Treating lumbar spinal stenosis

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Unless symptoms are severe, physicians will try various relief strategies before suggesting surgery.

Medications and physical therapy can help - and so can surgery.

In older adults, one of the most common causes of lower back (lumbar spine) pain is spinal stenosis - a narrowing of the spinal canal that puts pressure on the spinal cord, the nerve roots branching from it, or both.

The effects may extend to the buttocks, thighs, and lower legs as well, causing further pain, numbness or tingling, and weakness.

In severe cases, bowel and bladder control may be affected. The symptoms of spinal stenosis can severely curtail normal activities, including walking and standing.

When the symptoms become chronic, they may set the stage for health problems related to inactivity, such as cardiovascular disease, obesity, and depression.

The main cause of spinal stenosis is age-related changes in bone and other spinal tissues. The condition usually develops after age 50 but can occur earlier in people who have had a spine injury or were born with a narrow spinal canal.

As high as 35% of those seeking help for chronic low back pain may have the disorder. It's the main reason for spinal surgery in people over age 65.

The usual recommendation for treating lower back pain is to take a conservative approach, trying other options - medications, physical therapy, lifestyle modification, and possibly injections into the spine - before resorting to surgery.

These strategies don't always work for people with symptomatic spinal stenosis, who are usually older and have other conditions that exacerbate their back problems. Only about 20% improve substantially without surgery.

Even when conservative treatments fail, clinicians may hesitate to recommend surgery except in cases of extreme pain or disability. That's partly because the findings on surgical treatment have been limited and inconsistent.

A recently completed series of controlled trials comparing surgical and non-surgical methods could help change that picture.

Ouch, my spinal nerves

Most lumbar spinal stenosis is caused by degeneration in the disks, the ligaments, or the joints between the vertebrae (facet joints). Disc deterioration can contribute to nerve pinching in several ways.

The disk casing may weaken and give way - what's known as a ruptured or herniated disk - permitting the gelatinous contents to extend into the spinal canal and impinge on the spinal cord or nerve roots.

Sometimes the herniated disk presses on the root of the large sciatic nerve that supplies the back of the leg, causing sciatica - pain and numbness that radiate down the buttock and thigh and sometimes to the knee and foot.

With age, disks shrink, reducing the spaces between the bones of the facet joints. Stress on these surfaces can produce osteoarthritic changes, including bone spurs, which narrow the spaces through which nerve roots leave the spine.

Disk shrinkage can also cause the ligament that lines the back side of the spinal canal (the ligamentum flavum) to fold inward, crowding the spinal cord and nerve roots.

Another source of lower back pain, spondylolisthesis (pronounced spon-duh-low-lis-THEE-sis), is much more common in women than in men. In this condition, a lumbar vertebra slips forward on the one below it, misaligning the spinal column. Other causes of spinal stenosis include tumours, trauma, infection, complications from an earlier spinal surgery, and Paget's disease (a chronic bone disorder).

Diagnosing lumbar spinal stenosis

Your physician can usually diagnose spinal stenosis on the basis of your symptoms, your medical history, and a physical exam. Imaging studies - usually MRI or CT scans - may be needed to confirm the diagnosis or assess your condition before deciding on surgery.

The hallmark of spinal stenosis is neurogenic claudication - low back, buttock, and leg pain that worsens with walking or standing and improves with sitting, crouching, or leaning forward.

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