Welcome back amazing nerds.
In the previous post we discussed what is spinal stenosis and what can contribute to or cause it. Now that we understand what this condition is, I’m going to take you through what the available research says about its treatment and management. Before I start, I want to again highlight that these texts have the goal to inform, not diagnose or in any way substitute or equal a thorough assessment by a healthcare professional. So, if you’re in doubt, book an assessment with a qualified physiotherapist.
With that out of the way, let’s look at how to manage spinal stenosis.
Non-surgical Management
The general consensus is that management should start with non-surgical interventions. This includes interventions such as medication, lifestyle modification, physiotherapy, or multidisciplinary rehabilitation (Ammendolia et al, 2022; Wei et al, 2021). This is because many cases of nerve pain, even those where neurological symptoms such as pins and needles are present, will resolve even without intervention (McCartney et al, 2018).
Exercise appears to be a core modality in the management of stenosis at both the level of the neck and lumbar spine, with physiotherapy being the main discipline guiding this intervention (NICE, 2020; NICE, 2022a). Even when other treatment options are mentioned such as manipulation or soft tissue techniques, these are only recommended if they are part of a management plan that includes exercise (NICE, 2020; NICE 2022a).
If we are wondering about the effect of combining these therapies, some studies have looked at benefits of combining manual therapy with exercise to supervised exercise and to home/group exercises (Temporiti et al, 2022). They found that manual therapy plus exercise appears to provide more benefits for pain, walking ability and quality of life than home or group exercises, however no differences were found when comparing this manual therapy plus exercise to supervised exercise, even after 1 year post intervention (Temporiti et al, 2022). Because manual therapy was never compared on its own to other interventions, we don’t have evidence on its effects for spinal stenosis, with the only high quality study on this so far not finding any benefit to patients (Temporiti et al, 2022).
Even in multidisciplinary rehabilitation, exercise continues to play a core role. Multidisciplinary interventions could include something like psychological therapies – due to, as we have touched on before, pain being multifactorial (Ammendolia, 2022) – but should still only be considered if part of a management plan that includes exercise (NICE, 2020).
But now you may be asking yourself: what type of exercise is better?
A review by Temporiti et al (2022) tried to answer this exact question. Their findings suggest that supported body weight walking appears to be better at reducing pain and disability compared to usual body weight exercises but cycling appears to be better than both in reducing disability. When we look at aquatic exercises, such as those performed in hydrotherapy, these also appear to improve pain and walking ability more than land-based exercises (Temporiti et al, 2022).
Moving on to medication, for stenosis of the neck, oral and topical NDAIDS – think Ibuprofen, Naproxen, Diclofenac and similar (NICE, 2022b) – are suggested in cases that are struggling to cope with their pain (NICE, 2022a). As you can see, it’s not mentioned you immediately need them or that you need to have them at all if you can cope with your pain while receiving other forms of treatment.
For cases of stenosis linked to the lumbar spine, we find that we actually don’t have enough research showing there is benefit with NSAIDs for nerve pain and medications such as Gabapentinoids, oral corticosteroids or benzodiazepines are recommended against for this same type of pain (NICE, 2020)
A more specialised form of medication administration is injections. Epidural injections can be considered in acute cases of nerve pain, but are generally recommended against, particularly in cases of neurogenic claudication caused by stenosis of the central spinal canal (Ammendolia, 2022; NICE, 2020).
Now looking at less conventional management options, we don’t appear to have sufficient quality on clinical trials to reach a clear conclusion on the use of acupuncture and spinal manipulation for lumbar stenosis (Ammendolia et al, 2022).
Often we also hear about different machines that supposedly help with pain. When we look at studies comparing their effectiveness, we find that there was no difference between ultrasound and fake ultrasound, and no benefits for the use of TENS (Temporiti et al, 2022). A big limitation that this review found in studies relating to these modalities was that there is a very small number of studies available from different interventions, which only follow up people for a short amount of time, and for the overall included studies there is a lot of differences in design and intervention between studies, all of which greatly limit the conclusions we can make (Temporiti et al, 2022).
If you want to know how I interpret these results, I’m reading that doing something is better than doing nothing at all, and that exercising is better than no exercising, as it improves more outcomes than other interventions with likely less risks. Exercise also appears to be better when supervised instead of just giving people a sheet of exercise, and manual therapy still needs to show proof of its benefits. Besides that, currently, it’s not wise to put our hopes in gadgets to help patients.
Lastly, imaging modalities such as MRI have a role when symptoms include objective changes to neurological functions and have been persisting for over 6 weeks, but only if imaging is likely to change management (McCartney, 2018; NICE, 2020; NICE, 2022).
Surgical Management
Moving on to the dreaded, or sometimes very hopeful, option of surgery, we need to keep in mind that there should be an appropriate reason and timing for an intervention to be used.
Spinal decompression can be considered for people with nerve pain, with origin linked to either neck or lumbar spine, when non-surgical management was not helpful, or symptoms have worsened, and there is correlation between the person’s symptoms and findings on imaging (Davies et al, 2018; NICE, 2020; NICE 2022a).
The aim of surgery should generally be to reduce the mechanical compression on either the spinal cord or nerve, and thus spinal fusion or disc replacement procedures are recommended against (Davies et al, 2018; NICE, 2020).
The use of surgery is supported by some small studies that for pain associated with cases of lumbar stenosis, in both short and long-term, surgical interventions appears to be more beneficial than non-surgical options (Wei et al, 2021). However, these findings are contradicted by more recent reviews and surgical management does not appear to outperform non-surgical options in improving function, which, together with the limitations of the mentioned studies, means we should take these findings with some skepticism (Kirker et al, 2022; Wei et al, 2021).
In addition to this, a more recent review by Ammendolia et al (2022) suggests that we lack high-quality evidence for the general effectiveness of surgery in cases of stenosis of the lumbar spine.
What works better?
A significant barrier to providing better management of lumbar spinal stenosis is that a lot of the studies comparing the effectiveness of different types of interventions such as physiotherapy, injections, medication or surgery appear to be of overall low-quality (Kirker et al, 2022).
In a review by Kirker et al (2022), when comparing rehabilitation with no treatment or placebo, the former did not show proof of being more effective. However, I am somewhat sceptical to this conclusion, due to obvious professional bias, but also due to the fact that interventions of just acupuncture, which are obviously unscientific and dubious, were considered as part of rehabilitation for comparisons in this review (Kirker et al, 2022). This is not surprising as a sadly a significant number of physiotherapists apply these and other unscientific, borderline esoteric and non-evidence based interventions in their daily practice.
Lastly, the authors suggest that as no conclusions can really be made either way, but surgical treatments have a higher rate of more significant side effects, as well as significant re-operation rates, a trial of conversative treatment is first applied as it appears to have similar benefit (Kirker et al, 2022). But I recommend you skip the acupuncture in this case.
I hope this text has given you some more information about what research currently tells us about the management of cases of spinal stenosis, how different options compare and what can inform the timing of choosing certain options over others. Spinal stenosis can sound like something very scary on paper, so I would argue that understanding it and the options we have to help manage it are key.
I hope to see you amazing nerds in the next one,
The Physiolosopher
References:
Ammendolia, C., Hofkirchner, C., Plener, J., Bussières, A., Schneider, M. J., Young, J. J., Furlan, A. D., Stuber, K., Ahmed, A., Cancelliere, C., Adeboyejo, A., & Ornelas, J. (2022). Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: An updated systematic review. In BMJ Open (Vol. 12, Issue 1). BMJ Publishing Group. https://doi.org/10.1136/bmjopen-2021-057724
Davies, B. M., Mowforth, O. D., Smith, E. K., & Kotter, M. R. N. (2018). Degenerative cervical myelopathy. BMJ (Online), 360. https://doi.org/10.1136/bmj.k186
McCartney, S., Blagg, S., Baskerville, R., & McCartney, D. (2018). Cervical radiculopathy and cervical myelopathy: Diagnosis and management in primary care. British Journal of General Practice, 68(666), 44–46. https://doi.org/10.3399/bjgp17X694361
Kirker, K., Masaracchio, M. F., Loghmani, P., Torres-Panchame, R. E., Mattia, M., & States, R. (2022). Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions. In Physiotherapy Theory and Practice. Taylor and Francis Ltd. https://doi.org/10.1080/09593985.2021.2012860
McCartney, S., Blagg, S., Baskerville, R., & McCartney, D. (2018). Cervical radiculopathy and cervical myelopathy: Diagnosis and management in primary care. British Journal of General Practice, 68(666), 44–46. https://doi.org/10.3399/bjgp17X694361
NICE (2020, December). Low back pain and sciatica in over 16s: assessment and management. NICE- National Institute for Care Excellence. www.nice.org.uk/guidance/ng59
NICE (2022a, March). Neck pain – cervical radiculopathy. NICE – National Institute for Care Excellence. https://cks.nice.org.uk/topics/neck-pain-cervical-radiculopathy/
NICE (2022b, September). Non-steroidal anti-inflammatory drugs. NICE BNF – National Institute for Care Excellence British National Formulary. https://bnf.nice.org.uk/treatment-summaries/non-steroidal-anti-inflammatory-drugs/
Temporiti, F., Ferrari, S., Kieser, M., & Gatti, R. (2022). Efficacy and characteristics of physiotherapy interventions in patients with lumbar spinal stenosis: a systematic review. In European Spine Journal (Vol. 31, Issue 6, pp. 1370–1390). Springer Science and Business Media Deutschland GmbH. https://doi.org/10.1007/s00586-022-07222-x
Wei, F. L., Zhou, C. P., Liu, R., Zhu, K. L., Du, M. R., Gao, H. R., Wu, S. da, Sun, L. L., Yan, X. D., Liu, Y., & Qian, J. X. (2021). Management for lumbar spinal stenosis: A network meta-analysis and systematic review. In International Journal of Surgery (Vol. 85, pp. 19–28). Elsevier Ltd. https://doi.org/10.1016/j.ijsu.2020.11.014
The Physiolosopher 