It’s estimated that approximately 11% of adults have lumbar spinal stenosis (LSS) in the United States, and the prevalence increases with age.
Jeffrey N. Katz, MD, MS, director of the Orthopaedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital, Melvin C. Makhni, MD, director of Complex Spine Surgery in the Department of Orthopaedic Surgery at the Brigham, and colleagues recently reviewed in JAMA the current evidence about managing acquired, degenerative LSS.
This summary focuses on treatment, but the review also discusses the pathophysiology, clinical presentation, assessment and diagnosis, and prognosis of LSS.
Methods
The authors selected 68 articles on the diagnosis and treatment of LSS that were published between January 2000 and December 2021. 23 were randomized clinical trials that included at least 25 participants per treatment group.
Based on their review of randomized trials, the authors drew the following conclusions.
Medical Therapy
Many studies have assessed nonsteroidal anti-inflammatory medications (NSAIDs), acetaminophen, and other medications for low back pain, but little research is specific to LSS. While NSAIDs are a first-line treatment for LSS, the authors note that findings from studies of other spinal disorders should be applied cautiously to patients with LSS.
Gabapentin—In a randomized trial, gabapentin was associated with greater pain relief compared to a standard regimen of physical therapy with exercises, corset, and NSAIDs. However, the trial enrolled only 55 participants with LSS.
Nasal calcitonin—A Cochrane review concluded calcitonin does not reduce pain or improve walking distance in patients with LSS compared to placebo or acetaminophen.
Duloxetine and opiates—No clinical trials of these agents have been reported specifically for LSS.
Other Nonoperative Treatment
Patient counseling—Patients with LSS generally benefit from explaining the relationship between posture and symptoms. Exercises typically carried out in a lumbar flexion position, such as biking or swimming side stroke, can be recommended as a way to avoid exacerbating symptoms.
Physical therapy, manual therapy, and exercise—Randomized clinical trials have typically demonstrated the benefits of physical therapy, manual therapy, and structured, supervised exercise programs for improving pain and function in LSS. Manual therapies studied in these trials include lumbar distraction mobilization, hip and sacroiliac joint mobilization, manual stretching, and muscle strengthening. Exercise programs examined involved cycling, treadmill walking, or aquatic therapy.
Epidural steroid injections may provide greater pain relief than placebo injections for a few weeks. Rare but serious adverse events following epidural steroid injections include severe infection and permanent neurologic injuries such as foot drop. The authors suggest that epidural injections may be especially useful for a short-term goal such as attending a wedding.
Surgery
Patients who have persistent symptoms of LSS and functional limitations despite nonoperative therapy can be referred for consideration of surgery.
Direct surgical decompression, in which bone and/or disk are moved away from the affected nerve root(s), can be performed through an open or minimally invasive approach. Three randomized clinical trials have compared various nonoperative regimens with decompressive surgery. The results are mixed but suggest a benefit of surgery.
Instrumented fusion may be appropriate for patients who have concomitant degenerative spondylolisthesis and/or scoliosis. However, shared decision-making is particularly important in these cases. Patients must balance the greater risk of complications and longer period of rehabilitation with the likelihood the procedure may improve outcomes, especially when instability is apparent on flexion and extension films.
The review includes answers to four questions frequently asked by primary care physicians about treating LSS.