosed with spinal stenosis.

Pinched nerve or lumbar radiculopathy

If you have ever experienced a pinched nerve or lumbar radiculopathy, you know the pain is excruciating. Burning pain zooming down an extremity can cause such blinding pain, it will stop anyone in their tracks. But even in cases of acute pain, we have to ask why this problem started in the first place. The answer is ligament laxity, which causes the vertebrae to slip out of place and pinch the nerve.

In our office, these cases are often seen as needing a two-part solution.

  • First, we have to work to get the patient out of acute pain. Nerve blocks utilizing a 70.0% Sarapin and 0.6% lidocaine solution are often given, in addition to Prolotherapy. The nerve block provides initial pain relief, so the person is able to rest and repair while the Prolotherapy begins to work. Upon nerve relaxation, the vertebrae will realign and the nerve compression will cease. Even in cases of such extreme pain as a pinched nerve, the pain is typically positional. This means that it gets more intense when a person gets into certain positions. For example, if someone has unbearable pain upon sitting or kneeling, but is relieved somewhat while standing or lying flat, this means certain positions are causing the vertebrae to slip and pinch on the nerve. This also should be the point where someone is picking up the phone for a Prolotherapy treatment.
  • In our in-house analysis of consecutive patients treated for radiculopathy with Prolotherapy, the average starting pain level in patients treated for lumbar radiculopathy was 6.3 and ending pain level was 2.5 (VAS 0-10). In this same radiculopathy data, we looked at cervical radiculopathy patient outcomes as well. They were equally impressive with an average starting pain level of 5.6 and an ending pain level of 1.
  • Prolotherapy proved to be an excellent nonsurgical option for the unrelenting pain characteristic of radiculopathy. Whether the spine or other joints, positional pain is indicative of joint instability and an ideal application for Prolotherapy!

When presented with all this information, on a patient’s first visit, he/she is sometimes disbelieving that Prolotherapy or Prolotherapy in conjunction with Platelet Rich Plasma Therapy or Stem Cell Therapy can provide benefit and help relieve the pain of spinal stenosis, yet, the answer to their commonly asked questions can be found in the above research.

 

Research citations:

1 Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. Bmj. 2016 Jan 4;352:h6234. [Google Scholar]

1. Issack PS, Cunningham ME, Pumberger M, Hughes AP, Cammisa FP Jr. Degenerative lumbar spinal stenosis: evaluation and management. J Am Acad Orthop Surg. 2012;Aug;20(8):527-35.

2 Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016 Jan 29;(1): [Google Scholar]

3 Patel J, Osburn I, Wanaselja A, Nobles R. Optimal treatment for lumbar spinal stenosis: an update. Current Opinion in Anesthesiology. 2017 Oct 1;30(5):598-603. [Google Scholar]

3 Schroeder GD, Kurd MF, Vaccaro AR. Lumbar Spinal Stenosis: How Is It Classified? J Am Acad Orthop Surg. 2016 Dec;24(12):843-852.  [Google Scholar]

5 Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery: Let’s tell someone. Surg Neurol Int. 2016 Jan 25;7(Suppl 3):S96-S101.  [Google Scholar]

6. Ishimoto† Y, Noriko Y, Shigeyuki M, Hiroshi Y, et al. Associations between radiographic lumbar spinal stenosis and clinical symptoms in the general population: The Wakayama Spine Study. Osteoarthritis Cartilage. 2013 Mar 5. pii: S1063-4584(13)00706-1. doi: 10.1016/j.joca.2013.02.656.  [Google Scholar]

7. Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, Yang LJ. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine. 2015 May;22(5):496-502. doi: 10.3171/2014.10.SPINE14537. [Google Scholar]

8. Romero-Vargas S, Obil-Chavarria C, Zárate-Kalfopolus B, Rosales-Olivares LM, Alpizar-Aguirre A, Reyes-Sánchez AA. [Profile of the patient with lumbar failed surgery syndrome at National Institute of Rehabilitation. Comparative analysis]. Cir Cir. 2015 May 15.  [Google Scholar]

9. Kurosawa D, Murakami E, Aizawa T. Groin pain associated with sacroiliac joint dysfunction and lumbar disorders. Clinical Neurology and Neurosurgery. 2017 Aug 30.  [Google Scholar]

10. Radcliff K, Kepler C, Hilibrand A, Rihn J, Zhao W, Lurie J, Tosteson T, Albert T, Weinstein J. Epidural Steroid Injections Are Associated with Less Improvement in the Treatment of Lumbar Spinal Stenosis: A subgroup analysis of the SPORT. Spine (Phila Pa 1976). 2012 Dec 12.  [Google Scholar]

11. Jacks A, Barling T. Lumbosacral prolotherapy: a before-and-after study in an NHS setting. International Musculoskeletal Medicine. 2012 Apr 1;34(1):7-12.  [Google Scholar]

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