Diagnosis and Management of Lumbar Spinal Stenosis

Abstract

IMPORTANCE Lumbar spinal stenosis is a prevalent and disabling cause of low back and leg pain in older persons, affecting an estimated 103 million persons worldwide. Most are treated nonoperatively. Approximately 600 000 surgical procedures are performed in the US each year for lumbar spinal stenosis.OBSERVATIONS The prevalence of the clinical syndrome of lumbar spinal stenosis in US adults is approximately 11% and increases with age. The diagnosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI). Nonoperative treatment includes activity modification such as reducing periods of standing or walking, oral medications to diminish pain such as nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. In a series of patients with lumbar spinal stenosis followed up for up to 3 years without operative intervention, approximately one-third of patients reported improvement, approximately 50% reported no change in symptoms, and approximately 10% to 20% of patients reported that their back pain, leg pain, and walking were worse. Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated. Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management. For example, in a randomized trial of 94 participants with symptomatic and radiographic degenerative lumbar spinal stenosis, decompressive laminectomy improved symptoms more than nonoperative therapy (difference, 7.8 points; 95% CI, 0.8-14.9; minimum clinically important difference, 10-12.8) on the Oswestry Disability Index (score range, 0-100). Among persons with lumbar spinal stenosis and concomitant spondylolisthesis, lumbar fusion increased symptom resolution in 1 trial (difference, 5.7 points; 95% CI, 0.1 to 11.3) on the 36-Item Short Form Health Survey physical dimension score (range, 0-100), but 2 other trials showed either no important differences between the 2 therapies or noninferiority of lumbar decompression alone compared with lumbar decompression plus spinal fusion (MCID, 2-4.9 points). In a noninferiority trial, 71.4% treated with lumbar decompression alone vs 72.9% of those receiving decompression plus fusion achieved a 30% or more reduction in Oswestry Disability Index score, consistent with the prespecified noninferiority hypothesis. Fusion is associated with greater risk of complications such as blood loss, infection, longer hospital stays, and higher costs. Thus, the precise indications for concomitant lumbar fusion in persons with lumbar spinal stenosis and spondylolisthesis remain unclear.CONCLUSIONS AND RELEVANCE Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term bene...

Lumbar Stenosis Spinal Surgery-Associated Cerebrospinal Fluid Leak Without Headache: An Autobiographical Case Report

“…Indeed, the most common reason for spinal surgery in patients over age 65 years is lumbar spinal stenosis. In addition to decreased sensation and fatigue in the lower extremities, low back pain, and radiating pain in the legs (sciatica), additional symptoms of lumbar spinal stenosis may include impairment of urination and/or defecation and neurogenic--persistent or intermittent--claudication (with buttock and lower limb pain that is exacerbated when walking or standing for a long duration of time [ 3 , 4 , 8 ].…”

“…Symptoms can be slow in onset or sudden in development; typically, the pain is sharp or aching or both and extends from the buttocks to the thighs and then radiates below the knee into the foot and toes. Low back pain may also be present; however, less than half of the patients with sciatica have associated lower extremity weakness [ 1 , 2 , 8 ].…”

“…Computed tomography and radiographs are usually not utilized. Although electrodiagnostic evaluation (such as needle electromyography and nerve conduction studies) can be used to determine whether sciatica is caused by radiculopathy instead of a musculoskeletal etiology, its role in the assessment of sciatica remains to be established [ 1 , 2 , 8 ].…”

“…These include exercise, medication, and physical therapy. In addition, there are several other non-operative treatments (Table 1 ) [ 3 , 4 , 8 ].…”

“…It has a prevalence of approximately 11 percent in United States adults and commonly presents with sciatica symptoms. Management ranges from conservative non-surgical modalities to operative intervention [ 1 - 8 ].…”