Non-surgical treatment options for lumbar spinal stenosis

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

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

You have had recurring and chronic back pain. Sometimes this back pain flares up and becomes almost intolerable. But you have to go to work or continue on with your daily routine activities so this pain needs to be managed. Eventually, you make the appointment at the doctor and your trip to the doctor or health care provider reveals a diagnosis of lumbar spinal stenosis.

Now your medical journey gets filled with a diagnosis and terms that require you to educate yourself on what is happening in your back.

Often we will hear a patient say: “I had back and leg pain for months. I went to the doctor, I had an MRI and the doctor told me I had spinal stenosis. I had no idea what the doctor was talking about. My doctor told me that he/she would prescribe some pain relievers for me to see if that helped. My question to my doctor was “will this ever go away?” The doctor looked at me and said, “I hope so, but it is not likely without surgery.”

Surgery?

The health care provider may then try to explain to you that you have:

If you are reading this article it is very likely that you and your doctors have already made a valiant try to keep you away from surgery with a steady dose of medications, cortisone or epidural injections, physical therapy, and chiropractic. The recommendation to get surgery is coming closer and closer if it has not already been suggested to you. Some of you reading this article may already have a surgical date.

In some people, the state of their stenosis has made them a walking MRI interpretation. Maybe this is like you. You have been contacting doctor’s offices and simply emailing your MRI results to see if that doctor can help. We have been helping people coming up on three decades. While an MRI can be helpful in understanding someone’s problem, it may not truly represent the patient’s pain. This is why there is a problem with failed back surgery syndrome. The pain remains after surgery. The surgery was addressing the MRI and may have missed the true cause of the patient’s problem. One thing the MRI could miss is spinal ligament laxity. Which we will explain below.

Many people suffering from spinal stenosis do very well with surgery. The majority of patients have a great deal of pain relief. These are not the patients that we see at our center. We see the patients who have had surgery and now in some cases have been recommended to spinal fusion surgery. These people we see would like to see if avoiding that surgery is possible.


In this video, Ross Hauser, MD, discusses the difference between Dynamic Spinal Stenosis and Static Spinal Stenosis and who should get surgery and who can benefit without surgery

These are some learning points from the video:

How do we determine in the office who needs surgery and who doesn’t?

This picture describes how classical spinal canal stenosis can compress the spinal cord, whereas intervertebral neural foraminal stenosis impinges on the nerve root.

This picture describes how classical spinal canal stenosis can compress the spinal cord, whereas intervertebral neural foraminal stenosis impinges on the nerve root.

The Lumbar spinal stenosis treatment journey – from diagnosis to surgery

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 online 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.

The problems of spinal stenosis are a long journey. Your story may sound very similar to this one:

For the last few years, my back pain has been slowly getting worse. I have had a few diagnoses, hip bursitis was one, sacroiliitis was another. I was finally diagnosed with lumbar foraminal spinal stenosis (L5/S1). I have a bulging disc and arthritis in my spine. The degenerative disc disease I have is worse on the right side which correlates with the symptoms I have, primarily sciatica which radiates into my right leg down into my foot. It’s “better,” on the left side. The sciatica pain only goes to my knee.

Sometimes when I walk I have to be careful on inclines, slopes, or stairs as this will cause a very sharp pain in my back. 

I am told I will need surgery. Not now but sometime in the future. I basically have to wait for my condition to get worse. I do not want surgery but I do not know what else to do. 

First stop: the x-ray or MRI


The dangers of stenosis diagnosis based on MRI

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

Is this report correct? Maybe not the MRI reading can be wrong.

We have written extensively on the over-reliance of MRIs in determining back pain treatment and the great concern that the MRI is sending a patient for a surgery they do not need, will not help them, and may make the patient’s situation worse. Please see our article: MRIs causing spinal surgery patients don’t need. In this article, you will see

Conservative Care before surgery

If you are diagnosed with lumbar stenosis, there is a good chance surgery will be recommended. But before the surgery, there is usually a long period of conservative care options. Usually, a  patient will be happy to try these treatments as surgery is something they would like to consider last.

What is conservative care? Conservative means non-surgical.

Research: Is conservative care for lumbar stenosis a waste of time and resources?

For some people the answer appears to be yes: But what kind of people should just move forward with the surgery? Smokers; type 2 diabetics; and obese people.

This is a March 2019 study from the Departments of Neurosurgery at Rush University Medical Center, the University of Texas South Western Medical Center, and the University of Cincinnati Medical Center. It was published in the medical journal Spine. (1)

Here are the learning points:

The point of the study was that these patients who went to surgery anyway spent a lot of money and healthcare resources on treatments that would not help them. We are going to review the treatments that did not help them.

Is conservative care a waste of time and money for women?

The same research team published these findings in the December 2018 journal World Neurosurgery. (2)

Physical therapy for lumbar spinal stenosis

Epidural injections for lumbar spinal stenosis

Our opinions are based on over 25 years of empirical and clinical observation of how treatments help or not help lumbar stenosis patients. In our articles, we also like to bring in the opinion of specialists. Here is what pain management specialists offer as an opinion to conservative care options for lumbar spinal stenosis:

Treatment with Epidural injections is a frequent question we receive at our clinics: In our article Alternatives to Epidural Steroid Injections | why do patients still get epidurals? We answer common patient questions about epidurals and provide the research as to why we do not offer this treatment as a standard of care.

A brief discussion on epidural steroid injections for lumbar spinal stenosis – the news is not good


Little improvement, more complicated surgeries, and longer hospital stays, especially if you are over 60.

Research:

When discussing the use of epidural steroid injections, it is always best to bring in an orthopedic opinion.

The first study is from the Department of Orthopaedics, Wexner Medical Center, Ohio State University, and Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois. This research was published in the International Journal of Spinal Surgery, August 2018. (4)

Highlights: Attention Medicare People

This new study agrees with research published in the medical journal Spine, suggesting that the Epidural steroid 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 Epidural steroid injections. . . ”(5)

Research: Findings warn doctors to stop doing certain spinal surgeries


Research: Findings warn doctors to stop doing certain spinal surgeries

“The benefits of surgical treatment versus nonsurgical treatment for lumbar spinal stenosis is ultimately inconclusive”

In the medical journal Current Opinion in Anaesthesiology, (6pain management doctors discuss the latest trends in lumbar spinal stenosis treatments, this includes a rundown 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.

Finally,

In the British Medical Journal, (7) 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.”

In the medical journal Best Practice and Research. Clinical Rheumatology, (8) doctors wrote:

“Analgesics (painkillers), NSAIDs, muscle relaxants, and opioids 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.”

More studies: No clear benefits were observed with surgery versus non-surgical treatment in patients with lumbar stenosis. The one benefit conservative care offers – no immediate side-effects.

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. To be fair, we should point out that the Italian Scientific Spine Institute specializes in the non-surgical treatment of spinal diseases.

” 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery”

A November 2019 study (10) that combined patient outcomes at 13 medical universities, hospitals, and spine centers in Canada, Australia, and Denmark that included the University of Toronto, the University of Ottawa, the University of Calgary, Murdoch University, University of Southern Denmark, and McGill University Health Centre among others, examined patient groups following surgery for degenerative lumbar spinal stenosis. The research simply sought to see who the surgery would help and who it would not.

Study learning points:

Conclusion: “Although most patients experienced important reductions in pain and disability, 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery. These findings may inform appropriate expectation setting for patients and clinicians and highlight the need for better methods of treatment selection for patients with degenerative lumbar spinal stenosis.”

The different types of surgeries for lumbar spinal stenosis

Surgeons writing in the medical journal Pain Medicine (11) gave an excellent rundown of surgical procedures that someone with lumbar spinal stenosis can explore. Here is a brief summary of their learning points and some explanatory notes.

Surgical options range from minimally invasive decompression surgery for indirect lateral and central stenosis using interspinous spacers to more conventional invasive decompression surgery, either with or without fusion. Here are brief descriptions.

Minimally Invasive Lumbar Decompression

Endoscopic Decompression (for Foraminal Stenosis)

Invasive Open Decompression Surgery

Limited vs Multilevel Decompression Surgery

Risks 

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.

Bone spurs form as a result of microinstability of the spine. Bone spurs are an “inner cast” that 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.

Questioning surgery: No association has been found between the severity of pain and the degree of stenosis

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 the effectiveness of treatments.

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. (12)

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

Research: “Spine surgeons should be increasingly asked why they are offering these operations to their patients?”

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?”(13)

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.

One more time: Back to questioning the MRI


Research: “Spinal surgery failure for spinal stenosis patients is due mainly (61%) to surgical error and nearly 55% from misdiagnosis.”

Above we discussed problems with the MRI and the over-reliance of surgeons on recommending surgery to their patients.

Published in the medical journal Osteoarthritis and Cartilage researchers at one of Japan’s leading medical research centers, Wakayama Medical University Hospital, 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.

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. (14) 

In recent research, surgeons 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. (15)


YET, patients are convinced to have the surgery anyway

More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms”(16), according to research in the Journal of Neurosurgery from Wayne State University School of Medicine

Our option to Surgery and Conservative Care – Prolotherapy injections

In the research above we highlighted the research that suggests:

So if in your instance, it is not the stenosis causing pain as we outlined above, something else has to be responsible for the back pain or leg pain in diagnosed cases of spinal stenosis. What is it? How do you find out?

Treating the spinal ligaments may be the answer to stenosis


The examination of the patient with a stenosis diagnosis not responding to conservative care

When we examine a patient who has a big medical chart with x-rays, MRIs, treatment recommendations, surgeon recommendations, we usually start with: “When does your back hurt?”

Based on our experience and the observations of thousands of patients, this presents us with a clue that the spinal ligaments are loose and causing symptoms based on the patient’s position.

Our patients are people who want to avoid surgery for their lumbar spinal stenosis. They are also people that have exhausted all or most options on the conservative care side. They come to our clinics looking for the realistic possibility that simple dextrose injections (Prolotherapy) will help them achieve their goal of reducing or being pain-free without surgery and continuous treatments. Typically, in all their treatments, very few will have had any discussion with their health care provider about the role of spinal ligaments in spinal instability as the cause of their problems.

This picture describes degenerative progression of the lower spine.

 

In approximately 90% of patients, low back pain is mechanical in nature, typically originating from overuse, straining, lifting, or bending that results in ligament sprains, muscle pulls, or disc herniation. The popular understanding of back pain is disc herniation as a frequent cause, but to a much greater extent, ligament injury forms the underlying basis. Ligaments hold the disk in place, and with ligament weakness, the disk is more likely to herniate.

The first step in determining whether Prolotherapy will be an effective treatment for the patient is to determine the extent of ligament laxity or instability in the lower back by physical examination. The examination involves maneuvering the patient into various stretched positions. If weak ligaments exist, the stressor maneuver will cause pain. Pain here is an indicator that Prolotherapy can be very effective for the patient.

Treating the spinal ligaments may be the answer

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. 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 even after his/her doctor told them only surgery can help. These patients also find it hard to believe that after their Prolotherapy treatments that they do not have to go to surgery.

Research: Prolotherapy for back pain

There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.

Citing our own Caring Medical published research in which we followed 145 patients who had suffered from back pain on average of nearly five years, we examined not only the physical aspect of Prolotherapy but the mental aspect of treatment as well.

If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is a pain cure.

Prolotherapy for patients who had longstanding and often severe pain and disability

In other Prolotherapy research published in the journal International Musculoskeletal Medicine (20), researchers in the United Kingdom 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.

Prolotherapy injections for chronic low-back pain


The Spinal ligament repair injection treatment option Prolotherapy

Summary and Learning Points of Prolotherapy to the low back

Pinched nerve or lumbar radiculopathy in cases of stenosis

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, people with a pinched nerve or lumbar radiculopathy are cases are often seen as needing a two-part solution.

This picture illustrates how a Prolotherapy injection can tighten the spinal ligaments and provide relief through providing vertebral alignment therapy. This will help alleviate the pressure caused by pinched nerves and herniated discs.

This picture illustrates how a Prolotherapy injection can tighten the spinal ligaments and provide relief through providing vertebral alignment therapy. This will help alleviate the pressure caused by pinched nerves and herniated discs.

Spinal Stenosis at Rest, Spinal Stenosis with Activity – when should you consider surgery, when should you consider Prolotherapy?

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

This picture illustrates the severity of symptoms that can occur in situations referred to as Spinal Stenosis At Rest and Spinal Stenosis With Activity. It also explains when surgery will likely be recommended for Stenosis At Rest and when surgery can be avoided in cases of Stenosis With Activity.

This picture illustrates the severity of symptoms that can occur in situations referred to as Spinal Stenosis At Rest and Spinal Stenosis With Activity. It also explains when surgery will likely be recommended for Stenosis At Rest and when surgery can be avoided in cases of Stenosis With Activity.

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 are 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!

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 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.


Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your back problems and spinal instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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Research citations:

1 Adogwa O, Davison MA, Vuong VD, Khalid S, Lilly DT, Desai SA, Moreno J, Cheng J, Bagley C. Long Term Costs of Maximum Non-Operative Treatments in Patients with Symptomatic Lumbar Stenosis or Spondylolisthesis that Ultimately Required Surgery: A Five-Year Cost Analysis. Spine. 2018 Aug. [Google Scholar]
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11 Diwan S, Sayed D, Deer TR, Salomons A, Liang K. An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach. Pain Medicine. 2019 Dec 1;20(Supplement_2):S23-31. [Google Scholar]
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