Current Best Practices for Assessing and Managing Lumbar Spine Stenosis

A new study in Archives of Physical Medicine and Rehabilitation concluded: “For patients with neurogenic claudication due to lumbar spine stenosis (LSS), a comprehensive conservative program demonstrated superior, large and sustained improvements in walking ability and can be a safe non-surgical treatment option.”(53)

Chiropractic physicians who deliver “comprehensive conservative care” are validating their merit in the new fee-for-outcomes world. The following article will focus on current best practices for assessing and managing lumbar spine stenosis.

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Lumbar Spine Stenosis

Lumbar spine stenosis describes the narrowing of the central spinal canal, lateral recess, neural foramina or any combination of these sites. Stenosis is subclassified by the anatomic site of narrowing, i.e. central canal stenosis, lateral recess stenosis or foraminal stenosis. Neural encroachment by the surrounding bone and soft tissue can induce subsequent “neurogenic claudication” or radiculopathy with resulting leg pain, numbness, paresthesia, weakness, and difficulty walking.

Spinal stenosis may be classified as either primary, caused by congenital/ developmental abnormalities, or secondary/acquired, arising from degenerative changes, trauma, infection or surgery.  (1) The process of degenerative stenosis results from chronic accumulation of mechanical stresses, causing intervertebral disc degeneration, facet hypertrophy and ligamentum flavum fibrotic hypertrophy, or “wrinkling” (i.e., as discs thin, the ligamentum flavum “wrinkles” in much the same way that a pant leg would wrinkle if the leg shortened). (2,49) Central spinal stenosis most typically affects the three lowest lumbar levels, and foraminal stenosis most commonly involves the L5 nerve root, as the L5-S1 foramen has the least free space.  (2,3)

Symptoms are thought to arise from a compressive vascular compromise, or, in more severe cases, from direct pressure.  (4) The available space in the central canal and lateral recess decreases in extension (standing) and increases with flexion or axial distraction.  (5) The intervertebral foramina undergo a 15% decrease surface area in extension and at 12% increase surface area in flexion.  (6) Activities that require spinal extension or increase the metabolic demands of the neurologic tissues are more likely to generate symptoms, i.e., standing and walking.  (7)

Reduction before Impingement

Cadaveric studies suggest that the lumbar nerve roots can tolerate up to a 70% reduction in IVF diameter before undergoing impingement. (47) The critical dimensions for lumbar neuroforaminal encroachment have been identified as posterior disc thinning to less than 4 mm of height or reduction of the IVF height to less than 15mm. (48)

The reported incidence of spinal stenosis in patients with back pain is 3-14%, but not all patients meeting the clinical definition of stenosis will report symptoms. (10) Patients with anatomic lumbar spine stenosis may fall somewhat unpredictably on a spectrum between asymptomatic and severely disabled. No relevant association has been shown between the MRI finding of “stenosis” and the severity of the patient’s pain. (51) The course of symptomatic individuals continues on a variable course with 50-70% of spinal stenosis patients remaining stable, while the remainder are divided fairly equally into groups that inconsistently improve or worsen.  (8-11)

Symptoms

Symptoms of primary stenosis (non-degenerative acquired stenosis) may present early in life, while degenerative stenosis is uncommon before age 50, rarely appearing before the sixth or seventh decade.  (12)  Stenosis is the most common reason for lumbar spine surgery in those over 65.  (13) 

Symptomatic spinal stenosis often presents as chronic lower back pain with transient neurogenic claudication symptoms involving the buttock and lower extremity.  Patients may report bilateral and symmetrical pain, paresthesia, numbness, fatigue, heaviness and/or weakness in their legs. Lower extremity complaints are generally perceived as more bothersome than local symptoms.  Symptoms are bilateral in almost 7 out of 10 patients. (13,45) Although many other causes of lower back pain are exacerbated by prolonged sitting, lumbar spine stenosis patients report progressively increasing symptoms from standing or walking and relief while sitting. Patients may report diminished symptoms when walking with a shopping cart or lawn mower, which induces slight lumbar flexion. Walking downhill tends to increase the patient’s lumbar lordosis and is generally more uncomfortable than walking uphill. As the condition progresses, patients often adopt a slightly forward flexed posture with knee, hip and trunk flexion, i.e. “Simian” stance.  (14) Patients are generally more comfortable sleeping on their sides in a fetal position, as opposed to lying flat.  (15) Progression of stenosis may result in a wide-based gait, exercise intolerance and major lifestyle restrictions.  Patients with more significant cauda equina compression may report urinary incontinence.  (16,46)

Stenosis involving the lateral recess or intervertebral foramina presents with symptoms that are more likely unilateral and radicular in nature.  Konno, et al., offered a self-administered, self-reported history questionnaire that demonstrated 84% sensitivity and 78% specificity for the diagnosis & anatomic differentiation of lumbar stenosis. (17)

Konno Stenosis Questionnaire

Do you Have?

1.  Numbness and/or pain in the thighs down to the calves and shins.

2.  Numbness and/or pain increases after walking and is relieved by resting.

3.  Standing for a while brings on numbness and/or pain in the thighs down to the calves and shins.

 4.  Numbness and/or pain are reduced by bending forward.

5.  Numbness is present in both legs.

6.  Numbness is present in the soles of both feet.

7.  Numbness arises around the buttocks.

8.  Numbness is present, but pain is absent.

9.  A burning sensation arises around the buttocks.

10.  Walking nearly causes urination. 

(Affirmative answers to questions 1-4 predict the presence of lumbar spinal stenosis, with questions 5-10 differentiating between central and lateral stenosis.  Low positive scores on questions 5-10 suggest lateral recess involvement, while higher scores on these questions suggest central canal stenosis.)

Evaluation

Clinical evaluation will generally demonstrate a global reduction in lumbar mobility, particularly in extension.  (18,19) The degenerative changes of lumbar spine stenosis are often accompanied by intersegmental restriction and significant myofascial involvement.  (20)  Orthopedic maneuvers that require extension are intended to temporarily induce neurogenic claudication and are likely to provoke symptoms. Kemp’s test has been shown to be a reliable predictor of symptom severity.  (21) Other useful maneuvers include Sphinx test (sustained prone extension), Nachlas/ prone knee flexion and Yeoman test.  Straight leg raise is more likely to be positive in cases of lateral recess or foraminal stenosis. Neurologic findings may include motor weakness or sensory changes, which become more evident with provocative maneuvers.  (22) Diminished or absent reflexes are common in the aging population and are present in approximately half of stenosis patients.  (22) 

Clinicians should be cautious to rule out vascular claudication, which is characterized by five “Ps”:  pulselessness, paralysis, paresthesia, pallor, and pain.  Vascular claudication patients will often report symptoms that are provoked by walking and relieved by simply standing.  Vascular claudication would likely be induced when the patient rides a recumbent bicycle, whereas neurogenic patients could tolerate this activity. 

Radiology

Weight-bearing radiographs are necessary to confirm the diagnosis of lumbar spine stenosis.  A spinal canal diameter between 10 and 12 mm is defined as “relative stenosis,” and a diameter of less than 10 mm defines “absolute stenosis.”  (23) Up to 20% of asymptomatic patients meet the radiographic criteria for the diagnosis of lumbar spine stenosis.  (24,25) Radiographs frequently demonstrate associated degenerative changes.  MRI may help clarify the source of neural compression but is generally reserved for those patients who have reached a stage of symptomatic or functional impairment such that the clinician is considering surgical options.  (26) 

The differential diagnosis of lumbar spine stenosis includes vascular claudication, peripheral neuropathy, lumbar radiculopathy, disc lesion, lumbar DDD/DJD, mechanical low back pain, myofascial pain, hip pathology, fracture, infection, neoplasm, compression fracture, hip pathology or rheumatologic disease (polymyalgia rheumatica, polymyositis, etc). 

Treatment

Conservative care has been shown to help some patients with LSS. Schneider (50) identified four factors that help identify LSS patients who are most likely to respond to conservative manual therapy:

• lower initial VAS and disability scores
• relatively younger age
• radicular symptoms described as “pain”, as opposed to paresthesia or weakness
• higher body mass index (BMI)

Goals for the conservative management of lumbar spine stenosis include restoring mobility and function, decompressing neural structures and releasing perineural adhesions.  (27) Rehabilitation programs should include manual therapy, stretching and endurance strengthening exercises to retard de-conditioning.  (28-30) Spinal manipulation has been advocated for stenosis patients, although clinicians must be cognizant of relative contraindications from concurrent degenerative changes.  (31,32) Distraction manipulation, i.e., Cox, may be a useful tool, particularly in those where HVLA manipulation is contraindicated.  (33) Lumbar traction or decompression therapy shows varying degrees of long-term benefit. Nerve mobilization techniques may help to release perineural adhesions.  Sciatic mobilization may be initiated by performing a straight leg raise to tolerance and then rhythmically moving the ankle through plantar flexion and dorsiflexion while gradually increasing sciatic stretch.  (34) A comparative study of patients with lumbar spine stenosis found that acupuncture was significantly more effective than medication. (52)

Exercise

Exercise prescriptions should complement the treatment goals of increasing muscular, segmental and neurodynamic mobility.  Exercise programs should include cat/camel and sciatic nerve flossing exercises.  (35) Home stretching exercises may be necessary for hypertonic hamstring, psoas, and lumbar musculature. Recumbent cycling is usually tolerated and may help maintain aerobic function and overall fitness. Patients should limit provocative activities, including heavy lifting or those that induce extension, i.e., prolonged standing or overhead activity.  Patients who are forced to stand may find relief by slightly elevating one foot on a stool, cabinet, bar rail, etc. The use of a rigid brace should be discouraged, as this will likely induce extension and provoke symptoms.  (36) Inversion tables may provide palliative relief.

Medical management may include the use of NSAIDs, oral corticosteroids, gabapentin, diclofenac, and tricyclic antidepressants.  (37,38) The use of epidural steroid injections is controversial, with most studies showing no or only little short-term benefit.  (39-41) Patients who continue to experience debilitating symptoms and loss of function in spite of conservative efforts may be candidates for decompression by laminectomy and/ or spinal fusion surgery.  (42-44)

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