Lumbar spinal stenosis is a condition of the spine within the group of disorders classified as degenerative in nature. As this condition is prevalent in 30% of the older population, lumbar spinal stenosis (LSS) accounts for the largest growth in lumbar surgeries. The most common symptoms include a substantial limitation in walking, disability and an increased risk of falls. There was little high quality research in the non-operative management of this condition up until the past 6-8 years. We will discuss this condition further with some of the treatment options available.
As previously noted, one of the major symptoms of LSS is a limitation in walking. Generally, patients will walk for a few minutes, then they will experience pain, usually bilaterally, down the legs (the exact leg pain distribution will be dependent on the level of stenosis in the spine). Once pain sets in, the typical LSS patient will feel the need to bend forward, flexing the spine, or to sit down. Once rested for 1 min or so, they can once again proceed on their walk, until the pain sets in again, and the cycle repeats. Clinically, the leg pain is called neurogenic intermittent claudication (NIC). For some, the pain may be too great as soon as they stand up or extend the spine, and walking isn’t possible. In addition, the changed motor function in the muscles in the legs and impaired proprioceptive input results in a loss of balance, the other LSS common symptom.
Stenosis is defined as the abnormal narrowing of a space in the body. In LSS, there is a narrowing of the spinal canal, or the hole in which the spinal cord passes through. The vertebrae are stacked on top of one another and in doing so, form the spinal column, which houses the spinal cord. To see an image of the anatomy of a lumbar spine vertebrae, please see our instagram page @mmdchiropractic. Stenosis may occur at one level or multiple levels in the spine. In the lumbar spine, the most common level is L4/5.
The cases of LSS can be divided into congenital anomalies or acquired abnormalities. Congenital anomalies would include patients in which the vertebrae were malformed at birth, producing a smaller spinal canal. An acquired abnormality would include those caused from degeneration (like degenerative joint disease, disc degeneration, and hypertrophy of the ligamentum flavum), post-surgical stenosis, metabolic disease (Paget’s disease) or those resulting from injury trauma.
Let us take a look at the changes that occur when we consider the most common cause of LSS, degenerative arthritis of the spine. Below is a diagram of part of the spine showing areas of compression.
(image from Spinemobility.com)
We have to consider all of the structures which are a part of the spinal canal or could impact the spinal canal. These include: the superior articular facet, the inferior articular facet, lamina, pedicle, posterior aspect of the disc, posterior longitudinal ligament, ligamentum flavum, posterior vertebral body, dura and blood vessels supplying these structures. If degeneration or osteoarthritis occurs at one of these structures, the result could be osteophyte (bone spur) formation. If these osteophytes form and affect this ring or protrude into this ring of the spinal canal, then the structures in the spinal canal can become squished or compressed, resulting in NIC. The arrows in the single vertebrae show the different areas which can become compressed.
What is happening at the level of the compressed nerves within the spinal canal that cause NIC? At one time, the theory of what caused the NIC involved the compression of the nervous tissue, however, the most recent research points to a neuro-ischemic theory. The degenerative structures compress the tiny blood vessels that are surrounding and supplying the nerves. The result is an intermittent lack of nerve function presenting as pain, numbness or tingling. One of the non-operative treatments for LSS has been to increase cardiovascular exercise in a position that does not bring on symptoms, which in most cases is with a flexed spine. A flexed lumbar spine, either in a sitting or standing posture, increases the cross-sectional area of the spinal canal taking pressure off of the nerves/blood vessels. Cycling is an excellent option here to increase cardiovascular output while maintaining a less compressive posture.
Treatment recommendations:
The gold standard for treatment of LSS up until 2013/2014 included only two treatments, epidural injection or decompressive surgery. Although this may be the only option for some, the research is now supporting non-operative multimodal manual therapy, education, exercise and cognitive-behavioral therapy as an effective treatment for LSS with NIC (Ammendolia, et al, 2022).
What does non-operative treatment involve? In our clinic, we follow a protocol, called the LSS Bootcamp, that was developed by the author of the most recent review, Dr. Carlos Ammendolia. In this program, patients are required to record their steps when they walk everyday in order to identify the timing of when their symptoms are coming on. Each exercise session starts with the stationary bike, time dependent on the specific week in the bootcamp. Next, there are a series of exercises that are taught to the patient. These include some stretches and some body weight strengthening exercises. In the clinic, we want to maintain mobility throughout the spine and we may do this in several different ways. At MMD Chiropractic, we use the flexion-distraction table to flex the spine while adding some traction to separate the vertebrae slightly, add motion, and through a gently pumping motion, help move inflammatory fluid out of the affected areas. We may also do some muscle work through stretching or myofascial release techniques to stretch out the tight muscles and facilitate proper contractions. Treatment frequency is typically dependent on the level of pain and/or the amount of limitations to the patients daily activities. The exercise component is largely left to the patient, once demonstrations have been fully provided. In our experience, most patients have done quite well, and have avoided surgery.
With the remarkable research coming out of Dr. Ammendolia’s clinic, there are now other options to surgery when we are dealing with LSS. If you, or anyone you know, is experiencing pain while walking and you think LSS may fit with their symptoms, please have them contact us or use our online booking HERE to book an initial assessment.
References:
Seung Yeop Lee et al, Asian Spine J 2015;9(5):818-828. http://dx.doi.org/10.4184/asj.201.5.9.5.818 Michael Schneider et al, JAMA Network Open. 2019;2(1):e186828.doi:10.1001./jamanetworkopen.2018. 6828 Ammendolia C, et al. BMJ Open 2022;12:e057724.doi:10.1136/bmjopen-2021-057724