Spinal stenosis treatment

By: Charles Dean Ray, MD
April 3, 2007

Non-surgical treatment for spinal stenosis

Depending on the severity of symptoms, spinal stenosis can often be managed through non-surgical means. The three most common treatments for spinal stenosis include:

• Exercise Program. Although a suitable exercise program in the hands of a good physical therapist may be helpful, it is not curative. Even though it is not a cure, however, it is very important for patients to remain active as tolerated and not additionally debilitated from inactivity, so an appropriate exercise program is a key part of any spinal stenosis treatment program.

• Activity modification. Patients are usually counseled to avoid activities that cause the adverse symptoms of spinal stenosis. Patients are typically more comfortable while flexed forward. Examples of activity modification might include: walking while bent over and leaning on a walker or shopping cart instead of walking upright; stationary biking (leaning forward on the handlebars) instead of walking for exercise; sitting in a recliner instead of on a straight-back chair.

• Epidural injections. An injection of cortisone into the space outside the dura (the epidural space) can temporarily relieve symptoms of spinal stenosis. While these injections can seldom be considered curative, they can alleviate the pain in about 50% of cases. Up to three injections over a course of several months can be tried. Although they are not considered diagnostic in and of themselves, generally, if the pain caused by spinal stenosis is relieved by an epidural steroid injection, then the patient can also be expected to have a good result if they later choose surgery.

Anti-inflammatory medication (such as ibuprofen, aspirin) may be helpful in treating spinal stenosis. Some physicians recommend a multiple B-complex vitamin with 1200 mg of folic acid daily, but this has not been substantiated as an effective treatment in the medical literature.

Some people may successfully manage the symptoms of spinal stenosis with the non-surgical therapies either for a period of time or indefinitely. The key in choosing whether or not to have surgery is the degree of physical disability and disabling pain from lumbar spinal stenosis. As a guideline, when the (usually elderly) patient can no longer walk sufficiently to care for himself or herself (such as to go shopping for essentials), then spinal stenosis surgery is usually recommended.

Surgery for spinal stenosis is mainly designed to increase a patient’s activity tolerance, so he or she can do more activity with less pain.

Spinal stenosis surgery

In most cases of advanced claudication (spinal or vascular), decompressive surgery is required. There are several opinions and techniques used in spinal stenosis surgery, but there are key components common to all such approaches.

• First and foremost, a correct and very detailed anatomical diagnosis is required - knowing exactly where to go while considering the possibility of a double or triple location for choking of a nerve in it passages, on one or both sides.

• Secondly, the surgery should not create a new problem, such as nerve injury or a structural instability that might require additional surgeries.

• Thirdly, the approach to correcting spinal stenosis should be minimally destructive of normal structures. The surgeon should strive to leave as much as possible of the normal or slightly abnormal tissues alone. This again points to the importance of exactly identifying the offending stenosis.

• Fourthly, the metabolic and physical status of the patient is important. Even in the hands of an experienced surgeon a decompressive procedure - especially if more than one level and if bilateral procedures are needed - may require a few hours of anesthesia, and this is not well tolerated by some patients. Some surgeons will perform the spinal stenosis surgery under an epidural anesthetic instead of a general anesthetic.

Fortunately, a decompression surgery for spinal stenosis can be among the most rewarding surgical methods used on the spine (second only to removal of some herniated discs), because generally patients do well and are able to increase their activity and have a better walking tolerance postoperatively.

For more information on decompression surgery, please see Lumbar decompression surgery.

More recently, a few new surgical approaches have also been introduced and other devices are in various stages of development and clinical trials. At least one has been approved for use in the treatment of central spinal stenosis.

• Interspinous process devices. The goal of these devices is to help take the bucking out of the ligaments and disc that together are pressing on the central canal and hopefully also a widening of the nerve foramen. In cases of true bone spur foraminal or far lateral stenosis, however, this method is less likely to help. This device does limit backwards bending at the segment thus limiting the ligament and posterior disc buckling. The X-stop is a device that has been approved for treatment of spinal stenosis, principally of the central type. See also Interspinous process spacers.

• Facet replacement or total element replacement. This new class of devices is still principally investigational and hopes to replace the facet joints in the back of the spine (or the total segmental element of the back of the spine). Whether or not this will assist in spinal stenosis depends on the extent of the central decompression, as yet to be proven. It is more likely that they might be of benefit in degenerative arthritis of the facet joints, which can contribute to foraminal stenosis, however.

For more information on the above newer approaches, see Posterior motion preservation spine surgery: alternative to spinal fusion.