What is the best treatment for moderate to severe spinal canal stenosis and disc herniation: surgery, physical therapy (PT) or epidural steroid injections (ESI)?

From the Guidelines

For moderate to severe spinal canal stenosis and disc herniation, a stepped approach starting with conservative treatments such as physical therapy (PT) and epidural steroid injections (ESI) before considering surgery is typically recommended. This approach is supported by evidence from the American College of Physicians and the American Pain Society, which suggests that many patients improve with conservative care, and reserving surgery for those who truly need it minimizes unnecessary surgical risks while addressing pain and preserving neurological function 1.

Key Considerations

• Physical therapy (PT) is often the first-line treatment, focusing on core strengthening, flexibility, and proper body mechanics over 6-8 weeks with 2-3 sessions per week.
• If PT provides insufficient relief, epidural steroid injections (ESI) may be tried, typically using methylprednisolone (40-80mg) or triamcinolone (40-80mg) mixed with local anesthetic.
• Patients usually receive 1-3 injections spaced 2-4 weeks apart.
• Surgery becomes the preferred option when conservative treatments fail, neurological deficits worsen, or cauda equina syndrome develops.
• Surgical approaches include decompressive laminectomy for stenosis or discectomy/microdiscectomy for herniation.

Evidence-Based Recommendations

The American College of Physicians and the American Pain Society recommend that clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) 1. The natural history of lumbar disc herniation with radiculopathy in most patients is for improvement within the first 4 weeks with noninvasive management 1.

Patient-Centered Approach

The best treatment varies by individual factors including symptom severity, functional limitations, comorbidities, and patient preferences. Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options 1.

From the Research

Treatment Options for Moderate to Severe Spinal Canal Stenosis and Disc Herniation

The treatment options for moderate to severe spinal canal stenosis and disc herniation include surgery, physical therapy (PT), and epidural steroid injections (ESI). The choice of treatment depends on various factors, including the severity of symptoms, duration of symptoms, and individual patient characteristics.

Comparison of Treatment Options

• Surgery: Studies have shown that surgery can provide faster relief from symptoms compared to conservative management 2. However, the results of surgery may deteriorate in the long term due to recurrence of radicular and low back pain 2.
• Physical Therapy (PT): PT has been shown to be effective in improving pain and functional parameters in patients with lumbar spinal stenosis, with significant improvements noted up to 6 months of follow-up 3.
• Epidural Steroid Injections (ESI): ESI has been found to be effective in reducing symptoms and disability associated with lumbar disc herniation, with nearly half of patients experiencing relief for up to 3 years 4. However, ESI was not as effective as discectomy in reducing symptoms and disability.

Predicting the Need for Surgical Treatment

• A study found that patients with high-grade spinal canal stenosis were more likely to require surgical treatment, with a significantly higher probability of needing surgery if they had a high-grade stenosis of the spinal canal 5.
• Another study suggested that younger patients with a lesser degree of weakness for a shorter period of time may respond better to surgical treatment, but they also constitute a group that fares better without surgery 6.

Considerations for Treatment

• The main indication for surgical treatment should be pain rather than weakness 6.
• Patients who do not respond to conservative treatment after at least 2 months may be considered for surgery 2.
• ESI may be considered as a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation 4.