Non-Surgical Management to Lumbar Spinal Stenosis
A
Non-Surgical Approach to the Management of Lumbar Spinal Stenosis: A
Prospective Observational Cohort Study
Donald R Murphy; Eric L Hurwitz; Amy
A Gregory; Ronald Clary
Posted: 04/13/2006; BMC
Musculoskeletal Disorders © 2006 Delank et al., licensee BioMed
Central Ltd.
Abstract
Background: While it is widely held that
non-surgical management should be the first line of approach in patients with
lumbar spinal stenosis (LSS), little is known about the efficacy of
non-surgical treatments for this condition. Data are needed to determine the
most efficacious and safe non-surgical treatment options for patients with LSS.
The purpose of this paper is to describe the clinical outcomes of a novel
approach to patients with LSS that focuses on distraction manipulation (DM) and
neural mobilization (NM).
Methods: This is a prospective consecutive case series with long term
follow up (FU) of fifty-seven consecutive patients who were diagnosed with LSS.
Two were excluded because of absence of baseline data or failure to remain in
treatment to FU. Disability was measured using the Roland Morris Disability
Questionnaire (RM) and pain intensity was measured using the Three Level Numerical
Rating Scale (NRS). Patients were also asked to rate their perceived percentage
improvement.
Results: The mean patient-rated percentage improvement from baseline to
the end to treatment was 65.1%. The mean improvement in disability from
baseline to the end of treatment was 5.1 points. This was considered to be
clinically meaningful. Clinically meaningful improvement in disability from
baseline to the end of treatment was seen in 66.7% of patients. The mean
improvement in "on average" pain intensity was 1.6 points. This did
not reach the threshold for clinical meaningfulness. The mean improvement in
"at worst" pain was 3.1 points. This was considered to be clinically
meaningful.
The mean duration of FU was 16.5 months. The mean patient-rated percentage improvement
from baseline to long term FU was 75.6%. The mean improvement in disability was
5.2 points. This was considered to be clinically meaningful. Clinically
meaningful improvement in disability was seen in 73.2% of patients. The mean
improvement in "on average" pain intensity from baseline to long term
FU was 3.0 points. This was considered to be clinically meaningful. The mean
improvement in "at worst" pain was 4.2 points. This was considered to
be clinically meaningful. Only two patients went on to require surgery.
No major complications to treatment were noted.
Conclusion: A treatment approach focusing on DM and NM may be useful in
bringing about clinically meaningful improvement in disability in patients with
LSS.
Background
Lumbar spinal stenosis (LSS) is a
common and often disabling disorder that generally occurs in the sixth or
seventh decade of life,[1]
although it can uncommonly occur in younger individuals.[2] The incidence of this condition has
been reported to be 8-11%,[3] with a
slight preponderance in women.[1] LSS can lead to low back and leg pain, most typically via encroachment
on the central canal, lateral recess, or lateral canal. The source of the
encroachment is typically vertebral body osteophytes, hypertrophy of the ligamentum
flavum or zygapophyseal joint, or a combination of these.[1] The posterior longitudinal ligament
may be involved in some individuals.[4] The development of these degenerative changes is often accompanied by
restriction of segmental mobility.[1]
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.
LSS can involve the central canal,
the lateral recess, the lateral canal, or any combination of these.[6] This can lead to nerve root pain and
dysfunction, i.e., radiculopathy. The pathophysiology of radiculopathy
secondary to LSS is different from that of radiculopathy secondary to herniated
disc (HD). In recent years it has increasingly become clear that much of the
pain with acute radiculopathy secondary to HD is chemical, not compressive in
nature.[9,10] The chemical inflammatory process
with HD is initiated by the presence of nuclear material. But with LSS, it is
likely that a different, or additional, mechanism that is involved in the
production of nerve root pain.
Experimental evidence has suggested
that chronic compression of the nerve root in LSS causes compromise of blood
flow leading to congestion, ischemia, and intraneural edema.[11] This then leads to the development
of periradicular fibrosis.[12]
Increased pain with walking that is relieved with lumbar flexion (neurogenic
claudication) is one of the hallmarks for LSS. Neurogenic claudication likely
arises from increased metabolic demands
of the nerve root in the presence of vascular compromise[13] and traction on the adhesed nerve
root when lower extremity movement occurs during walking.[14] This may explain why the SLR is
often negative in pts with LSS,[8] but is typically positive in patients with herniated disc. With LSS,
compression, vascular compromise and perineural fibrosis dominate the
pathophysiological picture, thus maneuvers that increase IVF pressure, i.e.,
extension,[15] or increase metabolic demands of the
nerve root and movement of the fibrotic nerve root, as with walking, exacerbate
the pain.
A non-surgical approach that attempts
to target the unique pathophysiology of LSS may be best able to rapidly improve
pain and function in these patients. Such a treatment strategy would attempt to
mobilize the segment(s) involved, decompress the involved nerve root(s) and
mobilize the involved nerve root(s) to break up periradicular adhesion, thus
releasing nerve root entrapment, and restoring vascular function. It would
appear that maintaining intersegmental and nerve root mobility would then be
important in order to maximize the long term benefit of treatment.
The purpose of this study was to
assess, using rigorous outcome measures, the results of a non-surgical
management strategy for patients with LSS that focuses on distraction
manipulation (DM) and neural mobilization (NM). Theoretically, these methods
were employed in order to improve motion segment mobility (DM) and nerve root
mobility (NM). It is not known whether these modalities actually create these
effects, and this study does not evaluate these theoretical mechanisms. But the
outcome of a strategy that focused on these methods was assessed. This strategy
has not previously been evaluated.
Interventions
Patients were treated according to
the usual protocol utilized at the Rhode Island Spine Center for patients with
radiculopathy secondary to LSS. The primary interventions, which were utilized
in all patients, were:
• Distraction manipulation (DM) - This
is a manipulative technique developed by Cox.[18] Although other forms of manipulation
are believed to be effective in patients with LSS,[19] no form other than DM was used with
the patients in this study.
In applying DM, the patient lay prone
on a table that allows for distraction of the spine through inferiorward and
flexion movement of the lower body (figure 1). This maneuver has been
demonstrated to decrease intradiscal pressure[20] and is believed to create vertebral
motions and increase the intervertebral foramen.[21]
Figure 1. The application of distraction
manipulation.
• Neural mobilization (NM) - This a
manual and exercise oriented method that is theorized to mobilize nerve roots
that are suspected to be the source of nerve root pain.[22,23] Distal mobilization was applied by
having the patient lie supine while the doctor or therapist dorsiflexed the
ankle and flexed the hip with the knee extended. The leg was raised until the
practitioner felt the "barrier",[24] i.e., the point at which tension is initially felt. The
foot is then moved alternately into plantar flexion and dorsiflexion repeatedly
for several cycles.
• Exercises that are taught to the
patient and which are designed to compliment the DM and NM by mobilizing the
lumbar spine and the involved nerve root(s). These included the "cat and
camel" exercise[25] in which the patient is quadruped
and alternately flexes and extends (within the comfort level) the cervical and
lumbar spine, and "nerve flossing" exercises,[25] which attempt to mobilize the
involved nerve roots and there associated peripheral nerves.
DM and NM and the related exercises
are the constants of treatment in this study - all patients are treated with
these methods. In addition, certain patients may also have been had other
modalities included in their individual programs, such as mobilization exercises
and spinal stabilization exercise.[26,27] While the frequency and duration of care were determined on an
individual basis, patients were generally seen 2-3 times per week for 3 weeks
initially, after which the first follow up (FU) reexamination was performed,
which included the primary outcome measures (see below). This was typically
followed by either continued frequency of 2 times per week or a reduction in
frequency to 1 time per week, though some patients who are fully recovered were
released after the first FU reexamination to 3 week FU.
This was a practice-based project in which the data gathered were those data that are collected as part of the routine of practice at the Rhode Island Spine Center. Also, the treatments provided each patient were those that are provided in the routine care of patients with LSS at the Rhode Island Spine Center. No experimental procedures were used and no personally identifiable information on any patient is presented. The study protocol was reviewed and approved by the HIPAA compliance officer of the Rhode Island Spine Center. Because of this, it was not deemed necessary to obtain formal approval from an Institutional Review Board.
Conclusion
The combination of DM and NM may be a
safe and effective approach for patients with LSS. Because the sample size is
relatively small and there is no control group, firm conclusions regarding this
cannot be drawn. The outcome of this approach compares favorably with other
non-surgical treatments, and treatment with DM and NM may be a viable
non-surgical option before considering surgery for LSS. This approach deserves
closer scrutiny in the form of randomized controlled trials.
Authors' Contributions
DRM conceived of the idea of
compiling the data for publication, was one of the treating practitioners and
was the principle author of the manuscript. ELH was responsible for statistical
analysis, helped with design and presentation, and contributed to the writing
of the manuscript. AAG was one of the treating practitioners, helped with data
gathering and organization, and contributed to the writing of the manuscript.
RC helped with data gathering and organization and contributed to the writing
of the manuscript.
Pre-Publication History
The pre-publication history for this
paper can be accessed here:
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