Clinical Review State of the Art Review

Management of lumbar spinal stenosis

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.h6234 (Published 04 January 2016) Cite this as: BMJ 2016;352:h6234
  1. Jon Lurie, associate professor1,
  2. Christy Tomkins-Lane, associate professor2
  1. 1Department of Medicine, Dartmouth Medical School, Dartmouth Hitchock Medical Center, NH, USA
  2. 2Department of Health and Physical Education, Mount Royal University, Calgary, Canada
  1. Correspondence to: J Lurie jon.d.lurie{at}hitchcock.org

Abstract

Lumbar spinal stenosis (LSS) affects more than 200 000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.

Footnotes

  • Contributors: Both authors participated fully in the planning, conduct, and reporting of the work described in the article, and are responsible for the overall content as guarantors.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: CTL: none; JDL: consulting for FzioMed and the Informed Medical Decisions Foundation and stock options from NewVert; FzioMed and NewVert produce products related to surgery for intervertebral disc herniation but not for spinal stenosis. This work was supported in part by the Multidisciplinary Clinical Research Center in Musculoskeletal Diseases at Dartmouth, funded by NIAMS (P60-AR048094 and P60-AR062799).

  • Provenance and peer review: Commissioned; externally peer reviewed.

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