-
BMJ (Clinical Research Ed.) Jan 2016Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal... (Review)
Review
Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. 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. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.
Topics: Analgesics; Anti-Inflammatory Agents; Decision Support Techniques; Decompression, Surgical; Diagnostic Imaging; Humans; Incidence; Injections, Epidural; Intermittent Claudication; Lumbar Vertebrae; Musculoskeletal Pain; Physical Therapy Modalities; Postoperative Care; Prevalence; Scoliosis; Spinal Fusion; Spinal Stenosis; Spondylolisthesis; Steroids; United States
PubMed: 26727925
DOI: 10.1136/bmj.h6234 -
A Review of Lumbar Spinal Stenosis with Intermittent Neurogenic Claudication: Disease and Diagnosis.Pain Medicine (Malden, Mass.) Dec 2019Lumbar spinal stenosis (LSS) is a degenerative spinal condition affecting nearly 50% of patients presenting with lower back pain. The goal of this review is to present... (Review)
Review
OBJECTIVE
Lumbar spinal stenosis (LSS) is a degenerative spinal condition affecting nearly 50% of patients presenting with lower back pain. The goal of this review is to present and summarize the current data on how LSS presents in various populations, how it is diagnosed, and current therapeutic strategies. Properly understanding the prevalence, presentation, and treatment options for individuals suffering from LSS is critical to providing patients the best possible care.
RESULTS
The occurrence of LSS is associated with advanced age. In elderly patients, LSS can be challenging to identify due to the wide variety of presentation subtleties and common comorbidities such as degenerative disc disease. Recent developments in imaging techniques can be useful in accurately identifying the precise location of the spinal compression. Treatment options can range from conservative to surgical, with the latter being reserved for when patients have neurological compromise or conservative measures have failed. Once warranted, there are several surgical techniques at the physician's disposal to best treat each individual case.
Topics: Back Pain; Decompression, Surgical; Humans; Intermittent Claudication; Low Back Pain; Lumbar Vertebrae; Spinal Stenosis
PubMed: 31808530
DOI: 10.1093/pm/pnz161 -
F1000Research 2019Lumbar spinal stenosis is a degenerative process that is extremely frequent in today's aging population. It can result in impingement on the nerves of the cauda equina... (Review)
Review
Lumbar spinal stenosis is a degenerative process that is extremely frequent in today's aging population. It can result in impingement on the nerves of the cauda equina or on the thecal sac itself, and lead to debilitating symptoms such as severe leg pain, or restriction in the perimeter of ambulation, both resulting in dependency in daily activities. The impact of the disease is global and includes financial repercussions because of its involvement in the active work force group. Risk factors for the disease include some comorbidities such as obesity or smoking, daily habits such as an active lifestyle, but also genetic factors that are not completely elucidated yet. The diagnosis of lumbar stenosis can be difficult, and involves a combination of radiological and clinical findings. Treatment ranges from conservative measures with physical therapy and core strengthening, to steroid injections in the facet joints or epidural space, to a more radical solution with surgical decompression. The evidence available in the literature regarding the causes, diagnosis and treatment of lumbar spine stenosis can be confusing, as no level I recommendations can be provided yet based on current data. The aim of this manuscript is to provide a comprehensive and updated summary to the reader addressing the multiple aspects of this disease.
Topics: Back Pain; Constriction, Pathologic; Decompression, Surgical; Humans; Lumbar Vertebrae; Spinal Stenosis
PubMed: 30774933
DOI: 10.12688/f1000research.16082.1 -
BMJ Open Jan 2022Neurogenic claudication due to lumbar spinal stenosis (LSS) is a growing health problem in older adults. We updated our previous Cochrane review (2013) to determine the...
OBJECTIVES
Neurogenic claudication due to lumbar spinal stenosis (LSS) is a growing health problem in older adults. We updated our previous Cochrane review (2013) to determine the effectiveness of non-operative treatment of LSS with neurogenic claudication.
DESIGN
A systematic review.
DATA SOURCES
CENTRAL, MEDLINE, EMBASE, CINAHL and Index to Chiropractic Literature databases were searched and updated up to 22 July 2020.
ELIGIBILITY CRITERIA
We only included randomised controlled trials published in English where at least one arm provided data on non-operative treatment and included participants diagnosed with neurogenic claudication with imaging confirmed LSS.
DATA EXTRACTION AND SYNTHESIS
Two independent reviewers extracted data and assessed risk of bias using the Cochrane Risk of Bias Tool 1. Grading of Recommendations Assessment, Development and Evaluation was used for evidence synthesis.
RESULTS
Of 15 200 citations screened, 156 were assessed and 23 new trials were identified. There is moderate-quality evidence from three trials that: Manual therapy and exercise provides superior and clinically important short-term improvement in symptoms and function compared with medical care or community-based group exercise; manual therapy, education and exercise delivered using a cognitive-behavioural approach demonstrates superior and clinically important improvements in walking distance in the immediate to long term compared with self-directed home exercises and glucocorticoid plus lidocaine injection is more effective than lidocaine alone in improving statistical, but not clinically important improvements in pain and function in the short term. The remaining 20 new trials demonstrated low-quality or very low-quality evidence for all comparisons and outcomes, like the findings of our original review.
CONCLUSIONS
There is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment and that epidural steroids are not effective for the management of LSS with neurogenic claudication. All other non-operative interventions provided insufficient quality evidence to make conclusions on their effectiveness.
PROSPERO REGISTRATION NUMBER
CRD42020191860.
Topics: Aged; Back Pain; Exercise Therapy; Humans; Leg; Musculoskeletal Manipulations; Spinal Stenosis
PubMed: 35046008
DOI: 10.1136/bmjopen-2021-057724 -
Physical Therapy Dec 2013Physical therapy is commonly prescribed for patients with lumbar spinal stenosis (LSS); however, little is known about its effectiveness. (Review)
Review
BACKGROUND
Physical therapy is commonly prescribed for patients with lumbar spinal stenosis (LSS); however, little is known about its effectiveness.
PURPOSE
The purpose of this study was to systematically review randomized controlled trials (RCTs), controlled trials, and cohort studies evaluating the effectiveness of physical therapy for LSS.
DATA SOURCES
Studies were searched on electronic databases to January 2012.
STUDY SELECTION
Inclusion criteria were: clinical diagnosis of LSS with confirmatory imaging, evaluation of physical therapy treatment, presence of a comparison group, and outcomes of pain, disability, function, or quality of life.
DATA EXTRACTION
Outcomes were extracted and, when possible, pooled using RevMan 5, a freely available review program from the Cochrane Library.
DATA SYNTHESIS
Ten studies were included: 5 RCTs, 2 controlled trials, 2 mixed-design studies, and 1 longitudinal cohort study. Pooled effects of 2 studies revealed that the addition of a physical therapy modality to exercise had no statistically significant effect on outcome. Pooled effects results of RCTs evaluating surgery versus physical therapy demonstrated that surgery was better than physical therapy for pain and disability at long term (2 years) only. Other results suggested that exercise is significantly better than no exercise, that cycling and body-weight-supported treadmill walking have similar effects, and that corsets are better than no corsets.
LIMITATIONS
The limitations of this review include the low quality and small number of studies, as well as the heterogeneity in outcomes and treatments.
CONCLUSIONS
No conclusions could be drawn from the review regarding which physical therapy treatment is superior for LSS. There was low-quality evidence suggesting that modalities have no additional effect to exercise and that surgery leads to better long-term (2 years) outcomes for pain and disability, but not walking distance, than physical therapy in patients with LSS.
Topics: Disability Evaluation; Humans; Lumbar Vertebrae; Physical Therapy Modalities; Quality of Life; Severity of Illness Index; Spinal Stenosis; Treatment Outcome
PubMed: 23886845
DOI: 10.2522/ptj.20120379 -
Clinical Rehabilitation Mar 2024To analyse the components used in exercise interventions for people with symptoms of neurogenic claudication due to lumbar spinal stenosis and identify components...
OBJECTIVE
To analyse the components used in exercise interventions for people with symptoms of neurogenic claudication due to lumbar spinal stenosis and identify components associated with successful interventions.
DATA SOURCES
Eligible papers published up to April 2023 from MEDLINE, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and trial registry websites.
REVIEW METHODS
Literature searches were performed by an Information Specialist. We searched for randomised trials evaluating exercise interventions for people with neurogenic claudication symptoms (the primary symptom of lumbar spinal stenosis). Two authors independently performed study selection, data extraction, and quality assessments using the Cochrane Risk of Bias tool Version 2 and the TIDieR checklist for intervention reporting. Details of intervention components were extracted, tabulated, and synthesised using an intervention component analysis approach.
RESULTS
We found thirteen trials reporting 23 exercise interventions delivered to 1440 participants. These featured 60 different components. Most exercise interventions included supervision and flexion-based exercises. Balance exercises were rarely included. Exercise components featured more frequently in successful interventions included stretches, strength or trunk muscle exercises, fitness exercises, especially cycling, and psychologically informed approaches. Interpretation is limited by low study numbers and heterogeneity. No conclusions could be drawn about exercise supervision or dose.
DISCUSSION
Exercise interventions for people with neurogenic claudication typically feature multiple components. Common features such as supervision, lumbar flexion, and aerobic fitness exercises and also less common features such as stretches, strengthening exercises, and psychologically informed approaches warrant consideration for inclusion when designing and optimising exercise interventions for people with lumbar spinal stenosis.
Topics: Humans; Spinal Stenosis; Exercise; Exercise Therapy; Randomized Controlled Trials as Topic
PubMed: 37715644
DOI: 10.1177/02692155231201048 -
The New England Journal of Medicine May 2007Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical treatment has not been demonstrated in controlled trials.
METHODS
Surgical candidates from 13 centers in 11 U.S. states who had at least 12 weeks of symptoms and image-confirmed degenerative spondylolisthesis were offered enrollment in a randomized cohort or an observational cohort. Treatment was standard decompressive laminectomy (with or without fusion) or usual nonsurgical care. The primary outcome measures were the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) bodily pain and physical function scores (100-point scales, with higher scores indicating less severe symptoms) and the modified Oswestry Disability Index (100-point scale, with lower scores indicating less severe symptoms) at 6 weeks, 3 months, 6 months, 1 year, and 2 years.
RESULTS
We enrolled 304 patients in the randomized cohort and 303 in the observational cohort. The baseline characteristics of the two cohorts were similar. The one-year crossover rates were high in the randomized cohort (approximately 40% in each direction) but moderate in the observational cohort (17% crossover to surgery and 3% crossover to nonsurgical care). The intention-to-treat analysis for the randomized cohort showed no statistically significant effects for the primary outcomes. The as-treated analysis for both cohorts combined showed a significant advantage for surgery at 3 months that increased at 1 year and diminished only slightly at 2 years. The treatment effects at 2 years were 18.1 for bodily pain (95% confidence interval [CI], 14.5 to 21.7), 18.3 for physical function (95% CI, 14.6 to 21.9), and -16.7 for the Oswestry Disability Index (95% CI, -19.5 to -13.9). There was little evidence of harm from either treatment.
CONCLUSIONS
In nonrandomized as-treated comparisons with careful control for potentially confounding baseline factors, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically. (ClinicalTrials.gov number, NCT00000409 [ClinicalTrials.gov].).
Topics: Aged; Analgesics, Opioid; Anti-Inflammatory Agents; Female; Follow-Up Studies; Humans; Laminectomy; Lumbar Vertebrae; Male; Middle Aged; Observation; Physical Therapy Modalities; Regression Analysis; Spinal Fusion; Spinal Stenosis; Spondylolisthesis; Treatment Outcome
PubMed: 17538085
DOI: 10.1056/NEJMoa070302 -
The Bone & Joint Journal Dec 2022The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis... (Randomized Controlled Trial)
Randomized Controlled Trial
AIMS
The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.
METHODS
The Swedish Spinal Stenosis Study (SSSS) was conducted between 2006 and 2012 at five public and two private hospitals. Six centres participated in this two-year MRI follow-up. We randomized 222 patients with central lumbar spinal stenosis at one or two adjacent levels into two groups, decompression alone and decompression with fusion. The presence or absence of a preoperative spondylolisthesis was noted. A new stenosis on two-year MRI was used as the primary outcome, defined as a dural sac cross-sectional area ≤ 75 mm at the operated level (restenosis) and/or at the level above (proximal adjacent level stenosis).
RESULTS
A total of 211 patients underwent surgery at a mean age of 66 years (69% female): 103 were treated by decompression with fusion and 108 by decompression alone. A two-year MRI was available for 176 (90%) of the eligible patients. A new stenosis at the operated and/or adjacent level occurred more frequently after decompression and fusion than after decompression alone (47% vs 29%; p = 0.020). The difference remained in the subgroup with a preoperative spondylolisthesis, (48% vs 24%; p = 0.020), but did not reach significance for those without (45% vs 35%; p = 0.488). Proximal adjacent level stenosis was more common after fusion than after decompression alone (44% vs 17%; p < 0.001). Restenosis at the operated level was less frequent after fusion than decompression alone (4% vs 14%; p = 0.036). Vertebral slip increased by 1.1 mm after decompression alone, regardless of whether a preoperative spondylolisthesis was present or not.
CONCLUSION
Adding fusion to a decompression increased the rate of new stenosis on two-year MRI, even when a spondylolisthesis was present preoperatively. This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively.Cite this article: 2022;104-B(12):1343-1351.
Topics: Humans; Female; Aged; Male; Spinal Stenosis; Constriction, Pathologic; Follow-Up Studies; Spondylolisthesis; Magnetic Resonance Imaging; Lumbar Vertebrae; Decompression
PubMed: 36453045
DOI: 10.1302/0301-620X.104B12.BJJ-2022-0340.R1 -
International Journal of Molecular... Nov 2022Spinal stenosis (SS) is a multifactorial polyetiological condition characterized by the narrowing of the spinal canal. This condition is a common source of pain among... (Review)
Review
Spinal stenosis (SS) is a multifactorial polyetiological condition characterized by the narrowing of the spinal canal. This condition is a common source of pain among people over 50 years old. We perform a systematic review of molecular and genetic mechanisms that cause SS. The five main mechanisms of SS were found to be ossification of the posterior longitudinal ligament (OPLL), hypertrophy and ossification of the ligamentum flavum (HLF/OLF), facet joint (FJ) osteoarthritis, herniation of the intervertebral disc (IVD), and achondroplasia. FJ osteoarthritis, OPLL, and HLF/OLFLF/OLF have all been associated with an over-abundance of transforming growth factor beta and genes related to this phenomenon. OPLL has also been associated with increased bone morphogenetic protein 2. FJ osteoarthritis is additionally associated with Wnt/β-catenin signaling and genes. IVD herniation is associated with collagen type I alpha 1 and 2 gene mutations and subsequent protein dysregulation. Finally, achondroplasia is associated with fibroblast growth factor receptor 3 gene mutations and fibroblast growth factor signaling. Although most publications lack data on a direct relationship between the mutation and SS formation, it is clear that genetics has a direct impact on the formation of any pathology, including SS. Further studies are necessary to understand the genetic and molecular changes associated with SS.
Topics: Humans; Middle Aged; Spinal Stenosis; Ossification of Posterior Longitudinal Ligament; Ligamentum Flavum; Achondroplasia; Osteoarthritis
PubMed: 36362274
DOI: 10.3390/ijms232113479 -
Best Practice & Research. Clinical... Apr 2010Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to... (Review)
Review
Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.
Topics: Decompression, Surgical; Humans; Intermittent Claudication; Laminectomy; Lumbar Vertebrae; Spinal Stenosis; Treatment Outcome
PubMed: 20227646
DOI: 10.1016/j.berh.2009.11.001