A guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis.Degenerative lumbar spinal stenosis (DLSS), a condition in which the spinal canal narrows and puts pressure on the nerves and the spinal cord, is thought to affect 13 percent to 14 percent of people who seek medical help for lower back pain. Doctors don't know much about the true incidence nor the natural cause and prognosis of DLSS.
The authors of this literature review wanted to find an evidence-based tool to help physicians improve the quality and efficiency of care for patients with DLSS.
The Spinal Stenosis Work Group of the North American Spine Society (NASS) Clinical Guidelines Committee developed an evidence-based clinical guideline on DLSS. Here are the results:
- Degenerative lumbar spinal stenosis is a clinical syndrome that is comes across with buttock or leg pain, with or without back pain. There is diminished space for the nerves in the lumbar spine. Symptomatic lumbar spine stenosis has provocative (which means it can be brought on purposely) and palliative (which means it can be eased) features, which include exercise or positionally induced neurogenic claudication, pain in the back and legs (provocative), and relief from symptoms by bending forward, sitting, or lying down (palliative).
- Patients with mild to moderate DLSS rarely have neurological (nerve) decline.
- When an older patient presents with an abnormal gait (walk) and a history of severe pain in one or both legs, which is relieved when at rest, DLSS should be considered, particularly if the Romberg test, a test to check balance, is abnormal, and if pain in the thigh is worsened when the leg is extended.
- Magnetic resonance imaging (MRI) is the most appropriate non-invasive test for diagnosing DLSS.
- If patients cannot have an MRI or if MRI findings are not conclusive, a computed tomography myelography (CT myelography), a scan using contrast dye, may be helpful.
- If patients cannot have an MRI nor a CT myelography, a CT scan would be recommended.
- In order to determine the outcome after treatment, the Oswestry Disability Index (ODI) and the Zurich Claudication Questionnaire can be used. Other appropriate tests include the Maine-Seattle Back Questionnaire, Oxford Claudication Score, Shuttle Walking Test, and the Exercise Treadmill Test.
- Regarding treatment, there isn't much evidence that medications are helpful in this instance, including intranasal or intramuscular calcitonin, methylcobalamin, or intravenous lipoprostaglandin E(1). Intranasal calcitonin may provide some short-term relief, but the data suggest that this is not very well backed up.
- While there isn't any good evidence in the literature that physical exercise and/or exercise (stand alone treatment) are useful as treatment for DLSS, physiotherapy may be helpful for patients who have symptoms of neurogenic claudication.
- The literature suggests that using contrast-enhanced fluoroscopy to guide spinal injections helps to improve the accuracy of the treatment.
- Use of interlaminar epidural steroid injections, without guidance, as well as radiographically guided transforaminal epidural steroid injections, have been found to provide short-term relief (two to three weeks) in patients who have neurogenic claudication. As well, multiple guided injections may work long-term in some patients.
- A corset worn to protect and support the lumbosacral spine (the lower part of the back) can help relieve pain on walking but research doesn't show any evidence that the effect remains when the corset is taken off.
- Traction, electrical stimulation, and transcutaneous electrical stimulation are treatments that may be tried, but there is insufficient evidence in the literature that they are useful.
- Many patients with mild-to-moderate DLSS end up needing surgery. If the patients have received treatment for between two to 10 years, about 20 percent to 40 percent end up needing surgery. However, if they have not been receiving treatment, 50 percent to 70 percent will need surgery.
- If the patients have severe DLSS, surgery is effective about 80 percent of the time. It is effective about 70 percent of the time if the patient has mild-to-moderate DLSS.
- If the patients have surgical decompression (surgery for the DLSS) alone and not other interventions, if they have severe symptoms, surgery is effective about 80 percent of the time. However, if they only had medical intervention, the rate is about 33 percent.
- Some patients have a lumbar fusion, whereby the bones are fused together. The literature shows that decompression with fusion is better than decompression alone.
- Up to now, the long-term results for surgery is promising at good or excellent results for 50 percent to 79 percent of the patients.
William C. Watters, III, M et al. Degenerative Lumbar Spinal Stenosis: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis. In The Spine Journal. March 2008. Vol. 8. No. 2. pp. 305-310.
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