From the Guidelines
Treatment options for lumbar spinal stenosis should prioritize conservative approaches, including physical therapy, pain medications, and lifestyle modifications, before considering surgical interventions, as recommended by the American College of Physicians and the American Pain Society 1. The goal of treatment is to improve quality of life, maintain mobility, and minimize pain. Conservative treatments should be tried first and may include:
- Physical therapy focusing on core strengthening and flexibility exercises
- Pain medications such as NSAIDs (ibuprofen 400-800mg three times daily or naproxen 500mg twice daily) and acetaminophen (up to 3000mg daily)
- Muscle relaxants like cyclobenzaprine (5-10mg three times daily) in some cases
- Epidural steroid injections for temporary relief (3-6 months)
- Lifestyle modifications, including weight loss if needed and avoiding activities that worsen symptoms like prolonged standing or walking If conservative treatments fail after 3-6 months or neurological symptoms worsen, surgical options may be considered, including:
- Decompressive laminectomy (removing bone to relieve pressure on nerves)
- Spinal fusion if instability is present Surgery is generally more effective for leg pain than back pain, and the choice of treatment depends on symptom severity, functional limitations, and patient preferences, as outlined in the guidelines from the American College of Physicians and the American Pain Society 1.
From the Research
Diagnosis of Lumbar Spinal Stenosis
- Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain, associated with reduced space available for the neural and vascular elements of the lumbar spine 2.
- The diagnosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI) 3.
- Magnetic resonance imaging is the recommended diagnostic test because it allows cross-sectional measurement of the spinal canal 4.
Treatment Options for Lumbar Spinal Stenosis
- Nonoperative treatment includes activity modification, oral medications to diminish pain, and physical therapy 3.
- Options for non-surgical management include physical therapy, exercise programs, spinal injections with and without corticosteroids, chiropractic treatment, osteopathic manipulation, acupuncture, and lifestyle modifications 4.
- Multimodal care nonpharmacological therapies with education, advice, and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation may be initially selected for patients with LSS causing NC 5.
- Surgery may be considered if nonsurgical management is ineffective, and appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management 3, 2.
Pharmacological Therapies for Lumbar Spinal Stenosis
- Serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants may be considered for patients with LSS causing NC 5.
- The use of nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin, and gabapentin is not recommended for patients with LSS causing NC 5.
- Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated 3, 5.