What are the treatment options for spinal stenosis?

Treatment of Spinal Stenosis

The treatment of spinal stenosis should begin with conservative management for all patients, with surgery reserved for those who fail to improve after non-operative treatment. 1

Initial Assessment and Diagnosis

• MRI (preferred) or CT is recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions 2
• For patients with symptoms suggesting posterior cerebral or cerebellar ischemia, MRA or CTA is recommended for evaluation of vertebral arteries 2
• Key clinical findings to assess:
  • Neurological deficits (sensory loss, muscle weakness)
  • Gait abnormality
  • Neurogenic claudication (pain with walking relieved by sitting)
  • Age >65 years (associated with higher likelihood of spinal stenosis) 3

Conservative Management

First-Line Approaches

1. Patient Education and Self-Management

   • Advise patients to remain active and avoid bed rest 2, 3
   • Provide information about the generally favorable prognosis 3
   • Gradually resume normal activities as tolerated 3

2. Physical Therapy and Exercise

   • Supervised exercise programs with individual tailoring 3
   • Core and back muscle strengthening exercises 3
   • Stretching exercises for piriformis and hamstring muscles 3

3. Medication Management

   • Acetaminophen (maximum 3000mg daily) 3
   • NSAIDs for severe pain (with caution in elderly patients) 3
   • Avoid opioids except for short-term breakthrough pain 3
   • Consider gabapentin or pregabalin for neuropathic pain component 3

4. Heat Therapy

   • Effective for relieving pain and muscle spasm 3

Second-Line Approaches

1. Interventional Procedures

   • Epidural Steroid Injections:

     • 2025 BMJ guideline strongly recommends AGAINST epidural injections for chronic spine pain 2
     • However, epidural steroids are recommended by ASIPP guidelines for spinal stenosis (moderate to strong recommendation) 2

   • Radiofrequency Ablation:

     • Strong recommendation in favor of conventional or cooled lumbar radiofrequency ablation for low back pain 2
     • Perform only after a positive response to a medial branch block 2

   • Trigger Point Injections:

     • Strong recommendation in favor of trigger point injections for chronic back pain 2
     • Local anesthetic preferred; glucocorticosteroids not recommended 2

Surgical Management

Surgery should be considered when:

1. Conservative treatment fails to improve symptoms after 4-6 weeks 1
2. Patient has persistent disabling symptoms 3
3. Progressive neurological deficits are present 3
4. Cauda equina syndrome develops 3

Surgical Approaches

• Decompression: Treatment of choice for central spinal stenosis without significant instability or deformity 1

  • Preserving facet joint and pars interarticularis to avoid iatrogenic instability 1
  • Limited decompression with laminotomy may be indicated for lateral canal stenosis 1

• Decompression with Fusion: Consider when spinal stenosis is associated with:

  • Instability
  • Degenerative spondylolisthesis
  • Deformity
  • Postoperative instability
  • Recurrent stenosis 1

Outcomes and Considerations

• Surgical treatment shows better short-term improvement in symptoms compared to conservative treatment, but long-term outcomes are similar 4, 5
• Complication rates for surgery range from 10% to 24%, including spinous process fracture, hematoma, and risk of reoperation 5
• No significant side effects are typically reported with conservative treatment 5
• Patients with moderate or severe symptoms and those with leg pain and severely restricted walking ability may benefit more from surgery 6

Follow-up and Reassessment

• Reassess at 4-6 week intervals to evaluate treatment response 3
• Monitor for adverse effects of medications 3
• Adjust treatment plan based on response and side effects 3
• Consider surgical consultation if symptoms persist despite conservative management 1

Alternative Therapies

• Mindfulness-based stress reduction
• Massage therapy
• Tai chi, yoga, and qigong
• Cognitive behavioral approaches to address fear of movement 3