Spinal Stenosis      

This section is compiled by Frank M. Painter, D.C.
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Effectiveness of a 6-week Specific Rehabilitation Program
Combining Education and Exercises on Walking Capacity
in Patients with Lumbar Spinal Stenosis with
Neurogenic Claudication: A Randomized
Controlled Clinical Trial Protocol

Trials 2022 (Dec 27); 23 (1): 1046 ~ FULL TEXT

Neurogenic claudication (NC) is a clinical syndrome recognized as the hallmark of symptomatic lumbar spinal stenosis (LSS) [1], a degenerative musculoskeletal condition caused by age-related changes in the lower spine and defined as the narrowing of the spinal canal or intervertebral foramina. [2, 3] Neurogenic claudication is characterized by bilateral or unilateral buttock, thigh or leg pain, and discomfort such as numbness, tingling, and weakness. [4–7] These symptoms are exacerbated by prolonged standing or walking, and they are temporarily relieved by sitting and bending forward. [1, 6] Because of its symptomatology, especially during daily activities that require walking, NC represents one of the leading causes of pain and disability in the elderly. [8]

Effectiveness of Conservative Nonpharmacologic Therapies
for Pain, Disability, Physical Capacity, and Physical
Activity Behavior in Patients With Degenerative Lumbar
Spinal Stenosis: A Systematic Review and Meta-Analysis

Arch Phys Med Rehabil 2021 (Nov); 102 (11): 2247–2260 ~ FULL TEXT

For patients with LSS, there is low- to moderate-quality evidence that manual therapy with supervised exercises improves short-term walking capacity and results in small improvements in pain and symptom severity compared with self-directed or group exercise. The choice between rehabilitation and surgery for LSS is very uncertain owing to the very low quality of available evidence.

Non-operative Treatment for Lumbar Spinal Stenosis with
Neurogenic Claudication: An Updated Systematic Review

BMJ Open 2022 (Jan 19); 12 (1): e057724 ~ FULL TEXT

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

The Physical and Psychological Impact of Neurogenic Claudication:
The Patients' Perspectives

J Can Chiropr Assoc 2017 (Mar); 61 (1): 18–31 ~ FULL TEXT

The results of this qualitative study show that NC should be considered as multidimensional in its impact on patients. We found that pain, and limited walking and standing ability were the most bothersome aspects of NC that significantly impacted important activities of daily living, as well as meaningful recreational and social activities. Additionally, this study is the first to qualitatively identify the significant emotional impact of NC. This is a finding that should not be overlooked in clinical practice and future research. A holistic understanding of how psychosocial and other factors impact outcomes in this population is needed. We present a conceptual model of potential interactions between important outcomes in LSS as a framework for future study.

Trends, Major Medical Complications, and Charges Associated
with Surgery for Lumbar Spinal Stenosis in Older Adults

JAMA 2010 (Apr 7); 303 (13): 1259–1265 ~ FULL TEXT

Overall, surgical rates declined slightly from 2002–2007, but the rate of complex fusion procedures increased 15–fold, from 1.3 to 19.9 per 100,000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50–3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74–2.17). Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone. Among Medicare recipients, between 2002 and 2007, the frequency of complex fusion procedures for spinal stenosis increased, while the frequency of decompression surgery and simple fusions decreased. In 2007, compared with decompression, simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.

A Nonsurgical Approach to the Management of Patients With
Lumbar Radiculopathy Secondary to Herniated Disk:
A Prospective Observational Cohort Study
With Follow-Up

J Manipulative Physiol Ther 2009 (Nov); 32 (9): 723–733 ~ FULL TEXT

Our findings suggest that patients with LRSHD who are treated according to a strict DBCDR tend to have favorable outcome to treatment. This favorable outcome appears to be maintained over the long term. Fear beliefs also appear to improve with the approach, and a significant relationship between improvement in disability and improvement in fear beliefs was found. The absence of a control group does not allow firm conclusions to be drawn, but further research in the form of large cohort studies and randomized, controlled trials would be beneficial in determining the efficacy of this treatment approach in patients with LRSHD. The treatments used in the study appear to be safe in this patient population.

Diagnosis and Treatment of Low Back Pain: A Joint Clinical
Practice Guideline from the American College of Physicians
and the American Pain Society

Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491 ~ FULL TEXT

Low back pain is the fifth most common reason for all physician visits in the United States [1, 2]. Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months [2], and 7.6% reported at least 1 episode of severe acute low back pain (see Glossary) within a 1–year period [3]. Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998 [4]. In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year [5]. You will enjoy these recommendations because their ONLY recommendation for active treatment of acute low back pain is spinal adjusting (manipulation).

Diagnosis and Treatment of Low Back Pain
British Medical Journal 2006 (Jun 17); 332 (7555): 1430–1434 ~ FULL TEXT

The accumulated evidence from randomised trials and systematic reviews regarding the value of diagnostic and therapeutic interventions has now been incorporated in clinical guidelines. A few initial surveys have shown that these guidelines are being followed to some extent, but there is still room for improvement, especially in those countries and settings in which a large discrepancy exists between recommendations in guidelines and actual management in clinical practice. Measures should be taken to minimise this gap. Simply developing and publishing evidence based guidelines and subsequently disseminating these guidelines may not be effective enough to change practice. Implementation seems essential in changing clinical practice. Several trials have evaluated implementation of guidelines and its effect on patient and process outcomes. [25] [w8] These trials show modest effects at best. More intensive multifaceted interventions might be needed to achieve further progress in this area.

A Non-surgical Approach to the Management of Lumbar
Spinal Stenosis: A Prospective Observational Cohort Study

BMC Musculoskelet Disord. 2006 (Feb 23); 7: 16 ~ FULL TEXT

One of the hallmarks of LSS is neurogenic claudication, in which the patient develops low back and/or leg pain after a period of walking that progressively worsens as walking is continued, with improvement or resolution when walking ceases and the patient sits or flexes the lumbar spine. [5] LSS is one of the most common reasons for spine surgery in older people [6], although little is known about the efficacy of surgical management of patients with LSS, particularly compared to non-surgical management. [7] It is generally felt that most patients with LSS should be managed non-surgically before considering surgical intervention [8], but little is also known about what non-surgical approaches are most efficacious.


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