Lumbar Spinal Stenosis
Overview and RecommendationsBackground·Lumbar spinal stenosis is a clinical syndrome of neurogenic claudication and/or radicular pain due to narrowing of the spinal canal or nerve root impingement.
·Pain associated with lumbar spinal stenosis usually presents as radiating buttock or lower extremity pain, burning, or discomfort, often accompanied by low back pain, impairment of walking, sensory loss, paresthesias, or muscle weakness.
·Lumbar spinal stenosis typically develops in adults > 60 years old and is most commonly caused by age-associated spinal degeneration.
Evaluation·Suspect lumbar spinal stenosis in older patients with gluteal or lower extremity symptoms exacerbated by walking or standing and resolved by sitting or bending forward.
·Diagnosis requires characteristic symptoms, radiographic evidence of lumbar spinal stenosis, and exclusion of other causes of back pain.
·Magnetic resonance imaging (MRI) is the preferred radiologic technique for confirmation of anatomic narrowing of the spinal canal or nerve root impingement (Strong recommendation).
oComputed tomography (CT) myelography is used if an MRI is contraindicated or inconclusive (Strong recommendation), followed by CT if MRI and CT myelography are contraindicated or inconclusive (Strong recommendation).
oThere is no clear consensus on radiologic criteria for diagnosis of spinal stenosis.
·Electromyography (EMG) is not routinely warranted in the diagnosis of lumbar spinal stenosis; however, electrodiagnostic testing may be considered to help identify other conditions that may mimic the clinical syndrome of lumbar spinal stenosis, such as generalized peripheral neuropathies or focal neuropathies (Weak recommendation).
Management·Consider nonoperative treatment for patients with mild or moderate symptoms of lumbar spinal stenosis (Weak recommendation). Options include:
olimited course of active physical therapy (Weak recommendation)
olumbosacral corset for improvement in walking distance and decreased pain while the corset is worn (Weak recommendation)
omedications; insufficient evidence to recommend for or against use, but may include:
§acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), although there is no evidence of benefit in patients with lumbar spinal stenosis
§mild narcotic analgesics in patients who are unresponsive to or intolerant of NSAIDs
§gabapentinoids
·Consider surgical decompression with or without lumbar fusion to improve outcomes in patients with moderate-to-severe symptoms of lumbar spinal stenosis (Weak recommendation), and may provide long-term (≥ 4 years) improvement in patients with degenerative lumbar spinal stenosis (Weak recommendation).
·Consider decompression alone (without lumbar fusion) for patients with leg-predominant symptoms without instability (Weak recommendation).
·Active rehabilitation may improve back function and pain following primary spinal decompressive surgery for lumbar spinal stenosis.
Related Summaries·Chronic Low Back Pain
·Acute Low Back Pain
·Lumbar Disk Herniation
General InformationDescription·lumbar spinal stenosis is a clinical syndrome of variable back, buttock, and/or lower extremity pain caused by narrowing of spinal canal or nerve root impingement1,2,3
oassociated pain syndromes include
§radicular pain (radiating leg pain present regardless of activity)
§neurogenic claudication (leg pain brought on by walking or standing and relieved by rest or flexion)
omay also be associated with numbness, weakness, and impaired walking
·this topic primarily covers degenerative or acquired lumbar spinal stenosis
Also Called·lumbar stenosis
·lumbar canal stenosis
·pseudoclaudication
·spinal claudication
Definitions·clinical syndrome of lumbar spinal stenosis defined by presence of both1
ocharacteristic clinical presentation of neurogenic claudication and/or radicular pain
oradiographic or anatomic evidence of lumbar spinal stenosis
·neurogenic claudication refers to pain that1
oradiates beyond spine into lower extremity (1 or both legs)
oworsens with walking or prolonged standing
ois relieved with sitting or lumbar flexion
omay be associated with gait changes, lower extremity weakness, sensory loss, or fatigue
·radicular pain1
oradiates within unilateral or bilateral dermatomal distribution
ooccurs unrelated to activity
·radiographic lumbar spinal stenosis defined as narrowing of spinal canal found on cross-sectional imaging, further characterized as1
ocentral canal stenosis - narrowing between medial edges of 2 zygapophysial (facet) joints
olateral recess or subarticular stenosis - narrowing between medial edge of zygapophysial (facet) joint and medial pedicle border
oneuroforaminal stenosis - narrowing of neural foramina defined by medial and lateral pedicle borders
orelative lumbar spinal stenosis - narrowing ≤ 12 mm anteroposterior diameter of spinal canal
oabsolute lumbar spinal stenosis - narrowing ≤ 10 mm anteroposterior diameter of spinal canal
·anatomic lumbar spinal stenosis defined as spinal canal narrowing identified intraoperatively1
EpidemiologyWho Is Most Affected·older adults - typical onset of neurogenic claudication due to lumbar spinal stenosis occurs after age 60 years2
Incidence/Prevalence·incidence and prevalence of symptomatic lumbar spinal stenosis unknown, but it is the most frequent indication for spinal surgery in patients ≥ 65 years of age2
·estimated prevalence of radiographic lumbar stenosis in asymptomatic adults > 55 years old1
o21%-30% for moderate stenosis
o6%-7% for severe stenosis
·about 30% of adults may have radiographic spinal stenosis
obased on cross-sectional study
o191 adults (mean age 53 years) from Framingham Heart Study having abdominal and chest computed tomography for assessment of coronary and aortic calcification were also evaluated for radiographic spinal stenosis and prevalence of persistent low back pain (including lower extremity symptoms) lasting ≥ 1 month during previous year
o32% of patients had radiographic lumbar spinal stenosis regardless of symptoms
o19.4% reported persistent low back pain (76% of these patients reported ≥ 1 distal symptom with low back pain)
oamong patients reporting persistent low back pain
§29.7% had radiographic relative lumbar spinal stenosis (≤ 12 mm diameter of spinal canal)
§18.9% had radiographic absolute lumbar spinal stenosis (≤ 10 mm diameter of spinal canal)
oReference - Spine J 2009 Jul;9(7):545full-text
Risk Factors·conditions that increase risk for spinal stenosis include2
odegenerative spondylolisthesis (or spondylolisthesis due to prior spondylolysis)
oprior back surgery (such as laminectomy)
otrauma
ocorticosteroid excess, iatrogenic or endogenous (such as Cushing disease)
oPaget disease of bone
oachondroplastic dwarfism (onset of symptoms at age 20-40 years)
oacromegaly
Etiology and PathogenesisCauses·lumbar spinal stenosis most often caused by age-associated spinal degeneration1,2
·idiopathic congenitally shortened pedicles typically accelerate degenerative processes leading to spinal stenosis2
IMAGE 1 OF 1
Lumbar spinal stenosisA, Sagittal T2-weighted image near midline demonstrating advanced degenerative disk disease at the L3-4, L4-5, and L5-S1 levels. Note presence of a Schmorl node (black arrowhead). White lines indicate levels of axial images. B, Axial T2-weighted image at the L3-4 level demonstrating degenerative disk changes and a diffuse disk bulge (yellow arrowheads) resulting in mild stenosis of the central spinal canal. C, Axial T2-weighted image at the L4-5 level demonstrating degenerative disk changes and right-sided postoperative changes with indentation of the thecal sac (white arrowhead). D, Axial T2-weighted image at the L5-S1 level demonstrating degenerative disk changes and prior right hemilaminotomy (blue arrowhead). Overall, there were no significant changes in this MRI study compared with an earlier study performed in September 2003.
Pathogenesis·age-related degenerative changes in spinal structures result in constriction of space in central canal or neural foramina; several processes may be involved1,2
odisk and facet joint degeneration lead to loss of disk height, bulging of disk material, and infolding of ligamentum flavum
ofacet osteoarthritis and hypertrophy may lead to osteophyte formation and thickening of joint capsule
oin advanced osteoarthritis, facet joint synovial cysts may protrude into spinal canal
·postulated mechanisms of pain and neurologic symptoms include2
onerve root compression leading to radicular pain, weakness, and sensory deficits
oexacerbation of neurogenic claudication with extension of lumbar spine (such as with walking or standing) due to further reduction of cross-sectional area of spinal canal which impairs blood flow to venules resulting in venule engorgement and further compression of nerve roots; symptoms reversed when lumbar spine returns to flexion (seated, bent forward)2
·pain syndromes anecdotally linked to specific locations of stenosis (neurogenic pain with central stenosis, radicular pain with lateral stenosis), but varied clinical presentations can be seen in patients with similar imaging findings1
History and PhysicalHistoryChief Concern (CC)·if symptomatic, patient may report1,2
oradiating buttock or lower extremity pain, burning, or discomfort with walking or prolonged standing; symptoms are generally relieved with sitting or lumbar flexion
olow back pain, impairment of walking, sensory loss, paresthesias, or muscle weakness
History of Present Illness (HPI)·ask patient about
ocharacteristics of pain and other symptoms1,2,3
§in patients with neurogenic claudication
§pain or burning sensation that radiates down buttocks, thighs, lower legs, or feet is typical; pain may or may not originate in low back (leg pain is often more bothersome)
§more subtle symptoms may be described, including
§abnormal weakness or fatigue in lower extremities
§numbness in lower extremities or perineal region
§in patients with radicular pain, unilateral or bilateral radiating pain in ≥ 1 dermatome is typical; may occur alone or concurrent with neurogenic claudication
osymptom exacerbating and alleviating factors1,2,3
§symptoms of neurogenic claudication often worsen with lumbar extension (as in walking or prolonged standing) and improve with lumbar flexion (as in sitting or bending forward)
§radicular pain is not typically provoked by lumbar extension
oeffect on function, including abnormal gait or poor balance1
opresence of any other changes in activities of daily living, such as differences in nighttime urination frequency1
·symptoms that may predict lumbar spinal stenosis include burning sensation around buttocks or intermittent priapism when walking, urinary disturbance, and improved pain when bending forward (level 2 [mid-level] evidence)
obased on systematic review of studies with methodologic limitations
osystematic review of 46 studies evaluating diagnostic tests for detecting lumbar spinal stenosis
§20 studies evaluated imaging tests (computed tomography [CT], magnetic resonance imaging [MRI], myelography, ultrasound)
§11 studies evaluated electrodiagnostic tests (electromyography, dermatomal somatosensory-evoked potentials, caudal motor conduction time)
§15 studies evaluated clinical tests (standardized history, physical examination, pain drawings, gait analyses)
oall studies had ≥ 1 of the following limitations
§unclear or no blinding of reference standard or test under investigation
§unreliable reference standard
§unclear or unacceptable delay between tests
ono meta-analyses performed due to heterogeneity of tests, study populations, and reference standards (clinical reference standard [expert opinion based on clinical findings and imaging and/or surgery] or anatomic reference standard [based on imaging and/or surgery findings] were used among studies)
osymptoms with positive likelihood ratio (PLR) > 5 for lumbar spinal stenosis in single studies
§burning sensation around buttocks or intermittent priapism when walking (PLR 7.2 and specificity 99%) in 1 study with 468 patients
§urinary disturbance (PLR 6.9 and specificity 98%) in 1 study with 468 patients
§no pain when seated (PLR 6.6 and specificity 93%) in 1 study with 75 patients
§improved pain when bending forward (PLR 6.4 and specificity 92%) in 1 study with 468 patients
§bilateral buttock or leg pain (PLR 6.3 and specificity 92%) in 1 study with 179 patients
oReference - Spine (Phila Pa 1976) 2013 Apr 15;38(8):E469EBSCOhost Full Text, previous version of this systematic review can be found in JAMA 2010 Dec 15;304(23):2628EBSCOhost Full Text
·about 50% of older adults with pain or numbness in lower extremities may have lumbar spinal stenosis
obased on prospective cohort study
o468 adults (mean age 65 years) with primary symptoms of pain or numbness in lower extremities were evaluated
oprevalence of lumbar spinal stenosis (diagnosed by clinical exam and radiographic findings)
§47% overall
§15% in patients < 60 years old
§25% in patients aged 60-70 years
§64% in patients > 70 years old
oReference - Eur Spine J 2007 Nov;16(11):1951EBSCOhost Full Textfull-text
Past Medical History (PMH)·ask about prior back surgery (such as laminectomy)2
·ask about history of relevant degenerative or congenital conditions, including2
oosteoarthritis
odegenerative disk disease
ospondylolisthesis
oexcess of corticosteroids (endogenous as in Cushing syndrome or iatrogenic)
oPaget disease of bone
osee other conditions in Differential diagnosis
PhysicalGeneral physical·North American Spine Society (NASS) finds insufficient evidence to make recommendation for or against use of certain physical findings for diagnosis of degenerative lumbar spinal stenosis, including (NASS Grade I)3
oabnormal Romberg test
othigh pain exacerbated with extension
osensorimotor deficits
oleg cramps
oabnormal Achilles tendon reflexes
Back·observe posture in both sitting and in stance1,2
olumbar extension may provoke symptoms
oforward flexed posture may relieve symptoms
Extremities·consider straight leg raise (SLR) for elicitation of leg pain3
·Lumbar Spinal Stenosis Consensus Group guidelines for Minimally Invasive Spine Treatment (MIST) state neurogenic claudication must be differentiated from other sources of claudication (LSSCG Grade A, Level II-2, Consensus Strong)
odistal skin temperature and appearance should be assessed during vascular exam
opopliteal and pedal pulses should be checked by palpation and anklebrachial index if necessary
oif co-existent disease is suspected, further angiographic imaging is warranted
oReference - Pain Pract 2019 Mar;19(3):250
Neuro·perform neurologic assessment, including1,2
osensorimotor exam of lower extremities; motor findings, if present, are typically mild
oreflex testing of Achilles tendons
oRomberg maneuver
§patient is asked to stand with feet together and close eyes for 10 seconds
§test considered abnormal if compensatory movements are necessary to keep feet planted
§abnormal findings indicate involvement of proprioceptive fibers in the posterior columns
·in patients with lower extremity or back pain, wide-based gait may predict lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on systematic review limited by clinical heterogeneity
osystematic review of 4 diagnostic cohort studies evaluating accuracy of history and physical exam items in 741 patients with pain in lower extremities and/or low back
oclinical heterogeneity included differences between studies in
§reference standards (different combinations of expert physicians, history, physical exam findings, x-rays, magnetic resonance imaging, computed tomography, or myelography used)
§clinical settings (2 studies in specialty care only; 2 studies with primary care patients)
omean age of study patients 64-65 years in 3 studies; age of patients in 1 study not reported
oprevalence of clinical lumbar stenosis 44%-49%
oneurologic exam findings associated with lumbar spinal stenosis
§wide-based gait (positive likelihood ratio [PLR] 13)
§abnormal Romberg (PLR 4.2)
§vibration deficit (PLR 2.8)
§pinprick deficit (PLR 2.5)
§absent Achilles reflex (PLR 2.1)
§motor weakness (PLR 2.1)
oReference - JAMA 2010 Dec 15;304(23):2628EBSCOhost Full Textfull-text
DiagnosisMaking the Diagnosis·suspect diagnosis of lumbar spinal stenosis in older patients with
ogluteal or lower extremity symptoms exacerbated by walking or standing, and resolved by sitting or bending forward (NASS Grade C)3
opresence of characteristic clinical syndromes, which may include neurogenic claudication and/or radicular pain
·diagnosis of lumbar spinal stenosis is based on1,2,3
otypical signs and symptoms (patients whose pain is not made worse by walking have low likelihood of stenosis [NASS Grade C])
oevidence of anatomic narrowing of spinal canal or nerve root impingement on imaging, preferably with magnetic resonance imaging (MRI)
oexclusion of other causes of back pain
Differential Diagnosis·spinal disorders1
olumbosacral radicular pain secondary to nerve root impingement (such as lumbar disk herniation)
oreferred pain from lumbar spine structures (zygapophysial [facet] joints, intervertebral disks)
olumbar vertebral compression fracture
·extraspinal musculoskeletal disorders1
oreferred pain from hip disorder or sacroiliac joint disorder (including hip osteoarthritis)2
otrochanteric bursitis
opiriformis syndrome
omuscle strain or tear
omyofascial referred pain
·other causes of back and/or leg pain
ocompartment syndrome1
operipheral neuropathy1,2
operipheral artery disease1,2
ovisceral referred pain1
oexercise-induced leg pain, including
§medial tibial stress syndrome
§periostitis
§stress fracture of tibia or fibula
§fascial hernia
§common peroneal nerve compression
§venous stasis
§Reference - Phys Sportsmed 2001 Jun;29(6):35
ohematoma in spinal canal
§chronic spinal epidural hematoma in case reports (Zentralbl Neurochir 1994;55(3):166, Eur Spine J 1995;4(1):64, Neurosurgery 1984 Feb;14(2):230)
§spinal subdural hematoma in case report (Surg Neurol 1977 Oct;8(4):296)
Testing Overview·imaging studies used to confirm diagnosis of anatomic narrowing of spinal canal or nerve root impingement may include
omagnetic resonance imaging (MRI) (preferred) (NASS Grade B)
ocomputed tomography (CT) myelography if MRI contraindicated or inconclusive (NASS Grade B)
oCT scan if MRI and CT myelography contraindicated or inconclusive (NASS Grade B)
·electromyography (EMG) is not routinely warranted in diagnosis of lumbar spinal stenosis; however, electrodiagnostic testing may be useful in providing information about other conditions that may mimic the clinical syndrome of lumbar spinal stenosis, such as generalized peripheral neuropathies or focal neuropathies
Clinical Prediction Rules·insufficient evidence to make recommendation for or against3
ouse of self-administered questionnaires to improve accuracy of diagnosis of spinal stenosis (NASS Grade I)
odiagnostic reliability of patient-reported dominance of lower extremity pain and low back pain (NASS Grade I)
·clinical prediction rule based on history and physical exam items might be useful for ruling out lumbar spinal stenosis in patients with pain or numbness in lower legs (level 2 [mid-level] evidence)
obased on 1 diagnostic derivation cohort study and 1 validation study with poor interobserver agreement for diagnosis
o468 adults (mean age 64 years) with pain or numbness of lower legs were evaluated by physician for lumbar spinal stenosis in derivation cohort study
§reference standard was clinical diagnosis based on expert opinion
§47.3% had physician-diagnosed lumbar spinal stenosis, but substantial discrepancy in diagnosis (interobserver agreement 60.8%, kappa 0.261)
§factors identified and points assigned to develop prediction rule
§1 point for age 60-70 years, 2 points for > 70 years
§1 point for absence of diabetes
§3 points for intermittent claudication
§2 points for exacerbation of symptoms when standing
§3 points for symptom improvement when standing
§-1 point for symptoms induced when bending forward
§1 point for symptoms induced when bending backward
§3 points for good peripheral artery circulation
§1 point for abnormal Achilles tendon reflex
§-2 points for straight leg raising positive for pain
§prevalence of lumbar spinal stenosis
§6.3% for score -2 to 5 (bottom quartile of risk score)
§99% for score 12-16 (top quartile of risk score)
§positive score (≥ 7 points) associated with
§sensitivity of 93%
§specificity of 72%
§positive likelihood ratio 3.3
§negative likelihood ratio 0.1
§Reference - Eur Spine J 2007 Nov;16(11):1951EBSCOhost Full Textfull-text
o118 adults (mean age 68 years) with lower extremity symptoms were evaluated in validation study
§lumbar spinal stenosis present in 49%
§positive score (≥ 7 points) associated with
§sensitivity of 95%
§specificity of 40%
§Reference - J Orthop Sci 2009 Nov;14(6):711
·clinical prediction rule based only on self-reported patient information may not be useful for diagnosing or ruling out lumbar spinal stenosis in patients with pain or numbness in lower extremities (level 2 [mid-level] evidence)
obased on derivation and validation cohort studies (within same population) with poor agreement for diagnosis
o468 patients with pain or numbness in lower extremities were evaluated (374 in derivation set, 94 in validation set)
o47.3% had physician-diagnosed lumbar spinal stenosis, but substantial discrepancy in diagnosis (interobserver agreement 60.8%, kappa 0.261)
orisk score for clinical prediction rule
§2 points for age 60-70 years
§3 points for age > 70 years
§1 point for onset over 6 months
§2 points for symptoms that improve when bending forward
§-2 points for symptoms that improve when bending backward
§2 points for symptoms exacerbated while standing up
§1 point for intermittent claudication
§1 point for urinary incontinence
opositive score (≥ 5 points) associated with
§75% sensitivity
§51% specificity
olikelihood of lumbar spinal stenosis
§score ≤ 2 - 18% in derivation cohort, 13% in validation cohort
§score 3-4 - 25% in derivation cohort, 48% in validation cohort
§score 5-6 - 51% in derivation cohort, 55% in validation cohort
§score ≥ 7 - 77% in derivation cohort, 66% in validation cohort
oReference - Fam Pract 2008 Aug;25(4):237full-text
Imaging Studies·for diagnosis of lumbar spinal stenosis, advanced imaging is used to2
odetect reduction in cross-sectional area of central canal or neural foramina
oconfirm presumptive diagnosis of clinical syndrome based on symptoms
oidentify appropriate candidates for surgery or epidural corticosteroid injections
·x-rays of spine not routinely needed, but may show spondylolisthesis (common predisposing lesion)2
·North American Spine Society (NASS) imaging recommendations for lumbar spinal stenosis3
oto confirm diagnosis of anatomic narrowing of spinal canal or nerve root impingement, consider
§magnetic resonance imaging (MRI) first (suggested as the most appropriate noninvasive test) (NASS Grade B)
§computed tomography (CT) myelography if MRI is contraindicated or inconclusive (NASS Grade B)
§CT scan if MRI and CT myelography are contraindicated or inconclusive (NASS Grade B)
oconsider use of well-defined, articulated, and validated criteria for anatomic canal narrowing on MRI, CT myelography, or CT to improve interobserver and intraobserver reliability (NASS Grade B)
oconsider MRI or CT with axial loading in patients with all of (NASS Grade B)
§clinical signs and symptoms of lumbar spinal stenosis
§dural sac area < 110 mm2 at ≥ 1 level
§suspected but not verified central or lateral stenosis on routine unloaded MRI or CT
oinsufficient evidence to make a recommendation for and against a correlation between clinical symptoms or function with presence of anatomic narrowing of spinal canal on MRI, CT myelography, or CT (NASS Grade I)
·Lumbar Spinal Stenosis Consensus Group guidelines for Minimally Invasive Spine Treatment (MIST)
odiagnosis of symptomatic lumbar spinal stenosis requires both presence of neurogenic claudication symptoms and radiographic evidence (LSSCG Grade B, Level I, Consensus Strong)
othere are poor correlations between clinical presentation and severity of spinal stenosis radiographically (LSSCG Grade I, Level II, Consensus Strong)
oReference - Pain Pract 2019 Mar;19(3):250
·MRI may be useful for ruling out lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on systematic review of studies with methodologic limitations
osystematic review of 46 studies evaluating diagnostic tests for detecting lumbar spinal stenosis
§20 studies evaluated imaging tests (CT, MRI, myelography, ultrasound)
§11 studies evaluated electrodiagnostic tests (electromyography, dermatomal somatosensory-evoked potentials, caudal motor conduction time)
§15 studies evaluated clinical tests (standardized history, physical examination, pain drawings, gait analyses)
oall studies had ≥ 1 of the following limitations
§unclear or no blinding of reference standard or test under investigation
§unreliable reference standard
§unclear or unacceptable delay between tests
ono meta-analyses performed due to heterogeneity of tests, study populations, and reference standards (clinical reference standard [expert opinion based on clinical findings and imaging and/or surgery] or anatomic reference standard [based on imaging and/or surgery findings] were used among studies)
odiagnostic performance of imaging modalities for detection of lumbar spinal stenosis
§MRI
§sensitivity range 60%-96% in 8 studies (sensitivity was calculated based on 2 different imaging findings in 1 study)
§sensitivity of 60% in 1 study
§sensitivity of 77% in 2 studies
§sensitivity of 85%-88% in 3 studies
§sensitivity of ≥ 92% in 3 studies
§specificity range 43%-100% in 7 studies
§specificity 43% in 1 study (based on finding of sagittal sign)
§specificity of 60%-75% in 4 studies
§specificity of ≥ 88% in 2 studies
§3-dimensional magnetic resonance (MR) myelography
§sensitivity range 60%-100% in 3 studies (sensitivity was calculated based on 2 different imaging findings in 1 study)
§sensitivity of 60% in 1 study (based on findings of spinal nerve swelling)
§sensitivity of ≥ 96% in 3 studies
§specificity of 84% (based on finding of abnormal course of nerve root) and 99% (based on finding of spinal nerve swelling) in 1 study
§CT
§sensitivity range 21%-100% in 7 studies (sensitivity was calculated based on ≥ 2 different imaging findings in 4 studies)
§sensitivity of 21% in 1 study (based on anteroposterior diameter)
§sensitivity of 50%-75% in 3 studies
§sensitivity of 76%-89% in 3 studies
§sensitivity of ≥ 92% in 2 studies
§specificity range 60%-98% in 3 studies
§specificity of 60% in 1 study
§specificity of ≥ 81% in 2 studies
§myelography
§sensitivity range 54%-100% in 10 studies
§sensitivity of ≤ 62% in 2 studies
§sensitivity of 67%-87% in 4 studies
§sensitivity of ≥ 90% in 4 studies
§specificity range 88%-100% in 3 studies
§specificity of 88% in 1 study
§specificity of ≥ 91% in 2 studies
§ultrasound
§sensitivity range of 90%-95% in 2 studies
§specificity range of 96%-100% in 2 studies
oReference - Spine (Phila Pa 1976) 2013 Apr 15;38(8):E469
·no clear consensus on radiologic criteria for diagnosis of spinal stenosis
obased on 1 systematic review and 1 Delphi survey
osystematic review of semiquantitative and qualitative radiologic criteria for diagnosis of lumbar spinal stenosis
§14 criteria were identified, with wide variability in definitions and intra- and interrater reliability
§criteria for central stenosis
§compression of central spinal canal (for interrater reliability, kappa [k] ranged from 0.41-0.73)
§reduced or absent fluid around cauda equina (for interrater reliability, k ranged from 0.44-0.95)
§nerve root sedimentation sign (for interrater reliability, k = 0.93)
§hypertrophy of ligamentum flavum (for interrater reliability, no data was available)
§redundant nerve roots of cauda equina (for interrater reliability, no data was available)
§reduction of posterior epidural fat (for interrater reliability, no data was available)
§epidural lipomatosis (for interrater reliability, k ranged from 0.76-0.85)
§criteria for lateral stenosis
§compression of subarticular zone (for interrater reliability, k = 0.49)
§nerve root compression in lateral recess (for interrater reliability, no data was available)
§criteria for foraminal stenosis
§perineural intraforaminal fat (for interrater reliability, k ranged from 0.91-1)
§hypertrophic facet joint degeneration (for interrater reliability, k ranged from 0.07-0.89)
§compression of foraminal zone (for interrater reliability, k = 0.58)
§foraminal nerve root impingement (for interrater reliability, k ranged from 0.51-0.67)
§size and shape of foramen (for interrater reliability, k = 0.47)
§Reference - AJR Am J Roentgenol 2013 Nov;201(5):W735
o3-round Delphi survey of 21 expert musculoskeletal radiologists and neuroradiologists
§moderate consensus on diagnostic relevance of 5 qualitative indicators of spinal stenosis
§disk protrusion/extrusion/sequestration
§lack of perineural intraforaminal fat
§hypertrophic facet joint degeneration
§absence of fluid around the cauda equine
§hypertrophy of ligamentum flavum
§no consensus on quantitative criteria, highest rated were
§anteroposterior diameter of osseous spinal canal < 12 mm at level of endplate
§cross-sectional area of dural sac < 100 mm2
§dural sac midsagittal diameter < 12 mm
§foramen diameter < 3 mm
§lateral recess height < 3 mm
§Reference - Radiology 2012 Jul;264(1):174full-text, editorial can be found in Radiology 2012 Jul;264(1):3
·nerve root sedimentation sign evaluation did not improve diagnosis of lumbar spinal stenosis or predict treatment outcomes in 2 retrospective cohort studies (Spine (Phila Pa 1976) 2013 Nov 15;38(24):E1554, Spine J 2014 Apr;14(4):667)
Electrodiagnostic Testing·electrodiagnostic testing may be useful in providing information about other conditions that may mimic the clinical syndrome of lumbar spinal stenosis, such as generalized peripheral neuropathies or focal neuropathies1
·electromyography (EMG) is not routinely warranted in diagnosis of lumbar spinal stenosis; utility is limited due to inability to
olocalize exact anatomic site of pathology within lumbar spinal canal, only identifying root(s) physiologically involved (PM R 2013 May;5(5 Suppl):S41)
odetermine specific process causing symptoms in patients with simultaneous presentation of spinal stenosis and peripheral neuropathy2
·American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) recommendations on utility of electrodiagnostic testing in patients with lumbosacral radiculopathy
oin patients with suspected lumbosacral radiculopathy, consider tests that may assist in clinical diagnosis, including
§peripheral limb EMG (AANEM Class II, Level B)
§paraspinal mapping (PM) with needle EMG in lumbar radiculopathy (AANEM Class II, Level B)
§H-reflex in S1 radiculopathy (AANEM Class II/III, Level C)
oevidence suggests low sensitivity of peroneal and posterior tibial F-waves (AANEM Class II/III, Level C)
oinadequate evidence to recommend for or against use of the following electrodiagnostic studies
§dermatomal/segmental somatosensory evoked potentials (SEP) of L5 or S1 dermatomes (AANEM Class III, Level C)
§motor evoked potential (MEP) with root stimulation in making independent diagnosis of lumbosacral radiculopathy (AANEM Class III, Level U)
oReference - American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) evidence-based guideline on the utility of electrodiagnostic testing in evaluating patients with lumbosacral radiculopathy (Muscle Nerve 2010 Aug;42(2):276)
·North American Spine Society (NASS) electrodiagnostic testing recommendations for lumbar spinal stenosis3
oelectromyographic paraspinal mapping is suggested to confirm diagnosis of degenerative lumbar spinal stenosis in patients with mild or moderate symptoms, and radiographic evidence of stenosis (NASS Grade B)
oinsufficient evidence to recommend for or against use of many electrodiagnostic testing modalities for confirmation of lumbar spinal stenosis (but may be useful in identifying other comorbidities), including use of (NASS Grade I)
§F wave
§H reflex
§motor-evoked potentials
§motor nerve conduction studies
§somatosensory-evoked potentials
§dermatomal sensory-evoked potentials
§lower extremity EMG
ManagementManagement Overview·treatment of choice for lumbar spinal stenosis depends on (LSSCG Grade A, Level I-I, Consensus Strong)
odegree, level, and architecture of stenosis
oseverity of symptoms
opreviously failed, less invasive treatments
opatient comorbidities
oReference - Pain Pract 2019 Mar;19(3):250
·nonoperative treatment may be considered for patients with mild symptoms (NASS Work Group Consensus Statement) or moderate symptoms of lumbar spinal stenosis (NASS Grade C)
ophysical therapy or exercise
§limited course of active physical therapy is an option for treatment
§physical therapy may provide short-term improvements in pain and function, but may not improve walking ability in patients with lumbar spinal stenosis and neurogenic claudication (level 2 [mid-level] evidence)
olumbosacral corset may increase walking distance and decrease pain, but no evidence that results are sustained after removal of brace (NASS Grade B)
oinsufficient evidence to recommend for or against medications in the management of spinal stenosis (NASS Grade I)
§pain usually managed with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), but neither approach has been evaluated in randomized trials in patients with lumbar spinal stenosis
§consider mild narcotic analgesics in patients who are unresponsive to or intolerant of NSAIDs
§addition of gabapentin to standard therapy may improve pain scores in patients with spinal stenosis (level 2 [mid-level] evidence)
oepidural steroid injections
§epidural corticosteroid injections not associated with improved pain or function in patients with spinal stenosis (level 2 [mid-level] evidence); based on systematic review with incomplete assessment of trial quality (Ann Intern Med 2015 Sep 1;163(5):373EBSCOhost Full Text)
§addition of steroids to epidural lidocaine injection may not reduce disability or pain at 6-12 weeks in patients with spinal stenosis (level 2 [mid-level] evidence); based on 2 randomized trials with baseline differences (N Engl J Med 2014 Jul 3;371(1):11, and J Spinal Disord Tech 2012 Jun;25(4):226)
·decompressive surgery suggested to improve outcomes in patients with moderate-to-severe symptoms of lumbar spinal stenosis (NASS Grade B)
odecompressive surgery with or without fusion may provide slight improvement in disability at > 2 years compared to nonoperative management in adults with symptomatic lumbar spinal stenosis (level 2 [mid-level] evidence)
oaddition of lumbar fusion to decompression surgery increases length of hospital stay (level 1 [likely reliable] evidence), and may not improve pain, disability or reoperation rate in patients with lumbar spinal stenosis (level 2 [mid-level] evidence)
odecompression alone (without lumbar fusion) suggested for patients with leg-predominant symptoms without instability (NASS Grade B)
oactive rehabilitation appears to improve back function and pain following primary spinal decompressive surgery for lumbar spinal stenosis (level 2 [mid-level] evidence)
Nonoperative ManagementPhysical Therapy or Exercise·physical therapy is a primary strategy used in the management of lumbar spinal stenosis, particularly flexion-based therapy (such as cycling and inclined walking) as it can open the spinal canal, increasing blood flow (Curr Opin Anaesthesiol 2017 Oct;30(5):598)
·North American Spine Society (NASS) guidance on role of physical therapy or exercise3
oinsufficient evidence to recommend for or against physical therapy or exercise as stand-alone treatment for degenerative lumbar spinal stenosis (NASS Grade I)
olimited course of active physical therapy is an option for treatment
·physical therapy may provide short-term improvements in pain and function, but may not improve walking ability in patients with lumbar spinal stenosis and neurogenic claudication (level 2 [mid-level] evidence)
obased on Cochrane review of trials with limited evidence
osystematic review of 21 randomized trials evaluating nonoperative treatments in 1,851 patients with lumbar spinal stenosis and neurogenic claudication
o4 trials evaluated physical therapy
§exercise significantly improved leg pain and function at end of treatment vs. no treatment in 1 trial with 45 patients (below)
§inpatient physical therapy for 2 weeks significantly improved pain, function, and quality of life at end of treatment vs. home exercise program plus oral diclofenac in 1 trial with 29 patients (below)
§manual therapy plus exercise and unweighted treadmill walking had significant increase in short-term global improvement vs. flexion exercises plus walking and sham ultrasound in 1 trial with 68 patients (below)
§no significant difference in outcomes comparing cycling vs. unweighted treadmill walking in 1 trial with 68 patients (below)
§no significant difference in walking ability in any trial
oReference - Cochrane Database Syst Rev 2013 Aug 30;(8):CD010712
osimilar results found in systematic review of same trials (Spine (Phila Pa 1976) 2012 May 1;37(10):E609)
oexercise may reduce pain and disability, and addition of ultrasound to exercise may reduce analgesic use in patients with spinal stenosis (level 2 [mid-level] evidence)
§based on small randomized trial
§45 patients (mean age 53 years) with lumbar stenosis were randomized to 1 of 3 groups
§ultrasound plus exercise
§sham ultrasound plus exercise
§control (no intervention)
§exercise included stretching and strengthening of lumbar, abdominal, and leg muscles, and low-intensity cycling
§ultrasound applied at 1 megahertz, 1.5 watt/cm2 intensity in continuous mode over back muscles for 10 minutes in 15 sessions (5 sessions/week for 3 weeks)
§fifteen 45-minute exercise sessions (5 sessions/week for 3 weeks) included warm-up, flexibility training, cycling, and warm-down
§compared to baseline, total ambulation time (on treadmill test) increased in both intervention groups (p ≤ 0.04 for each) and decreased in control group (not significant); no significant differences among groups in mean total ambulation time after treatment (p = 0.069)
§compared with control group at 3 weeks
§mean leg pain decreased in both intervention groups (p ≤ 0.007)
§mean disability score decreased in both intervention groups (p ≤ 0.014)
§mean analgesic consumption was less in ultrasound plus exercise group (p = 0.016)
§no significant differences between 2 intervention groups
§Reference - Clin Rehabil 2010 Jul;24(7):623
oinpatient physical therapy and epidural steroid injections may each reduce pain and improve mobility at 2 weeks (level 2 [mid-level] evidence)
§based on small randomized trial
§33 adults (mean age 59 years) with lumbar spinal stenosis receiving diclofenac and home-based exercise program were randomized to 1 of 3 groups and followed for 6 months
§inpatient physical therapy program 5 days/week for 2 weeks (including ultrasound, hot pack, and transcutaneous electrical nerve stimulation [TENS])
§epidural steroid injection
§control (diclofenac and home-based exercise program only)
§88% of adults completed trial
§compared to control at 2 weeks, inpatient physical therapy and epidural steroid injections associated with
§decreased pain on visual analog scale (VAS) (p < 0.01)
§increased physical mobility (p < 0.05)
§no significant difference in pain reductions between physical therapy and epidural steroid groups
§Reference - Spine 2009 May 1;34(10):985
omanual physical therapy plus tailored exercises and body-weight supported treadmill ambulation associated with greater symptom relief than flexion exercises plus treadmill walking in adults with lumbar spinal stenosis (level 2 [mid-level] evidence)
§based on small randomized trial with baseline differences
§58 adults ≥ 50 years old with symptomatic lumbar spinal stenosis were randomized to 1 of 2 treatments provided via physical therapy sessions lasting 45-60 minutes twice weekly for 6 weeks
§manual physical therapy plus exercise and walking group received
§manual physical therapy interventions and exercise techniques based on underlying impairments identified by treating physical therapist including thrust and nonthrust manipulation of spine and lower extremity joints, manual stretching, and muscle strengthening exercises
§instruction on exercises to address impairments in mobility, strength, and/or coordination
§lumbar flexion exercises
§body-weight supported treadmill ambulation
§flexion exercise plus walking group received
§lumbar flexion exercises
§progressive treadmill walking program
§subtherapeutic ultrasound
§baseline differences included
§more women in flexion exercise plus walking group (57%) vs. manipulation plus exercises group (33%) (p = 0.06 for baseline difference)
§higher rate of hip or knee osteoarthritis in flexion exercise plus walking group (62%) vs. manipulation plus exercises group
§scores on the global rating of change (GRC) scale (score range -7 [very great deal worse] to +7 [very great deal better]) were dichotomized based on perceived recovery, with scores of 3 (「somewhat better」) or greater defining improvement
§comparing manipulation plus exercises vs. flexion exercise plus walking
§perceived recovery at 6 weeks in 79% vs. 41% (p = 0.0015, NNT 3)
§perceived recovery at 1 year in 62% vs. 41% (not significant)
§no significant differences between groups in disability or walking distance at 6 weeks or 1 year
§Reference - Spine 2006 Oct 15;31(22):2541
§DynaMed commentary -- The design of this study does not allow conclusions to be made regarding efficacy for specific components of the intervention.
ocycling associated with similar improvements in disability and pain at 3-6 weeks as treadmill walking with body weight support in patients with lumbar spinal stenosis (level 2 [mid-level] evidence)
§based on randomized trial with high loss to follow-up
§68 adults (mean age 58 years) with symptomatic lumbar spinal stenosis for ≥ 12 weeks were randomized to treadmill walking with body weight support vs. cycling twice weekly for 6 weeks
§29% patients lost to follow-up at 6 weeks
§disability scores improved from baseline in overall analysis (p < 0.001)
§no significant difference in
§improvement of Oswestry Disability Index score
§improvement in pain score
§patient-perceived benefit
§walking ability (of ≥ 800 meters)
§Reference - Aust J Physiother 2007;53(2):83
·physical therapy associated with similar improvement in function up to 2 years compared to surgical decompression in adults with lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on randomized trial with high crossover rate
o169 adults with symptomatic lumbar spinal stenosis randomized to physical therapy vs. surgical decompression and evaluated at 10 weeks, and 6, 12, and 24 months
ophysical therapy intervention focused on lumbar flexion and general conditioning exercises, and patient education (mean number of sessions 8.4)
o57% of physical therapy group crossed over to surgery during study period
ono significant differences in physical function
§at any time point (measured by Short Form-36 Health Survey)
§in sensitivity analyses to account for high crossover rate from physical therapy to surgery
oReference - Ann Intern Med 2015 Apr 7;162(7):465EBSCOhost Full Text, editorial can be found in Ann Intern Med 2015 Apr 7;162(7):518EBSCOhost Full Text, summary for patients can be found in Ann Intern Med 2015 Apr 7;162(7)EBSCOhost Full Text
·home exercise program may not improve symptoms in adults with neurogenic claudication (level 2 [mid-level] evidence)
obased on randomized trial with baseline differences
o76 adults ≥ 50 years old with limited walking ability due to neurogenic claudication symptoms randomized to home exercises twice daily for 6 weeks plus advice and education vs. advice and education alone (control)
ohome exercises consisted of flattening of lumbar lordosis, lumbar flexion, abdominal muscle activation, trunk muscle strengthening, and aerobic fitness
oall 37 patients with available magnetic resonance imaging (MRI) data had lumbar spinal stenosis
opatients in control group were younger (mean difference 5 years) and had longer duration of symptoms (mean difference 6.5 years) (no p values reported)
ono significant differences in neurogenic claudication symptom severity, physical function, pain, or walking tolerance at 8 weeks
oReference - PLoS One 2013;8(9):e72878EBSCOhost Full Text
Walking Supports·wheeled walker set to induce lumbosacral flexion reported to improve walking and reduce pain in some patients (level 3 [lacking direct] evidence)
obased on case series
o52 patients with imaging-confirmed spinal stenosis were treated with wheeled walker set to induce lumbosacral flexion
oimprovement in ambulation considered excellent in 30 (58%) and good in 7 (13%)
oamong 48 patients with neurogenic pain, pain relief considered excellent in 22 (46%) and good in 11 (23%)
oReference - J Fam Pract 2008 Apr;57(4):257EBSCOhost Full Text
·use of walking stick may not improve walking performance or posture in patients with neurogenic claudication (level 2 [mid-level] evidence)
obased on small randomized trial
o46 adults (mean age 71 years) with neurogenic claudication were randomized to home use of walking stick vs. no walking stick for 2 weeks
ono significant differences in symptom severity, function scores, or psychological scores after 2 weeks of stick vs. no stick
oat 2 weeks, 40 adults randomized to shuttle walking test with stick vs. without stick, then crossed over to other group
ono significant difference in walking performance or spinal flexion on shuttle walking test between groups
oReference - Arch Phys Med Rehabil 2010 Jan;91(1):15
Lumbosacral Corset·corsets may help patients maintain posture of slight lumbar flexion (but should be worn for limited hours/day to avoid atrophy of paraspinal muscles)2
·North American Spine Society (NASS) states use of lumbosacral corset may increase walking distance and decrease pain in patients with lumbar spinal stenosis, but there is no evidence that results are sustained after removal of brace (NASS Grade B)3
·The Lumbar Spinal Stenosis Consensus Group states there is little evidence supporting use of axial bracing for treatment of neurogenic claudication and spinal stenosis; if instability suspected, bracing as treatment for neurogenic claudication related to spinal segmental motion may be helpful (LSSCG Grade C, Level II, Consensus Moderate) (Pain Pract 2019 Mar;19(3):250)
·lordosis-reducing lumbar spinal stenosis belt is not more effective than traditional lumbar support for improving walking distance in patients with neurogenic claudication due to degenerative lumbar spinal stenosis (level 1 [likely reliable] evidence)
obased on randomized trial
o104 adults (mean age 71 years) with neurogenic claudication, degenerative lumbar spinal stenosis, and limited walking ability were randomized to a lordosis-reducing lumbar spinal stenosis belt vs. lumbar support
§lordosis-reducing lumbar spinal stenosis belt had waist strap and 2 straps that wrapped around each upper thigh, with an inflatable rubber diaphragm to provide comfortable pressure below apex of sacrum
§lumbar support wrapped around lower lumbar spine
owalking distance measured using self-paced walking test (SPWT); minimum clinically important difference (MCID) defined as ≥ 30% improvement from baseline
ofollow-up assessment was within a week of baseline assessment; 93.3% of adults completed trial and were included in analyses
ocomparing lumbar spinal stenosis belt vs. lumbar support
§mean improvement in walking distance 125 m vs. 167.1 m (not significant)
§≥ 30% mean improvement in walking distance in 62% vs. 82% (p = 0.087)
§≥ 50% mean improvement in walking distance in 60% vs. 78% (not significant)
§discomfort from belt/support wear in 28% vs. 2% (no p value reported)
oReference - Spine J 2019 Mar;19(3):386
Other Nonoperative Treatments·North American Spine Society (NASS) states there is insufficient evidence to recommend for or against any of the following for treatment of lumbar spinal stenosis (NASS Grade I)3
ospinal manipulation
otraction
oelectrical stimulation
otranscutaneous electrical nerve stimulation (TENS)
oacupuncture
·acupuncture might be more effective for improving function compared to exercise in patients with lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on quasi-randomized trial
o119 Japanese adults (mean age 70 years) awaiting surgical treatment for L5 root radiculopathy associated with lumbar spinal stenosis were assigned to 4 weeks of medication vs. exercise vs. acupuncture
§medication consisted of acetaminophen 900 mg 3 times daily
§exercise consisted of 6 sets of 10 repetitions per day of back flexion exercises (instructions on how to perform from physical therapist); manual was also provided describing flexion exercise, and evidence-based information on treatment and prevention of lumbar spinal stenosis
§acupuncture performed 5 times (twice in first week, then once weekly from weeks 2-4)
oprimary outcomes measured with Zurich claudication questionnaire (ZCQ) which consists of 3 subscales including symptom severity (score range 1-5 points), physical function (score range 1-4 points), and patient satisfaction (score range 1-4); higher score indicates greater disability, and minimally clinically important difference for symptom severity and physical function defined as ≥ 0.8 points
omean change in ZCQ physical function score
§-0.15 points with medication (p = 0.09 vs. exercise)
§+0.07 points with exercise
§-2.1 points with acupuncture (p = 0.02 vs. exercise, and p = 0.06 vs. medication)
omean improvement in ZCQ symptom severity score (no significant differences among groups)
§0.19 points with medication
§0.17 points with exercise
§0.42 points with acupuncture
omean ZCQ surgery satisfaction score
§2.78 points with medication (p = 0.09 vs. exercise)
§2.48 points with exercise
§2.16 points with acupuncture (p = 0.0004 vs. medication, and p = 0.06 vs. exercise)
oReference - BMC Complement Altern Med 2018 Jan 19;18(1):19full-text
MedicationsRecommendations·North American Spine Society (NASS) states there is insufficient evidence to recommend for or against pharmacological treatment in management of spinal stenosis (NASS Grade I)3
·Lumbar Spinal Stenosis Consensus Group states there is low-quality evidence for using nonsteroidal anti-inflammatory drugs (NSAIDs), neuropathic pain medications (membrane-stabilizing agents [MSAs]), and opioids as monotherapy in the management of spinal stenosis; these medications should be employed judiciously, balancing patient’s individual risks and benefits (LSSCG Grade D, Level I, Consensus Strong) (Pain Pract 2019 Mar;19(3):250)
Analgesics·pain usually managed with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), but neither approach has been evaluated in randomized trials in patients with lumbar spinal stenosis2 (no randomized trials identified in MEDLINE search 2019 Aug 15 )
·consider mild narcotic analgesics in patients who are intolerant of NSAIDs, or with pain unresponsive to NSAIDs2
Calcitonin·calcitonin injections may not improve pain or walking performance in patients with lumbar spinal stenosis and neurogenic claudication (level 2 [mid-level] evidence)
obased on Cochrane review of trials with methodologic limitations
osystematic review of 21 randomized trials evaluating nonoperative treatments in 1,851 patients with lumbar spinal stenosis and neurogenic claudication
o6 trials with 231 patients compared calcitonin injections vs. placebo (5 trials) or paracetamol (1 trial)
oall 6 trials had ≥ 1 limitation including
§unclear randomization method
§unclear or lack of allocation concealment
§lack of or unclear blinding
ono significant differences in pain or walking performance in any trial (regardless of mode of administration)
ominor adverse effects of calcitonin injections reported in 40%-89% of patients, including nausea and rash
oReference - Cochrane Database Syst Rev 2013 Aug 30;(8):CD010712
osimilar results found in systematic review of same trials (Spine (Phila Pa 1976) 2012 May 1;37(10):E609)
Anticonvulsants (Gabapentinoids)·gabapentinoids are reported to be effective for neuropathic pain as they bind to calcium channels (alpha 2, delta 1 receptors), inhibiting synapse secretion of pain-related mediators (Curr Opin Anaesthesiol 2017 Oct;30(5):598)
·efficacy of gabapentinoids in randomized trials
oaddition of gabapentin to standard therapy may improve pain scores and sensory deficits in patients with spinal stenosis (level 2 [mid-level] evidence)
§based on small randomized trial without placebo control
§55 patients with lumbar spinal stenosis and neurologic claudication randomized to gabapentin plus standard therapy vs. standard therapy alone
§gabapentin started at 900 mg/day in 3 divided doses and increased weekly by 300 mg according to patient's response (maximum 2,400 mg/day)
§standard therapy included physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and lumbosacral bracing
§gabapentin associated with improved pain scores (p = 0.006) and recovery of sensory deficit (p = 0.04)
§Reference - Spine 2007 Apr 20;32(9):939
§no additional trials evaluating gabapentin identified in systematic review (Can J Anaesth 2010 Jul;57(7):694EBSCOhost Full Text)
opregabalin does not appear effective for improving pain or function at 10 days in patients with lumbar spinal stenosis and neurogenic claudication symptoms (level 2 [mid-level] evidence)
§based on small randomized crossover trial
§29 adults > 50 years old with radiographically confirmed lumbar spinal stenosis and neurogenic claudication symptoms for ≥ 3 months were randomized to pregabalin vs. active placebo orally twice daily for 14 days, then crossed over to alternate treatment after 7-day washout period
§pregabalin started at 75 mg twice daily on day 1, increased to 150 mg twice daily on day 4, then decreased to 75 mg twice daily on day 11
§diphenhydramine 6.25 mg twice daily used as active placebo and administered following same 2-step titration and taper regimen
§outcome assessments performed at baseline and at day 10 of each treatment period
§91% completed trial and were included in analyses
§no significant differences between groups in
§time to first moderate pain during treadmill test
§pain intensity at rest or after treadmill test
§distance walked
§functional disability
§most common adverse events with pregabalin included dizziness, somnolence, and peripheral edema
§Reference - Neurology 2015 Jan 20;84(3):265full-text
opregabalin may not be effective long-term for chronic lumbosacral radiculopathy pain (level 2 [mid-level] evidence)
§based on randomized trial with allocation concealment not stated
§215 patients with chronic lumbosacral radiculopathy who responded to flexible dose pregabalin (150-600 mg/day) during entry phase were randomized to double-blind optimal dose pregabalin vs. placebo for 5 weeks
§patients had pain radiating to calf or foot due to spinal stenosis or herniated disk
§30% pain reduction in 58% patients in single-blind phase
§no significant difference in double-blind treatment phase in
§time to loss of treatment response (primary outcome)
§mean change in pain score
§withdrawal due to adverse effects
§Reference - Pain 2010 Sep;150(3):420, editorial can be found in Pain 2010 Sep;150(3):380
ocombination therapy with pregabalin plus limaprost may be no more effective than monotherapy with pregabalin or limaprost for improving disability, quality of life, or walking ability in adults with degenerative lumbar spinal stenosis (level 2 [mid-level] evidence)
§based on randomized trial with high loss to follow-up
§182 adults aged 20-75 years with degenerative lumbar spinal stenosis were randomized to 1 of 3 interventions 3 times daily for 8 weeks
§pregabalin 75 mg
§limaprost 5 mcg
§combination of limaprost plus pregabalin
§69.2% of adults completed 8-week trial, but all patients were included in intention-to-treat analyses
§no significant differences among groups during follow-up assessments over 8-week period for mean improvement in Oswestry Disability Index, visual analog scale (VAS) for leg pain, European Quality of Life-5 dimensions scale, or initial claudication distance
§adverse events occurred in
§50% with pregabalin (p = 0.002 vs. limaprost, NNH 2)
§14.8% with limaprost
§26.2% with combination of limaprost plus pregabalin (p = 0.009 vs. limaprost, NNH 8)
§Reference - Spine J 2016 Jun;16(6):756
·efficacy of gabapentinoids in observational studies and uncontrolled trials
ogabapentin or pregabalin (membrane-stabilizing agents [MSAs]) might not improve quality of life in patients with lumbar spinal stenosis and neurogenic claudication (level 2 [mid-level] evidence)
§based on retrospective cohort study
§2,805 adults > 45 years old with lumbar spinal stenosis and neurogenic claudication were treated with MSAs vs. without MSAs and followed for 4 months
§all adults received additional conservative treatments at the discretion of their health care provider, including but not limited to, other medications, acupuncture, and exercise
§propensity score matching used to account for baseline demographic differences between groups
§quality of life outcome measures included
§EuroQOL-5 Dimensions (EQ-5D) (each dimension scored 1-3 points with lower score indicating greater severity, minimum clinically important difference [MCID] 0.1)
§Patient Health Questionnaire-9 (PHQ9) (score range 0-27 points with higher score indicating greater severity, MCID 5 points)
§Pain Disability Questionnaire (PDQ) (score range 0-150 points with higher score indicating greater disability, MCID of 16 points)
§compared to baseline, both groups had significant improvements in all outcome measures
§comparing MSA vs. no MSA at 4 months, mean improvement from baseline on
§EQ-5D was 0.11 points vs. 0.06 points (p = 0.049); significant, but results of questionable clinical significance
§PHQ-9 was 1.3 points vs. 1.3 points (not significant)
§PDQ was 5.8 points vs. 4.2 points (not significant)
§Reference - Global Spine J 2016 Mar;6(2):139full-text
opregabalin reported to improve pain, function and sleep quality at 6 weeks in patients with neuropathic leg pain and neurological intermittent claudication due to lumbar spinal stenosis (level 3 [lacking direct] evidence)
§based on uncontrolled trial
§104 patients with neuropathic leg pain and neurological intermittent claudication due to lumbar spinal stenosis were treated with pregabalin and followed for 6 weeks
§at baseline, all patients had symptoms refractory to NSAIDs for ≥ 1 month
§pregabalin started at 25 mg/day and gradually increased weekly over 6 weeks up to 150 mg/day until 100-mm visual analog scale (VAS) pain score of < 30 mm achieved
§100-mm VAS used to evaluate leg pain and sleep quality, and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) used to evaluate low back-related activities of daily living (ADL)/quality of life (QOL) (5-dimension questionnaire with score range of 0-100, with higher score indicating better health status)
§96 patients included in safety analyses (8 patients with comorbidities [such as diabetes or peripheral vascular disease] or inaccurate medical history were excluded)
§57 patients included in efficacy analyses (an additional 39 patients with insufficient data/evaluations and/or gap in date of introduction of pregabalin were excluded)
§pregabalin associated with improved
§leg pain (p < 0.0001)
§sleep quality (p = 0.0006)
§JOABPEQ scores for
§pain-related disorders (p < 0.0001)
§lumbar spine dysfunction (p = 0.031)
§gait disturbance (p = 0.028)
§psychological disorders (p = 0.014)
§among patients in safety analyses, 12.5% reported minor treatment-related adverse events, including ataxia (in 3.1%), dizziness (in 2.1%), nausea (in 2.1%), and edema (in 1%)
§Reference - Pain Res Manag 2016;2016:5079675full-text
Surgery and ProceduresSurgerySurgical indications and recommendations·surgery is generally indicated in patients with intolerable symptoms or in patients with persistent symptoms despite nonoperative management, with primary goal of decompressing the central spinal canal and neural foramina to eliminate pressure on spinal nerve roots2
·North American Spine Society (NASS) recommendations on surgery3
oin patients with degenerative lumbar spinal stenosis, consider surgical treatment to provide long-term (≥ 4 years) improvement in symptoms (NASS Grade C)
oin patients with moderate-to-severe symptoms of lumbar spinal stenosis, consider decompressive surgery to improve outcomes (NASS Grade B))
oin patients ≥ 75 years old with lumbar spinal stenosis, consider surgical decompression as an option (NASS Grade C); based on evidence for similar benefit as in patients aged 65-74 years
oin patients with leg-predominant symptoms without instability, consider decompression alone (without lumbar fusion) (NASS Grade B)
oinsufficient evidence to recommend for or against placement of interspinous process spacing device (NASS Grade I)
Decompressive SurgeryComparing decompressive surgery to nonoperative management·decompressive surgery with or without fusion may provide slight improvement in disability at > 2 years compared to nonoperative management in adults with symptomatic lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on Cochrane review of trials without blinding or with small sample sizes
osystematic review of 5 randomized trials comparing surgical vs. nonsurgical treatments in 643 adults with symptomatic lumbar spinal stenosis
ocomparing decompressive surgery with or without fusion to usual conservative care
§for outcome of disability (assessed using Oswestry Disability Index, scale 0%-100%, with lower score indicating less disability)
§decompressive surgery associated with reduced disability at 2 years (mean difference -4.43%, 95% CI -7.91% to -0.96%) in analysis of 2 trials with 315 patients
§no significant differences
§at 6 months in analysis of 2 trials with 349 patients
§at 1 year in analysis of 2 trials with 340 patients
§decompressive surgery nonsignificantly decreased pain at 4 and 10 years in 1 trial with 31 patients
§surgery-associated complications
§intraoperative (mainly dural tear or spinal fluid leak) and postoperative (including wound hematoma, infection and other unspecified problems) complications 10% each in 1 trial with 138 patients
§intraoperative or postoperative complications in 24% in 1 trial with 50 patients
§4-year reoperation rate 13% in 1 trial with 138 patients
oReference - Cochrane Database Syst Rev 2016 Jan 29;(1):CD010264
·select included trials in Cochrane review
odecompressive laminectomy for spinal stenosis with radiculopathy might have benefit over nonsurgical therapy for improving pain and function (level 2 [mid-level] evidence)
§based on 2 randomized trials each with high crossover rates and 2 prospective cohort studies evaluated on as-treated basis
§Spine Patient Outcomes Research Trial [SPORT] enrolled patients with spinal stenosis and radiculopathy in 1 of 4 studies
§randomized trial comparing surgery vs. nonoperative treatment in patients with degenerative spondylolisthesis who consented to randomization
§randomized trial comparing surgery vs. nonoperative treatment in patients without degenerative spondylolisthesis who consented to randomization
§prospective observational study in patients with degenerative spondylolisthesis who consented to follow-up but selected treatment course without randomization
§prospective observational study in patients without degenerative spondylolisthesis who consented to follow-up but selected treatment course without randomization
§inclusion criteria for SPORT study were
§age > 18 years
§neurogenic claudication or radicular leg symptoms
§spinal stenosis demonstrated on cross-sectional imaging (and degenerative spondylolisthesis on standing lateral x-rays for the 2 spondylolisthesis studies)
§persistent symptoms for at least 12 weeks
§determination that patients were surgical candidates
§surgery was standard posterior decompressive laminectomy with or without bilateral single-level fusion (iliac crest bone grafting with or without posterior pedicle screw instrumentation)
§nonoperative treatment included active physical therapy, education/counseling with home exercise instruction, and nonsteroidal anti-inflammatory drugs if tolerated
§in SPORT trial of patients with degenerative spondylolisthesis
§304 patients randomized to surgery vs. conservative treatment
§of 159 patients randomized to surgery, only 57% had surgery at 1 year and 64% at 2 years
§of 145 patients randomized to nonsurgical treatment, 44% had surgery at 1 year and 49% at 2 years
§303 patients included in observational cohort
§173 patients chose surgery, of whom 97% had surgery at 1 year and 97% at 2 years
§130 chose nonsurgical treatment, of whom 17% had surgery at 1 year and 25% at 2 years
§no significant difference in primary outcomes in intention-to-treat analysis of randomized trial
§with such high crossover rates, authors combined randomized and nonrandomized cohorts and analyzed as observational study according to treatment actually received
§372 patients had surgery
§235 patients had nonsurgical treatment
§comparing surgery vs. nonsurgical treatment at 2 years in combined observational as-treated analysis
§mean change in bodily pain score 29.9 vs. 11.7 (p < 0.05) on 0-100 scale with higher score indicating less severe symptoms
§mean change in physical function score 26.6 vs. 8.3 (p < 0.05) on 0-100 scale with higher score indicating less severe symptoms
§mean change in disability index -24.2 vs. -7.5 (p < 0.05) on 0-100 scale with lower score indicating less severe symptoms
§treatment satisfaction (very or somewhat satisfied with symptoms) in 68.8% vs. 32.2% (p < 0.05)
§self-rated major improvement in 74.1% vs. 24.1% (p < 0.05)
§Reference - SPORT trial (N Engl J Med 2007 May 31;356(22):2257full-text), editorial can be found in N Engl J Med 2007 May 31;356(22):2239, commentary can be found in N Engl J Med 2007 Sep 20;357(12):1255, BMJ 2007 Nov 10;335(7627):949
§in SPORT trial of patients without degenerative spondylolisthesis
§289 patients randomized to surgery vs. conservative treatment
§of 138 patients randomized to surgery, only 63% had surgery at 1 year and 67% at 2 years
§of 151 patients randomized to nonsurgical treatment, 42% had surgery at 1 year and 43% at 2 years
§365 patients included in observational cohort
§219 patients chose surgery, of whom 95% had surgery at 1 year and 96% at 2 years
§146 chose nonsurgical treatment, of whom 17% had surgery at 1 year and 22% at 2 years
§in intention-to-treat analyses of randomized trial
§no significant differences in any of 3 primary outcomes (bodily pain, physical function, Oswestry Disability Index) at 1 year
§no significant differences in 2 of 3 primary outcomes (physical function, Oswestry Disability Index) at 2 years
§small but statistically significant difference favoring surgery in bodily pain at 2 years
§with such high crossover rates, authors combined randomized and nonrandomized cohorts and analyzed as observational study according to treatment actually received
§comparing surgery vs. nonsurgical treatment at 2 years in combined observational as-treated analysis
§mean change in bodily pain score 26.9 vs. 13.3 (p < 0.05) on 0-100 scale with higher score indicating less severe symptoms
§mean change in physical function score 23 vs. 11.8 (p < 0.05) on 0-100 scale with higher score indicating less severe symptoms
§mean change in disability index -20.5 vs. -9.3 (p < 0.05) on 0-100 scale with lower score indicating less severe symptoms
§treatment satisfaction (very or somewhat satisfied with symptoms) in 68.2% vs. 29.6% (p < 0.05)
§self-rated major improvement in 62.9% vs. 28.7% (p < 0.05)
§Reference - SPORT trial (N Engl J Med 2008 Feb 21;358(8):794full-text)
§surgery maintained greater improvement at 4-year follow-up in as-treated analysis (Spine (Phila Pa 1976) 2010 Jun 15;35(14):1329full-text)
osurgical decompression associated with similar improvement in function at 2 years compared to physical therapy in adults with lumbar spinal stenosis (level 2 [mid-level] evidence)
§based on randomized trial with high crossover rate
§169 adults with symptomatic lumbar spinal stenosis randomized to surgical decompression vs. physical therapy and evaluated at 10 weeks, and 6, 12, and 24 months
§physical therapy intervention focused on lumbar flexion and general conditioning exercises, and patient education (mean number of sessions 8.4)
§57% of physical therapy group crossed over to surgery during study period
§no significant differences in physical function
§at any time point (measured by Short Form-36 Health Survey)
§in sensitivity analyses to account for high crossovers rate from physical therapy to surgery
§Reference - Ann Intern Med 2015 Apr 7;162(7):465EBSCOhost Full Text, editorial can be found in Ann Intern Med 2015 Apr 7;162(7):518EBSCOhost Full Text, summary for patients can be found in Ann Intern Med 2015 Apr 7;162(7)EBSCOhost Full Text
Minimally invasive surgical techniques·minimally invasive lumbar decompression (MILD Procedure)
oMILD procedure is a fluoroscopically-guided procedure that removes small portions of lamina and selectively debulks hypertrophic ligamentum flavum to restore space in the spinal canal; physicians require certification to perform procedure, which is generally performed in about 1 hour and uses local anesthetic and moderate sedation (Pain Physician 2016 May;19(4):229EBSCOhost Full TextPDFEBSCOhost Full Text, MILD procedure informationEBSCOhost Full Text)
oMILD procedure may improve pain, function, and patient satisfaction at 1 year compared to epidural steroid injections in adults with lumbar spinal stenosis and neurogenic claudication (level 2 [mid-level] evidence)
§based on randomized trial with blinding of outcome assessors not stated
§302 adults (mean age 75 years) with lumbar spinal stenosis and neurogenic claudication for ≥ 3 months that was refractory to conservative therapies were randomized to MILD procedure vs. epidural steroid injection (triamcinolone acetonide or methylprednisolone acetate 40-80 mg up to 4 times) and followed for 1 year
§274 patients received their assigned treatment (96% of those randomized to MILD procedure and 86% of those randomized to epidural steroid injection), 272 (90%) were included in analyses
§comparing MILD procedure vs. epidural steroid injection at 1 year
§improved back and leg pain in 57.3% vs. 27.1% (p < 0.001, NNT 4), defined as ≥ 2-point improvement on Numeric Pain Rating Scale (NPRS)
§improved functional disability in 58% vs. 27.1% (p < 0.001, NNT 4), defined as ≥ 10-point improvement on Oswestry Disability Index (ODI)
§improved symptom severity in 51.7% vs. 31.8% (p < 0.001, NNT 5), defined as ≥ 0.5-point improvement on Zurich Claudication Questionnaire (ZCQ)
§improved physical function in 44.1% vs. 17.8% (p < 0.001, NNT 4), defined as ≥ 0.05-point improvement on ZCQ
§improved patient satisfaction in 61.5% vs. 33.3% (p < 0.001, NNT 4), defined as ZCQ score ≤ 2.5
§device- or procedure-related adverse events in 2 patients vs. 3 patients (not significant)
§consistent results in interim analysis at 6 months
§MILD procedure took significantly longer (mean 43 minutes) and required different types of anesthesia (mostly MAC sedation) compared to epidural steroid injections
§Reference - MiDAS ENCORE trial (Pain Physician 2016 May;19(4):229EBSCOhost Full TextPDFEBSCOhost Full Text)
§MILD procedure reported to have sustained improvements in pain, function, and patient satisfaction at 2 years (level 3 [lacking direct] evidence)
§based on follow-up study of randomized trial above
§99 adults out of initial 143 who had MILD procedure completed 2-year follow-up
§compared to baseline, mean improvement in
§ODI 22.7 points (clinically meaningful improvement defined as ≥ 10-points)
§NPRS 3.6 points (clinically meaningful improvement defined as ≥ 2-points)
§ZCQ symptom severity subscale 1 point (clinically meaningful improvement defined as ≥ 0.05 points)
§ZCQ physical function subscale 0.8 points (clinically meaningful improvement defined as ≥ 0.05 points)
§at 2 years, mean ZCQ satisfaction score was 2 points (clinically meaningful threshold defined as ZCQ score of ≤ 2.5 points)
§Reference - Reg Anesth Pain Med 2018 Oct;43(7):789full-text
·minimally invasive unilateral laminotomy reported to have lower rates of reoperation and slip progression, and greater patient satisfaction compared to traditional open laminectomy in patients with lumbar spinal stenosis associated with stable low-grade degenerative spondylolisthesis (level 3 [lacking direct] evidence)
obased on systematic review with indirect comparisons
osystematic review of 37 studies evaluating minimally invasive unilateral laminotomy or traditional open laminectomy in 1,156 patients with lumbar spinal stenosis associated with stable low-grade degenerative spondylolisthesis
ono identified studies directly compared minimally invasive unilateral laminotomy to open laminectomy; therefore, a formal between group comparison (meta-analysis) could not be performed
oclinical heterogeneity among studies included variability in type of procedure performed, definition of spondylolisthesis, outcomes assessed, and duration of follow-up
oindirect pooled comparisons of minimally invasive unilateral laminotomy vs. open laminectomy
§secondary fusion procedure in 3.3% vs. 12.8%
§total reoperation in 5.8% vs. 16.3%
§slip progression in 0% vs. 72%
§satisfactory outcome in 76% vs. 62.7%
ocomplications ranged from 0%-8.1% with minimally invasive unilateral laminotomy vs. 0%-5.4% with open laminectomy
oReference - Neurosurgery 2017 Mar 1;80(3):355
·microdecompression surgery and open laminectomy appear to have similar functional outcomes at 1 year in adults with central lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on prospective cohort study
o885 adults (mean age 68 years) with central lumbar spinal stenosis having surgery at 1-2 lumbar levels with microdecompression (53.2%) or open laminectomy (46.8%) were assessed
opropensity score for surgical technique was calculated for each adult based on multiple demographic and clinical factors
o246 adults from each group were included in propensity-matched analysis (tries to reduce bias from confounding factors)
ominimally clinically important difference (MCID) defined as improvement of ≥ 8 points on Oswestry Disability Index (ODI) score from baseline to 12 months
oequivalence defined as upper and lower bounds of 95% CI < 8 points for difference between groups in ODI score at 12 months
ocomparing microdecompression vs. laminectomy
§mean improvement in ODI score 18.4 points vs. 17.1 points in overall analysis (mean difference 1.28 points, 95% CI -1.36 to 3.92, equivalence met)
§mean improvement in ODI score 18.5 points vs. 17 points in propensity-matched analysis (mean difference 1.5, 95% CI -2.41 to 5.49, equivalence met)
omicrodecompression associated with shorter length of hospital stay
ono significant differences in quality of life or rate of complications in propensity-matched analysis
oReference - BMJ 2015 Apr 1;350:h1603full-text
Efficacy of other surgical techniques·interspinous process decompression
ointerspinous spacer may not reduce pain or disability, and may increase reoperation rate compared to decompression surgery in patients with lumbar spinal stenosis (level 2 [mid-level] evidence)
§based on Cochrane review of trials with methodologic limitations
§systematic review of 24 randomized trials comparing surgery vs. no treatment, placebo or sham surgery, or another surgical technique in 2,352 patients with symptomatic lumbar spinal stenosis and neurogenic claudication
§3 trials compared interspinous spacer to decompression surgery; select trials included below
§all trials comparing interspinous spacer to decompression surgery had unclear allocation concealment, inadequate blinding of patients, or early termination
§comparing interspinous spacer to decompression
§no significant differences in
§pain at ≥ 12 months in analysis of 3 trials with 328 patients
§disability at ≥ 12 months in analysis of 3 trials with 327 patients
§duration of hospital stay in analysis of 2 trials with 240 patients
§interspinous spacer associated with higher reoperation rate in analysis of 3 trials with 326 patients
§risk ratio 3.95 (95% CI 2.12-7.37)
§NNH 2-12 with reoperation rate 7% in decompression group
§Reference - Cochrane Database Syst Rev 2016 Nov 1;(11):CD012421
§interspinous process device does not appear to improve recovery and may increase reoperation rate compared to conventional surgical decompression in adults with lumbar spinal stenosis (level 2 [mid-level] evidence)
§based on randomized trial with inadequate blinding of patients
§159 adults aged 40-85 years with lumbar spinal stenosis at 1 or 2 levels who failed conservative treatment were randomized to interspinous process device implantation vs. conventional surgical decompression and followed for 1 year
§successful recovery was defined as improvement in ≥ 2 of 3 subscales on Zurich Claudication Questionnaire (decrease of ≥ 0.5 points on symptom severity or physical function subscales, or score < 2.5 on patient satisfaction subscale)
§successful blinding of adults in 67% in device group vs. 86% in standard decompression group (no p value reported)
§89% of adults were included in analyses
§comparing interspinous process device vs. conventional surgical decompression
§successful recovery at 8 weeks in 63% vs. 72% (not significant)
§successful recovery at 1 year in 66% vs. 69% (not significant)
§reoperation due to lack of recovery in 29% vs. 8% (p < 0.001, NNH 4)
§mean operating time 24 minutes vs. 43 minutes (p < 0.001)
§no significant differences in disability, leg or back pain, walking capacity, length of hospital stay, or health-related quality of life
§Reference - FELIX trial (BMJ 2013 Nov 14;347:f6415full-text)
§interspinous process decompression system (X-STOP) may be as effective as minimally invasive decompression for lumbar spinal stenosis, but X-STOP associated with increased reoperation rate (level 2 [mid-level] evidence)
§based on randomized trial with unclear blinding and early termination
§96 adults ≥ 50 years old with neurogenic intermittent claudication symptoms due to lumbar spinal stenosis at 1-2 levels for ≥ 6 months were randomized to interspinous process decompression system (X-STOP) vs. minimally invasive decompression and followed for 2 years
§all adults had neurogenic intermittent claudication symptoms within 250-meter walking distance
§all adults experienced symptom relief through spinal flexion
§trial was terminated early at planned interim analysis due to increased reoperation rate with X-STOP, but no predefined stopping rule reported
§84% completed follow-up, all adults included in analyses
§no significant differences between groups in
§symptom severity and physical function (assessed on Zurich Claudication Questionnaire)
§disability (assessed on Oswestry Disability Index)
§quality of life (assessed on EuroQol 5-dimensional questionnaire utility index)
§leg and back pain (assessed on numerical rating scale 11)
§X-STOP and minimally invasive decompression each associated with significantly improved outcomes from baseline
§reoperation for persistent or recurrent symptoms in 25% with X-STOP vs. 4.9% with minimally invasive decompression (p < 0.05, NNH 5)
§Reference - Spine (Phila Pa 1976) 2015 Jan 15;40(2):77, editorial can be found in Spine (Phila Pa 1976) 2015 Jan 15;40(2):86
odecompression surgery plus fusion may slightly increase disability compared to interspinous spacer in patients with lumbar spinal stenosis (level 2 [mid-level] evidence)
§based on Cochrane review with confidence interval including differences that may not be clinically important
§systematic review of 24 randomized trials comparing surgery vs. no treatment, placebo or sham surgery, or another surgical technique in 2,352 patients with symptomatic lumbar spinal stenosis and neurogenic claudication
§all trials compared ≥ 2 surgical techniques; 2 trials compared decompression plus fusion to interspinous spacer
§comparing decompression plus fusion to interspinous spacer
§decompression plus fusion associated with
§greater disability at ≥ 12 months (mean difference [MD] -5.72 points [range 0-100 points], 95% CI -1.28 to -10.15 points) in analysis of 2 trials with 308 patients, but confidence interval includes differences that may not be clinically important
§longer duration of hospital stay (MD 1.58 days, 95% CI 0.9-2.27 days) in analysis of 2 trials with 382 patients
§no significant differences in
§pain at ≥ 12 months in analysis of 2 trials with 308 patients
§reoperation rate in 1 trial with 322 patients
§Reference - Cochrane Database Syst Rev 2016 Nov 1;(11):CD012421
·addition of fusion to decompression surgery
oaddition of lumbar fusion to decompression surgery increases length of hospital stay (level 1 [likely reliable] evidence), and may not improve pain, disability or reoperation rate in patients with lumbar spinal stenosis (level 2 [mid-level] evidence)
§based on Cochrane review limited by heterogeneity for pain and disability and with wide confidence interval for reoperation rate
§systematic review of 24 randomized trials comparing surgery vs. no treatment, placebo, sham surgery, or another surgical technique in 2,352 patients with symptomatic lumbar spinal stenosis and neurogenic claudication
§all trials compared ≥ 2 surgical techniques
§5 trials compared decompression plus fusion to decompression surgery alone; largest trials included below
§comparing decompression plus fusion to decompression alone
§no significant differences in
§pain at ≥ 12 months in analysis of 4 trials with 380 patients, results limited by significant heterogeneity
§disability at ≥ 12 months in analysis of 3 trials with 335 patients, results limited by significant heterogeneity
§walking ability at ≥ 12 months in analysis of 3 trials with 316 patients, results limited by significant heterogeneity
§reoperation rate (risk ratio 1.25, 95% CI 0.81-1.92) in analysis of 5 trials with 443 patients, but confidence interval includes possibility of benefit or harm
§decompression plus fusion associated with longer duration of hospital stay (mean difference 1.69 days, 95% CI 1.26-2.12 days) in analysis of 2 trials with 295 patients
§Reference - Cochrane Database Syst Rev 2016 Nov 1;(11):CD012421
§addition of lumbar fusion to decompression surgery does not improve function, pain, or quality of life in patients ≥ 50 years old with lumbar spinal stenosis (level 1 [likely reliable] evidence)
§based on randomized trial
§247 adults aged 50-80 years with lumbar spinal stenosis at 1-2 adjacent lumbar vertebral levels and cross-section area of dural sac ≤ 75 mm2 were randomized to decompression plus fusion surgery vs. decompression surgery alone
§all patients had pseudoclaudication in 1 or both legs and back pain with visual analog scale score > 30 (range 0-100 with higher scores indicating more severe pain), and symptom duration > 6 months
§patients were excluded for spondylolysis, degenerative lumbar scoliosis, previous lumbar spinal surgery for spinal stenosis or instability, stenosis due to herniated disk, stenosis not due to degenerative changes, other spinal conditions, or history of vertebral compression fractures in affected segments
§55% had degenerative spondylolisthesis
§92.3% were included in per-protocol analysis
§comparing decompression plus fusion vs. decompression alone at 2 years in per-protocol analyses
§in patients with degenerative spondylolisthesis
§mean Oswestry Disability Index score 29 vs. 27 (not significant)
§satisfaction with surgery in 52% vs. 53% (not significant)
§decrease in back pain in 75% vs. 65% (not significant)
§in patients without degenerative spondylolisthesis
§mean Oswestry Disability Index score 25 vs. 21 (not significant)
§satisfaction with surgery in 64% vs. 68% (not significant)
§decrease in back pain in 79% vs. 82% (not significant)
§decompression plus fusions associated with significantly increased length of hospitalization, operating time, and blood loss
§no significant differences in complications, reoperations, back pain, leg pain, Zurich Claudication Questionnaire score, 6-minute walk test distance, analgesic use for back problems, or quality of life
§consistent results in modified intention-to-treat analysis including 98% of randomized patients (excluded 3 patients inappropriately randomized for age < 50 years, and 2 patients considered too ill for spinal surgery)
§Reference - N Engl J Med 2016 Apr 14;374(15):1413, editorial can be found in N Engl J Med 2016 Apr 14;374(15):1478
§addition of fusion to decompressive laminectomy may slightly improve physical health-related quality of life, but not back pain-related disability, in patients with symptomatic lumbar grade I degenerative spondylolisthesis with lumbar stenosis (level 2 [mid-level] evidence)
§based on randomized trial with baseline differences and without intention-to-treat analysis
§66 adults aged 50-80 years (mean age 67 years, 80% female) with lumbar grade I degenerative spondylolisthesis (degree of spondylolisthesis 3-14 mm) with lumbar stenosis and neurogenic claudication were randomized to decompressive laminectomy plus posterolateral instrumented fusion at single level of spondylolisthesis vs. decompressive laminectomy alone
§patients were excluded for lumbar instability on radiograph, history suggestive of lumbar instability, previous lumbar spinal surgery, or American Society of Anesthesiologists (ASA) class IV-VI disease
§minimum clinically important differences (MCIDs) defined as
§5 points for physical component score of 36-Item Short-Form Health Survey (SF-36) (range 0-100 points, with higher score indicating getter quality of life)
§10 points for Oswestry Disability Index (range 0-100, with higher score indicating greater disability)
§comparing decompression plus fusion vs. decompression alone at baseline
§mean SF-36 physical component score 38.7 vs. 44.7 (p = 0.08)
§ASA class III disease in 11% vs. 0% (p = 0.09)
§mean degree of spondylolisthesis 5.6 mm vs. 6.5 mm (p = 0.1)
§86% completed 2-year follow-up and 68% completed 4-year follow-up
§comparing decompression plus fusion vs. decompression alone at 2 years
§mean improvement in SF-36 physical component score 15.2 vs. 9.5 (p = 0.046)
§> 5-point improvement in SF-36 physical component score at 2 years in 85.7% vs. 70% (not significant)
§mean improvement in Oswestry Disability Index at 2 years 26.3 vs. 17.9 (p = 0.06)
§reoperation within 4 years in 14% vs. 34% (p = 0.05)
§decompression plus fusion associated with significantly increased blood loss and length of hospital stay
§no significant differences at 2 or 4 years in quality of life or disability in additional analysis of 40 patients who refused randomization (17 had decompression plus fusion and 23 had decompression alone)
§Reference - SLIP trial (N Engl J Med 2016 Apr 14;374(15):1424), editorial can be found in N Engl J Med 2016 Apr 14;374(15):1478
§DynaMed commentary -- The statistical analysis should have been adjusted for multiple outcomes, which implies that the results should be interpreted cautiously as p values near 0.05 may overestimate significance. Although there was a borderline significant difference in mean improvement in the SF-36 physical component score at 2 years, this result may be skewed by a higher response in very few patients given the overall size of the trial. The interpretation of the mean improvement is further cautioned by the lack of a statistically significant difference in the percentage of patients reaching a clinically important difference by the MCID.
·bilateral laminotomy associated with higher perceived recovery rate compared to conventional laminectomy in adults with degenerative lumbar stenosis (level 2 [mid-level] evidence)
obased on Cochrane review of trials with unclear or no blinding
osystematic review of 10 randomized trials evaluating posterior decompression techniques that preserve posterior midline structures with ≥ 6-month follow-up in 733 adults with degenerative lumbar stenosis
oduration of follow-up ranged from 9 to 65 months
oleg and back pain measured on 0-10 point visual analog scale (VAS), 0 points = no pain, minimal clinically important difference defined as 1.5 points
opatient-perceived recovery measured by structured interview
ocomparing bilateral laminotomy to conventional laminectomy
§bilateral laminotomy associated with
§higher patient-perceived recovery rate in analysis of 2 trials with 223 adults
§odds ratio (OR) 5.69 (95% CI 2.55-12.71)
§NNT 4-6 with recovery in 66% of conventional laminectomy group
§reduced leg pain (mean difference [MD] -0.29 points, 95% CI -0.48 to -0.11 points) in analysis of 2 trials with 223 adults, results limited by significant heterogeneity
§reduced back pain (MD -0.51 points, 95% CI -0.8 to -0.23 points) in analysis of 2 trials with 223 adults
§reduced disability (MD -2.73 points, 95% CI -4.59 to -0.87 points on 100-point scale, with higher score indicating greater disability) in analysis of 3 trials with 294 adults
§decreased iatrogenic instability in analysis of 3 trials with 294 adults
§OR 0.1 (95% CI 0.02-0.55)
§NNT 13-29 with iatrogenic instability in 8% of conventional laminectomy group
§no significant difference in complications in analysis of 3 trials with 303 adults, results limited by significant heterogeneity
ocomparing unilateral laminotomy to conventional laminectomy
§no significant differences in disability score, recovery, and complications
§unilateral laminotomy associated with nonsignificant reduction in iatrogenic instability (OR 0.28, 95% CI 0.07-1.15) in analysis of 3 trials with 166 adults
ocomparing split-spinous process to conventional laminectomy
§split-spinous process associated with
§reduced leg pain (MD -0.29 points, 95% CI -0.41 to -0.17 points) in analysis of 2 trials with 107 adults, results limited by significant heterogeneity
§nonsignificant reduction in back pain (MD -1.07 points, 95% CI -2.15 to 0 points) in analysis of 2 trials with 107 adults
§no significant differences in disability score and complications
oReference - Cochrane Database Syst Rev 2015 Mar 11;(3):CD010036
·selective decompression plus fusion may be as effective as multi-segmental decompression plus fusion for improving pain and function in patients with multi-segment lumbar spinal stenosis and single-segment degenerative spondylolisthesis (level 2 [mid-level] evidence)
obased on retrospective cohort study
o42 patients with multi-segment lumbar spinal stenosis and single-segment degenerative spondylolisthesis had selective decompression plus fusion or multi-segmental decompression plus fusion and were followed ≥ 3 years
§selective decompression involved precise and limited decompression depending on site and degree of spinal stenosis, including hemilaminectomy, undercutting decompression of lateral recess, or total laminectomy with preservation of spinous process, interspinous, and supraspinous ligaments
§multi-segmental decompression involved standard laminectomy and foraminal decompression, pedicle screw fixation, or interbody fusion at slipped segments and all decompressed segments
ocompared to baseline, both groups had significant improvement in mean visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) scores, and Short Form 36 (SF-36) scores at 1- and 3-year follow-up
ocomparing selective decompression to multi-segmental decompression
§selective decompression associated with reduced operative time (p < 0.01) and blood loss (p < 0.01)
§no significant differences between groups in mean improvement in VAS pain, ODI or SF-36 scores at each time point, or complications
o2 patients in multi-segmental decompression plus fusion group developed postoperative instability at adjacent segments above fused segments at 3-year follow-up
oReference - J Orthop Surg Res 2019 Feb 12;14(1):46full-text
Complications of decompressive surgery·potential complications of lumbar decompressive surgery
opossible complications include
§recurrent or continuing symptoms due to another slipped disk, weakened spine, new bone or thickened ligament formation putting pressure on spine, or scarring around nerves
§infection
§blood clots
§dural tear
§cerebrospinal fluid leak
§transient facial sores (due to position during procedure) and loss of vision
§nerve injury and paralysis
§death
§Reference - National Health Service Risks of Lumbar decompression surgery 2018 Jul
·incidental dural tear
oreported to occur in 1%-17% of surgeries; incidence generally depends on type and complexity of procedure
orisk factors for iatrogenic durotomy include revision surgery, decompression for spinal stenosis, increasing age, ossified ligamentum flavum or posterior longitudinal ligament, and higher BMI
otypically detected and repaired intraoperatively, but if undetected (such as with pinhole-type durotomies) presentations may include postural headache plus combination of
§nausea and/or vomiting
§pain or tightness in neck or back
§dizziness
§diplopia due to VI cranial nerve paresis
§photophobia
§tinnitus
ocerebrospinal fluid (CSF) leak is major complication of dural tear, and may lead to further serious complications including
§CSF fistula formation or pseudomeningocele
§surgical site infections, meningitis, arachnoiditis, or epidural abscess
§rarely, chronic subdural hematomas
omanagement of dural tears
§standard treatment is suturing, with or without biologic augmentation with fibrin analogues
§fascia or fat patch, different fibrin glues, and alternative sealants have been reported
§lumbar drains proximal to durotomy is hypothesized to help wound heal due to reduction of hydrostatic pressure
oReferences - Global Spine J 2018 Jun;8(4):359full-text, Asian J Neurosurg 2010 Jan;5(1):54full-text
Postoperative pain prevention and management·epidural morphine-soaked microfibrillar collagen hemostatic sponge may reduce postoperative pain, and nausea or vomiting compared to intermittent intramuscular bolus injection of meperidine (level 2 [mid-level] evidence)
obased on retrospective cohort study
o165 patients having short-segment posterior lumbar spinal decompression and fusion surgery received 1 of 3 postoperative pain control treatments
§absorbable low-dose morphine-soaked microfibrillar collagen hemostatic sponge (MMCHS) placed on epidural sac
§patient-controlled analgesia (PCA)
§intermittent intramuscular bolus injection meperidine
oepidural MMCHS and PCA each significantly associated with greater analgesic effect than meperidine on postoperative day 1 and day 2
oMMCHS associated with significantly reduced severity of postoperative nausea and vomiting compared to PCA or meperidine
oside effects reported for epidural MMCHS included nausea (25%), pruritus (12.5%), vomiting (5%), and hypotension (2.5%)
oReference - Spine (Phila Pa 1976) 2011 Dec 1;36(25):2224
·intraoperative epidural fentanyl may reduce early postoperative pain following lumbar canal decompression (level 2 [mid-level] evidence)
obased on small randomized trial
o60 adults (mean age 68 years) having lumbar canal decompression randomized to intraoperative fentanyl 100 mcg bolus through epidural catheter vs. placebo
oall patients had neurogenic claudication or lower limb radiculopathy plus lumbar spinal canal stenosis
opain assessed by visual analog scale (range 0-10) with higher scores indicating more severe pain
omean preoperative pain scores were 3.4 in fentanyl group vs. 4.1 in placebo group (not significant)
o56 patients were evaluated for pain during recovery room stay
ocomparing fentanyl vs. placebo
§mean pain score in recovery 2.6 vs. 4.7 (p = 0.003)
§mean length of hospital stay 2 days vs. 2 days (not significant)
§urinary catheter in 12.5% vs. 0% (not significant)
ono significant differences in pain scores at 1 or 2 days, or in adverse events
oReference - Spine J 2012 Aug;12(8):646
·dexamethasone plus pregabalin associated with reduced pain 24 hours after lumbar spinal surgery and may improve pain and function at 1 month postoperatively (level 2 [mid-level] evidence)
obased on randomized trial without intention-to-treat analysis
o120 patients (mean age 53 years) with herniated lumbar disk or degenerative spinal stenosis having lumbar spinal surgery were randomized to 1 of 3 postoperative pain management regimens and were followed for 6 months
§pregabalin 150 mg orally every 12 hours (total 8 doses) beginning 1 hour prior to anesthesia induction plus placebo injection
§dexamethasone 16 mg injection prior to anesthesia induction plus pregabalin 150 mg (same schedule as above group)
§2 placebos
o10% were lost to follow-up or had reoperation and were excluded from analyses
oin analysis of mean pain scores at rest and with motion (visual analog scale) in postoperative period
§dexamethasone plus pregabalin associated with reduced pain at rest at 24 hours after surgery vs. placebo only (p = 0.011)
§no other significant differences in any comparisons of pain outcomes at 12, 24, 48, or 72 hours after surgery
ono significant differences among groups in nausea and vomiting from 0 to 72 hours after surgery except dexamethasone plus pregabalin associated with reduced incidence of nausea and vomiting at 12-24 hours after surgery vs. control (p < 0.05)
oin analysis of pain and functional outcomes up to 6 months after surgery
§dexamethasone plus pregabalin associated with reduced back pain intensity at work (p = 0.048) and improvement in daily activities (p = 0.006) at 1 month vs. placebo only
§no other significant differences in any comparisons of pain or daily activity outcomes at 1-, 3-, or 6-months follow-up
oReference - Clin J Pain 2013 Jan;29(1):9
Other perioperative considerations·tranexamic acid may decrease need for blood transfusion and reduce blood loss in patients having spine surgery (level 2 [mid-level] evidence)
obased on systematic review without reporting of individual trial quality measures
osystematic review of 11 randomized trials comparing tranexamic acid vs. placebo or no treatment in 644 patients having spine surgery
osurgical procedures included spinal fixation surgery, decompressive laminectomy with fusion, cervical laminoplasty, surgery for adolescent scoliosis, spinal fusion, or surgery for degenerative lumbar instability with stenosis
ocomparing tranexamic acid to placebo, tranexamic acid associated with
§decreased need for blood transfusion in analysis of 11 trials with 504 patients
§risk ratio 0.67 (95% CI 0.54-0.83)
§NNT 5-13 with blood transfusion in 46% of placebo group
§reduced intraoperative blood loss (mean difference -219.03 mL, 95% CI -321.67 mL to -116.38 mL) in analysis of all trials, results limited by significant heterogeneity
§reduced postoperative blood loss (mean difference -119.15 mL, 95% CI -140.76 mL to -97.54 mL) in analysis of 4 trials with 322 patients
§reduced total blood loss (mean difference -202.07, 95% CI -229.25 mL to -104.88 mL) in analysis of 6 trials with 376 patients, results limited by significant heterogeneity
oReference - Spine J 2015 Apr 1;15(4):752
·head elevation during lumbar spine fusion may reduce intraocular pressure elevation compared to neutral head position in adults (level 3 [lacking direct] evidence)
obased on nonclinical outcome from randomized trial without intention-to-treat analysis
o63 adults having lumbar spine fusion were randomized to head elevation (10-degree inclination) vs. neutral head position during surgery and followed for ≥ 6 months
o82.5% received intervention and were included in analyses
omean increase in intraocular pressure during surgery 9.26 mm Hg with head elevation vs. 13.79 mm Hg with neutral head position (p = 0.0074)
ono significant difference in duration of surgery, and no visual loss or cervical spine-related complications reported
oReference - J Bone Joint Surg Am 2015 Nov 18;97(22):1817
·pain relief as treatment outcome preferred over increased function by 79% of patients with neurogenic claudication
obased on cross-sectional study
o269 patients with neurogenic claudication were evaluated for treatment outcome preferences
otreatment outcome options were decreased pain or increased function
o221 patients completed treatment preference questionnaire and were included in analysis
o79% preferred pain relief and 21% preferred increased function
oReference - Neurology 2015 Oct 6;85(14):1250
Postoperative rehabilitation·active rehabilitation appears to improve back function and pain following primary spinal decompressive surgery for lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on Cochrane review of trials without blinding
osystematic review of 3 randomized trials comparing active rehabilitation vs. usual care in 373 adults who had primary spinal decompressive surgery with or without fusion for lumbar spinal stenosis
§active rehabilitation included group or therapist-led exercise training or stabilization training involving muscle-strengthening exercises and flexibility training, and educational materials encouraging activity
§usual care included limited advice provided postoperatively to stay active or brief general program of exercises
oin analyses of all trials at 12 months, active rehabilitation associated with significant improvement in
§low back pain (corresponding to mean percentage improvement of 18% [95% CI 5%-30%])
§leg pain (corresponding to mean percentage improvement of 21% [95% CI 1%-37%])
§back-specific functional score (corresponding to mean percentage improvement of 23% [95% CI 5%-37%])
ono significant difference in general health up to 12 months
oReference - Cochrane Database Syst Rev 2013 Dec 9;(12):CD009644
·cognitive behavioral-based physical therapy may reduce severity of back and leg pain and low back disability at 3 months more than educational program in adults with high fear of movement having surgical treatment of degenerative lumbar condition (level 2 [mid-level] evidence)
obased on randomized trial with confidence intervals including clinically unimportant differences
o86 adults with chronic pain and high fear of movement having surgical treatment for degenerative lumbar condition were randomized at 6 weeks after surgery to cognitive behavioral-based physical therapy (CBPT) vs. education program once weekly for 6 weeks and evaluated 3 months after treatment
§CBPT focused on improving pain and disability through reducing fear of movement and increasing self-efficacy
§education program focused on postoperative recovery and provided information on benefit of physical therapy, proper biomechanics after surgery, importance of daily exercise, and ways to promote healing
oboth groups received 1-hour in-person session followed by 5 weekly half-hour sessions by telephone with physical therapist
oback/leg pain intensity and pain interference with daily life evaluated with Brief Pain Inventory (score 0-10 with higher score indicating more pain/pain interference, minimum clinically important difference defined as 1.2-2 points for pain intensity and 1.6-2.2 points for pain interference)
olow back disability evaluated with Oswestry Disability Index (score 0-50 with higher score indicating lower functioning, minimum clinically important difference defined as 10-12.8 points)
omean change from baseline comparing CBPT vs. education for
§back pain intensity score -1.1 points vs. -0.26 points (mean difference [MD] -0.88, 95% CI -1.5 to -0.25)
§leg pain intensity score -1.3 points vs. -0.1 points (MD -1.2, 95% CI -2.1 to -0.34)
§pain interference score -1.7 points vs. -0.26 points (MD -1.5, 95% CI -2.4 to -0.57)
§low back disability score -17.3 points vs. -7.5 points (MD -9.8, 95% CI -15.3 to -4.4)
oReference - J Pain 2016 Jan;17(1):76
ProceduresEpidural InjectionsEpidural Steroid Injections·North American Spine Society (NASS) guidance on epidural steroid injections3
oconsider interlaminar epidural steroid injections to provide short-term symptom relief in patients with neurogenic claudication or radiculopathy due to degenerative lumbar spinal stenosis, but conflicting evidence for long-term efficacy (NASS Grade B)
oconsider repeated image-guided transforaminal epidural steroid injections or caudal injections for recurrent or progressive pain for patients with radiculopathy or neurogenic intermittent claudication from lumbar spinal stenosis (NASS Grade C)
ocontrast-enhanced fluoroscopic guidance recommended for epidural steroid injections to improve accuracy of medication delivery (NASS Grade A)
oDynaMed commentary -- The NASS recommendations were published in 2013 and as a result do not include more recent evidence demonstrating that epidural steroid injections may not improve pain and/or function in patients with spinal stenosis.
·efficacy of epidural steroid injections
oepidural corticosteroid injections not associated with improved pain or function in patients with spinal stenosis (level 2 [mid-level] evidence); based on systematic review with incomplete assessment of trial quality (Ann Intern Med 2015 Sep 1;163(5):373EBSCOhost Full Text)
oaddition of steroids to epidural lidocaine injection may not reduce disability or pain at 6-12 weeks in patients with spinal stenosis (level 2 [mid-level] evidence); based on 2 randomized trials with baseline differences (N Engl J Med 2014 Jul 3;371(1):11, and J Spinal Disord Tech 2012 Jun;25(4):226)
orepeated caudal epidural steroid injections may not reduce pain more than repeated injections with lidocaine alone in patients with chronic function-limiting spinal stenosis (level 2 [mid-level] evidence); based on preliminary results of randomized trial with inadequate statistical power (Pain Physician 2008 Nov-Dec;11(6):833)
·adverse effects rare but may include bleeding, infection, and nerve damage
·see Epidural Steroid Injection for details
Epidural Etanercept Injection·etanercept associated with improved short-term pain relief compared to dexamethasone in patients with lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on randomized trial without blinding
o80 adults (mean age 66 years) with lumbar spinal stenosis accompanied by low back pain and radicular leg pain randomized to 1 epidural injection with dexamethasone 3.3 mg vs. etanercept 10 mg and followed for 4 weeks
oboth treatments administered with 2 mL of lidocaine
oetanercept associated with reduced leg pain at 3 days and at 1, 2, and 4 weeks (p < 0.05 for all) and reduced low back pain and leg numbness at 3 days, 1 week, and 2 weeks (p < 0.05 for all)
oReference - Spine (Phila Pa 1976) 2012 Mar 15;37(6):439
Percutaneous Epidural Adhesiolysis·percutaneous epidural adhesiolysis (PEA) with inflatable balloon catheter may improve pain and physical function at 6 months compared to PEA without inflatable balloon catheter in patients with refractory central lumbar spinal stenosis (level 2 [mid-level] evidence)
obased on randomized trial without intention-to-treat analysis
o60 adults ≥ 40 years old with refractory central lumbar spinal stenosis were randomized to PEA with inflatable balloon catheter vs. PEA without inflatable balloon catheter and followed for 6 months
oprimary outcome was pain intensity in leg and in lower back assessed using Numeric Rating Scale (NRS) (scale 0-10, with higher scores indicating greater pain intensity)
oat baseline, balloon catheter group had median NRS score of 6 points and no balloon catheter group had median score of 7 points
osecondary outcomes included
§physical function assessed using Oswestry Disability Index (ODI) (scale 0-100, with higher scores indicating greater disability)
§patient satisfaction and improvement assessed using Global Perceived Effect of Satisfaction (GPES) on 7-point Likert scale, with higher scores indicating greater satisfaction
o57% attended 6-month follow-up; 73% included in analyses
o6-month outcomes comparing PEA with balloon catheter vs. PEA without balloon catheter
§mean NRS score for back pain 2.96 points vs. 5 points (p= 0.011)
§mean NRS score for leg pain 3.58 points vs. 5.46 points (p = 0.004)
§mean ODI score 21.89 points vs. 35.62 points (p = 0.001)
§mean GPES score 5.33 points vs. 4.2 points (p = 0.014)
ono significant difference between groups in NRS and ODI scores at 1 or 3 months
ono serious adverse events reported
oReference - Pain Physician 2018 Nov;21(6):593PDF
Follow-up·early detection of complications and evaluation of the postoperative spine may be performed with computed tomography or magnetic resonance imaging (Insights Imaging 2015 Dec;6(6):579full-text)
Complications and PrognosisComplications·cauda equina syndrome
·peripheral or focal radiculopathy1
·neurogenic bladder
·neuropathic arthropathy
Prognosis·prognosis without treatment3
ofor patients with mild-to-moderately symptomatic degenerative lumbar stenosis, limited evidence regarding natural history suggests
§favorable outcome in 35%-50% patients
§rapid or catastrophic neurologic decline is rare
ofor patients with clinically or radiographically severe degenerative lumbar stenosis, insufficient evidence to determine natural history
·treatment may provide long-term (2-10 years) improvement in large percentage of patients with degenerative lumbar stenosis (NASS Grade C)3
oabout 20%-40% will ultimately have surgery
o50%-70% patients treated without surgery will have improvement in pain
·surgical intervention may improve pain and function in patients with diabetes and spinal stenosis or degenerative spondylolisthesis, but associated with increased complication rates compared to patients without diabetes
obased on cohort analysis of Spine Patient Outcomes Research Trial [SPORT] trial
o2,405 patients with spinal stenosis or degenerative spondylolisthesis were analyzed
o199 patients (8.3%) had diabetes
opatients with diabetes were significantly older and had higher body mass index than nondiabetic patients
ocompared to nonoperative treatment, surgical intervention associated with improved pain and function in patients with spinal stenosis or degenerative spondylolisthesis (p < 0.05)
ocompared to patients without diabetes, patients with diabetes and
§spinal stenosis had increased postoperative complications (p = 0.002)
§degenerative spondylolisthesis had increased perioperative blood replacement (p < 0.03)
ono significant difference between surgical intervention compared to nonoperative treatment for pain and function in patients with diabetes and intervertebral disc herniation
oReference - Spine (Phila Pa 1976) 2011 Feb 15;36(4):290full-text
·presence of concomitant degenerative spondylolisthesis does not appear to alter outcomes after decompression surgery in patients with degenerative lumbar stenosis
obased on systematic review
osystematic review of 11 studies (including 10 cohort studies and 1 randomized trial) evaluating outcomes following decompression alone in 1,081 patients with degenerative lumbar stenosis
§469 patients had concomitant degenerative spondylolisthesis (Meyerding grade I-II)
§612 patients did not have concomitant degenerative spondylolisthesis
ocomparing patients with spondylolisthesis vs. without spondylolisthesis, no significant differences between groups for function, pain, or rates of reoperation, slippage, or postoperative instability
oReference - World Neurosurg 2019 Mar;123:226
Prevention and Screening·not applicable
Guidelines and ResourcesGuidelinesUnited States Guidelines·North American Spine Society (NASS) evidence-based clinical guideline on diagnosis and treatment of degenerative lumbar spinal stenosis can be found in Spine J 2013 Jul;13(7):734
·Lumbar Spinal Stenosis Consensus Group guideline on minimally invasive spine treatment can be found in Pain Pract 2019 Mar;19(3):250
·American Association of Neuromuscular and Electrodiagnostic Medicine evidence-based guideline on the utility of electrodiagnostic testing in evaluating patients with lumbosacral radiculopathy can be found in Muscle Nerve 2010 Aug;42(2):276
·American Pain Society (APS) guideline on interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain can be found in Spine (Phila Pa 1976) 2009 May 1;34(10):1066
United Kingdom Guidelines·National Institute for Health and Care Excellence (NICE) guideline on low back pain and sciatica in over 16s: assessment and management can be found at NICE 2016 Nov:NG59PDF
·National Institute for Health and Care Excellence (NICE) interventional procedure guidance on interspinous distraction procedures for lumbar spinal stenosis causing neurogenic claudication can be found at NICE 2010 Nov:IPG365PDF
European Guidelines·Danish Health Authority (DHA) National clinical guideline on treatment of lumbar spinal stenosis can be found at DHA 2017 Sep 25
Canadian Guidelines·Université du Québec à Trois-Rivières diagnostic imaging practice guidelines on musculoskeletal complaints in adults (spinal disorders) can be found in J Manipulative Physiol Ther 2008 Jan;31(1):33
Review Articles·review can be found in N Engl J Med 2008 Feb 21;358(8):818, commentary can be found in N Engl J Med 2008 Jun 12;358(24):2647
·review of lumbar spinal stenosis in older adults can be found in Rheum Dis Clin North Am 2018 Aug;44(3):501
·review of classification of lumbar spinal stenosis can be found in J Am Acad Orthop Surg 2016 Dec;24(12):843
·review of evaluation and management of degenerative lumbar spinal stenosis can be found in J Am Acad Orthop Surg 2012 Aug;20(8):527
·editorial discussion on diagnosis and management of lumbar spinal stenosis can be found in JAMA 2010 Jan 6;303(1):71EBSCOhost Full Text, commentary can be found in JAMA 2010 Apr 21;303(15):1479EBSCOhost Full Text
·review of management of lumbar spinal stenosis can be found in
oCurr Opin Anaesthesiol 2017 Oct;30(5):598
oEur J Orthop Surg Traumatol 2016 Oct;26(7):695
oBMJ 2016 Jan 4;352:h6234
oPain Pract 2015 Jan;15(1):68
·Cochrane review of surgical options for lumbar spinal stenosis can be found in Cochrane Database Syst Rev 2016 Nov 1;11:CD012421
·review of accuracy of clinical examination for diagnosis of clinical syndrome of lumbar spinal stenosis can be found in JAMA 2010 Dec 15;304(23):2628full-text
·review of optimal clinical care for patients following sport-related neuropraxic injuries can be found in Spine (Phila Pa 1976) 2010 Oct 1;35(21 Suppl):S193
MEDLINE Search·to search MEDLINE for (Spinal stenosis) with targeted search (Clinical Queries), click therapy, diagnosis or prognosis
Patient Information·handouts from
oEBSCO Health Library or in Spanish
oAmerican Academy of Orthopaedic Surgeons or in Spanish
oAmerican Association of Neurological Surgeons
·handout on lumbar spinal canal stenosis from American Academy of Family Physicians or in Spanish
·handout on lumbar decompression surgery from National Health Service
ICD CodesICD-10 Codes·M48.0 spinal stenosis
oM48.05 thoracolumbar region
oM48.06 lumbar region
oM48.07 lumbosacral region
oM48.08 sacral and sacrococcygeal region
ReferencesGeneral References Used1.Suri P, Rainville J, Kalichman L, Katz JN. Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? JAMA. 2010 Dec 15;304(23):2628-36EBSCOhost Full Textfull-text
2.Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008 Feb 21;358(8):818-25, commentary can be found in N Engl J Med 2008 Jun 12;358(24):2647
3.Kreiner DS, Shaffer WO, Baisden JL, et al; North American Spine Society. Evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013 Jul;13(7):734-43, editorial can be found in Spine J 2013 Jul;13(7):744, commentary can be found in Spine J 2014 Jan;14(1):200
Recommendation grading systems used·North American Spine Society (NASS) grading system for recommendations
ogrades of recommendation
§Grade A - good evidence (Level I studies with consistent findings) for or against recommending intervention
§Grade B - fair evidence (Level II or III studies with consistent findings) for or against recommending intervention
§Grade C - poor-quality evidence (Level IV or V studies) for or against recommending intervention
§Grade I - insufficient or conflicting evidence not allowing recommendation for or against intervention
§Work Group Consensus Statement - in the absence of reliable evidence, it is the work group’s opinion that a test or intervention may be appropriate
olevels of evidence
§Level I
§for diagnostic studies - testing of previously developed diagnostic criteria on consecutive patients with universally applied reference standard or systematic review of Level I studies
§for therapeutic studies
§high-quality randomized trial with statistically significant difference or no statistically significant difference but narrow confidence intervals
§systematic review of Level I randomized controlled trials (RCTs) with homogeneous study results
§Level II
§for diagnostic studies - development of diagnostic criteria on consecutive patients with universally applied reference standard or systematic review of Level II studies
§for therapeutic studies
§lesser-quality RCT (for example, < 80% follow-up, no blinding, or improper randomization)
§prospective comparative study
§systematic review of Level II studies or Level I studies with inconsistent results
§Level III
§for diagnostic studies - study of nonconsecutive patients without consistently applied reference standard or systematic review of Level III studies
§for therapeutic studies - case-control study, retrospective comparative study, or systematic review of Level III studies
§Level IV
§for diagnostic studies - case-control study with poor reference standard
§for therapeutic studies - case series
§Level V - expert opinion (for both therapeutic and diagnostic studies)
oReference - NASS clinical guideline on diagnosis and treatment of degenerative lumbar spinal stenosis (Spine J 2013 Jul;13(7):734)
·Lumbar Spinal Stenosis Consensus Group grading system for recommendations
ogrades of recommendation
§Grade A - extremely recommendable; good evidence that measure is effective and that benefits outweigh harms
§Grade B - recommendable; at least moderate evidence that measure is effective and that benefits exceed harms
§Grade C - neither recommendable nor inadvisable; at least moderate evidence that measure is effective, but benefits are similar to harms and a general recommendation cannot be justified
§Grade D - inadvisable; at least moderate evidence that measure is ineffective or that harms exceed benefits
§Grade I - insufficient, low-quality, or contradictory evidence; balance between benefit and harms cannot be determined
olevels of evidence
§Level I - ≥ 1 controlled and randomized clinical trial, properly designed
§Level II-1 -well-designed, controlled, nonrandomized clinical trials
§Level II-2 - cohort or case studies and well-designed controls, preferably multicenter
§Level II-3 - multiple series compared over time, with or without intervention, and surprising results in noncontrolled experiences
§Level III - clinical experience-based opinions, descriptive studies, clinical observations, or reports of expert committees
ostrength of consensus
§Strong - > 80% consensus
§Moderate - 50% to 79% consensus
§Weak - < 49% consensus
oReference - Lumbar Spinal Stenosis Consensus Group guideline on minimally invasive spine treatment (Pain Pract 2019 Mar;19(3):250)
·American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) grading system for recommendations
oclasses of evidence
§Class I - evidence provided by prospective study in broad spectrum of persons with suspected condition, using reference (gold) standard for case definition, where test is applied in a blinded evaluation, and enabling assessment of appropriate tests of diagnostic accuracy. All patients undergoing the diagnostic test have presence or absence of disease determined
§Class II - evidence provided by prospective study of narrow spectrum of patients with suspected condition, or well-designed retrospective study of broad spectrum of persons with an established condition (by gold standard) compared with a broad spectrum of controls, where testing applied in blinded evaluation, and enabling assessment of appropriate tests of diagnostic accuracy
§Class III - evidence provided by retrospective study where either persons with established condition or controls are of a narrow spectrum, and where reference standard, if not objective, is applied by someone other than the person who performed test
§Class IV - any design where test not applied in independent evaluation or evidence provided by expert opinion alone or in descriptive case series (without control subjects)
ostrength of recommendation
§Level A - established as effective, ineffective, or harmful (or established as useful/predictive or not useful/predictive) for given condition in specified population
§Level B - probably effective (or probably useful/predictive or not useful/predictive) for given condition in specified population
§Level C - possibly effective (or possibly useful/predictive or not useful/predictive) for given condition in specified population
§Level U - data inadequate or conflicting; given current knowledge, test is unproven
oReference - AANEM evidence-based guideline on utility of electrodiagnostic testing in evaluating patients with lumbosacral radiculopathy (Muscle Nerve 2010 Aug;42(2):276)
Synthesized Recommendation Grading System for DynaMed·DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
·Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
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·We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
oStrong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
oWeak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
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·DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114133, Lumbar Spinal Stenosis; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T114133. Registration and login required.