This document discusses conservative management options for lumbar spinal stenosis (LSS). It begins by reviewing the clinical presentation and causes of LSS, then lists conservative treatment options including medications, physical therapy, epidural steroid injections, and alternative therapies. It proposes debating when conservative management is reasonable compared to surgery. Finally, it summarizes two studies on conservative treatment for LSS - a study showing 25% improvement with conservative treatment over 3 years, and the Maine Lumbar Spine Study comparing surgical to non-surgical outcomes up to 10 years.

1. Lumbar Spinal Stenosis
Conservative Management for the
“Simple” Minded Practitioner
By Joe Hlavin PA-C

2. The Only Way To
Heal Is With Ice Cold
Steal

3. Conservative Management
of LSS is Anything and
Everything Other than the
Last Slide
And when the patient in your office tells
you:
I don’t want surgery, you might look
like this…

5. But Seriously……..

6. Current Treatment of Lumbar
Stenosis
Role of Non-Operative Management
By
Joseph Hlavin PA-C

7. Goals of this Presentation
(BUT Not to bore you)
• Quickly
– Review the clinical presentation of LSS
– Review causes of LSS
• List the different conservative treatments
available
• Propose a debate on when it is reasonable to
offer conservative management over surgery
• Offer articles/studies as a guide for who, when
and for how long

8. Overview
1. Hypertrophy of the Yellow
Ligament
2. Flattening/bulging disc
3. Facet Hypertrophy
4. Foraminal Stenosis
5. Canal Stenosis

9. Hallmark Symptoms
• Neurogenic Claudication
• +/- Lower back pain
• +/- hip and/or radicular pain
• Improvement of pain with forward flexion
of the lumbar spine:
– Shopping cart sign
– Easier walking up hill

10. Neurogenic Claudication
• Not to be confused with Vascular
Claudication
– Neurogenic:
• Symptoms w/ walking AND standing
• Variable walking distance w/o symptoms
• Relief w/ sitting & flexion
• Lower extremity pulses OK

11. Neurogenic Claudication
– Vascular Claudication
• Symptoms w/ walking BUT NOT standing
• NO variability in walking distance prior to
onset of symptoms
• NO relief with lumbar flexion
• Diminished pulses in feet

12. Degenerative Lumbar Stenosis
• Age related: (Spondylosis)
– Spondylosis – Degeneration
of the facet joints
– Degenerative spondylolithesis
– Facet arthropathy
– Degenerative disc bulge/spur
– Hypertrophic ligamentum flavum

13. Stenosis to a Degree
• Mild
• Moderate
• Severe

14. Degenerative Lumbar Stenosis
Mild

15. Lumbar Stenosis - Moderate

16. Lumbar Stenosis - Severe
Flaniken, Doris H St. Joseph Regional Health Center
St.
M000473610 LUMBAR SPINE MRI W/O CONTRAST
Flaniken, Doris A St. Joseph Regional Health Center 12/14/1935
Regional t2_tse_rst_sag
M000473610 LUMBAR SPINE MRI W/O CONTRAST F 2/12/2007 15:27:21
001087049
12/14/1935 t2_tse_rst_tra_msma
F 2/12/2007 15:40:26 LOC: -6.87
001087049 THK: 4 SP: 4.4
HFS
LOC: -100.81
THK: 4 SP: 4.4
HFS
R L A P
EC: 0
SE
FA: 180 L4-5 Z: 1.60
TR: 8830 C: 314
TE: 86 W: 708 EC: 0
Compressed 7 :1 SE
FA: 170 Z: 1.14
Page: 32 of 39 P IM: 32 SE: 4 TR: 3750 C: 110
cm 3750
TE: 115 W: 378
Compressed 7 :1
Page: 9 of 15 F IM: 9 SE: 2
cm

17. Lumbar Stenosis – Other
Causes
• Causes of non-
arthritic lumbar canal
stenosis:
– Disc rupture
– Tumor
– Abscess
– Hematoma
– Trauma/FX

18. Spinal Stenosis - Trauma

19. Lumbar Stenosis – Abscess

20. Lumbar Stenosis - Tumors

21. The Conservative Approach
• Medications
– NSAIDs
Acetaminophen
Oral corticosteroids
Muscle relaxants
Narcotics
Neurontin / Lyrica

22. The Conservative Approach
• Physical Therapy
Conditioning
Stretching
Strengthening
Modalities
(i.e., heat, ice, ultrasound, electrical
stimulation)
• Encourages weight loss; improves aerobic
conditioning
• Lumbosacral corset (soft) or Lumbosacral
orthosis (rigid)

23. The Conservative Approach
• Epidural Steroid Injections
– including:
• Caudal blocks
• Central epidural steroids
• Foraminal epidural steroids

24. Epidural Steroid Inj (ESI)
• Staple of conservative management
• Usually given in a “series” of 3
• But usually limited to 3 injections in a year
• Not a long term solution
• Literature support is limited

25. The Conservative Approach
• Alternative treatments
– Chiropractor
– DRX-9000 (Traction Device)

26. Questions?
• Who gets surgery, who does not?
• When do we institute conservative
treatment?
• How long do we pursue a
conservative route?
• What literature is out there to provide
guidance?

27. Who gets what treatment?
Flaniken, Doris H St. Joseph Regional Health Center
M000473610 LUMBAR SPINE MRI W/O CONTRAST
12/14/1935 t2_tse_rst_sag
F 2/12/2007 15:27:21
001087049
LOC: -6.87
THK: 4 SP: 4.4
HFS
A P
OR
EC: 0
SE
FA: 170 Z: 1.14
TR: 3750 C: 110
TE: 115 W: 378
Compressed 7 :1
Page: 9 of 15 F IM: 9 SE: 2
cm
-71 y/o female -64 y/o female
-Severe claudication -Incapacitating LBP
-Over weight -N. Claudication
-Poor cardiac -Healthy
function
-Newly diagnosed
pulmonary lesion

28. At what point should conservative
treatment be used?
• In a perfect world, all non operative
management is tried prior to the first visit to the
office
• For certain patients, non surgical means should
be exhausted prior to surgical consideration
• Initial focus should be on patient education, pain
control, and getting the patient back to ADL

29. How long do we give non operative
treatment?
• Based on each individual patient
– Symptoms
– Clinical findings
• The “gut” feeling of the practitioner based
on experience

30. Now is the time for the coffee to
kick in!!!
BORING RESEARCH DATA ALERT!!

31. What does the literature say?
• Non operative treatment of LSS w/ 3 year
outcome analysis by Simotas et al (2000)
• Maine Lumbar Spine Study by Atlas et al
(2005) – perspective observational study
• A randomized controlled trial for surgical
vs. non surgical treatment of LSS,
Malmivaar et al (2006)

32. Non operative treatment of LSS w/
3 year analysis
• 49 patients treated non operatively
• Excluded if < 50 y/o and history of
previous lumbar surgery
• Inclusions were severe back, buttock, and
leg pain w/ MRI and/or CT evidence of
single level central LSS
• Methodic regimen of conservative therapy

33. Non operative treatment of LSS w/
3 year analysis
• Conservative regimen (each step based
on outcome of previous treatment)
– Bed rest
– Tapered oral corticosteroids
– Epidural steroid (2 – 3 at physician discretion)
– NSAIDS for 4 -6 week periods
• Aggressive rehab/PT during above tx

34. Non operative treatment of LSS w/
3 year analysis
• Mean F/U 33 months (16 – 55 months)
• conclusion:
– Authors suggest that conservative treatment
is a viable option for LSS base on:
• 25% significant improvement in symptoms and
satisfaction
• Rare neurologic deterioration over time of study
• But you decide for your self
Is 25% acceptable?

35. Maine Lumbar Spine Study
• 1,4,and 8 to 10 year follow ups
• Patients recruited from various orthopedic,
neurosurgical, and occupational clinics in
Maine
• 148 initial patient population
• 81 patients underwent surgical
decompression
• 67 patients treated non surgically

36. Maine Lumbar Spine Study
• Moderate findings/ moderate symptoms
• Surgical patients had the worse baseline
symptoms and function
• Conclusions after 1 year:
– Best outcomes in the surgical population were
observed in the first 3 months after surgery
– No significant change in symptoms were noted in the
non operative population but also no worsening of
neurologic function

37. Maine Lumbar Spine Study
• Conclusions at 4 years:
– 119 patients remaining
– 70% of surgical patients report improvement in
symptoms vs. 52% of non surgical patients
– 63% of surgical patients satisfied with symptoms vs.
42% of non surgical patients
– Moderate decline in the satisfaction of the surgical
group
– Conversely, the non operative group moderate
improvement in symptoms and stability
– ? convergence

38. Maine Lumbar Spine Study
• Conclusions at 8 to 10 years:
– 105 remaining patients at 8 years
– 97 remaining at 10 years
– 53% of surgical patients improved
– 52% of non surgical patients improved
– 55% of surgical patients satisfied
– 49% of non surgical patients satisfied

39. Maine Lumbar Spine Study
• Results were tainted by:
– 23% of surgical patients required re-operation
– 39% of non surgical patients underwent at least on
lumbar surgery
• Ultimately:
– There was a similarity between the results of the
initial treatment and the 8/10 F/U
– Leg pain relief and functional issues still favored initial
surgical management

40. A randomized controlled trial for surgical vs. non
surgical treatment of LSS
• 94 patients
• 50 surgical/ 44 non surgical
• Surgical: segmental decompression w/o
facetectomy
• Non surgical: under the care of physiatrist
(NSAIDS and physical therapy. No mention of
ESI in this report)
• 6 month, 1 year, and 2 year F/Us

41. A randomized controlled trial for surgical vs.
non surgical treatment of LSS
• Included:
– Clinical symptoms of LSS
– Persistent pain w/o neurological deficit
– Spinal canal <10mm on MRI
– Duration of symptoms > 6 months
– Disease level could be treated either way

42. A randomized controlled trial for surgical vs.
non surgical treatment of LSS
• Extensive exclusion list:
– Previous surgery
– Severe stenosis w/ progressive neurologic deficit
– LSS that was too mild (wouldn’t warrant surgery)
– Other spinal disorders/pathology
– Diabetic neuropathy
– Other disorders of the lower limbs
– Psychiatric disorders/alcoholism
– Diagnosis of herniated lumbar disc in past 12 mon

43. A randomized controlled trial for surgical vs.
non surgical treatment of LSS
• Of note:
– Mean age was 62/63 (ns/s)
– Majority of both group were retired
– time of symptoms from onset (yrs): 14/16
– Most participants in both groups perceived their
health as poor
– Exam: neg SLR, low percent of LBP, better w/ lumbar
FF, >50% decreased vib sense, and >30% had loss
of AJ reflex

44. A randomized controlled trial for surgical vs.
non surgical treatment of LSS
• Results:
– 4 areas calculated:
• Oswestry Disability Index
• Leg pain during walking
• LBP during walking
• Self reported walking distances

45. A randomized controlled trial for surgical vs.
non surgical treatment of LSS
• Oswestry Index (disablility) (0 – 100%)
– Ref. 0-20% stbl/no tx, 21-40% mod/cons tx
– At 24 months: (NS) 29% vs (S) 21%
• Leg pain w/ walking (@ 24 months)
– 0 – 10 pain scale
– 4.5 (NS) vs. 3 (S)
• LBP w/ walking (@ 24 m, same scale)
– ~5 (NS) vs. ~2.5 (S)

46. A randomized controlled trial for surgical vs.
non surgical treatment of LSS
• Self reported walking distances
– At 1 year F/U
• 1.28 miles (NS) vs. 1.38 miles (S)
– At 2 year F/U
• 1.26 miles (NS) vs. 1.29 miles (S)
– Not a very significant difference in distance
from one group to the other

47. A randomized controlled trial for surgical vs.
non surgical treatment of LSS
• Conclusions:
– Surgical patients did better in terms of
disability, leg pain, and LBP
– Walking distance was not clinically significant
as noted
– There was meaningful recovery in the non
surgical group
– Supports surgical decompression after
exhaustion of conservative treatments

48. My Conclusions
• Simply:
– Each patient represents a different set of
circumstances regarding their level and
tolerance of pain and disability
– Finding on studies and neurological deficit
tend to push surgeons to offer decompression
– BUT patients are motivated more by how they
feel and what they are willing to tolerate

49. My Conclusions
• Moreover:
– Studies have proven efficacy of conservative
management for patients with LSS
– When to institute non operative therapy and
once started, when to stop are not well
outlined for the practitioner
– Individual conservative measures need to be
studied better

50. My Conclusions
• So FINALLY:
– Nothing short of surgical decompression will
structurally change the diameter of the stenotic
segment
– Although extensive studies have proven the worth of
conservative management for LSS, most came up
short of providing data that allows the practitioner to
make a confident decision

51. Thank You