What are the treatment options for pain management in spinal stenosis?

Pain Management for Spinal Stenosis

For patients with spinal stenosis, a stepped approach to pain management is recommended, beginning with acetaminophen or NSAIDs as first-line medications, followed by physical therapy and exercise, with interventional procedures reserved for those who fail conservative management. 1

Pharmacological Management

First-Line Medications

• Acetaminophen is a reasonable first-line option due to its favorable safety profile, though it provides slightly less pain relief than NSAIDs 1
• NSAIDs are more effective for pain relief than acetaminophen but carry gastrointestinal and cardiovascular risks that should be assessed before prescribing 1
• Use the lowest effective NSAID dose for the shortest period necessary to minimize adverse events 1

Second-Line Medications

• Muscle relaxants (such as cyclobenzaprine, tizanidine, or metaxalone) can be considered for short-term use when muscle spasm contributes to pain 1
• Opioid analgesics should only be used judiciously in patients with severe, disabling pain that is not controlled with acetaminophen and NSAIDs due to substantial risks of adverse effects and potential for dependence 1
• Gabapentin may provide small, short-term benefits in patients with radiculopathy associated with spinal stenosis 1

Non-Pharmacological Approaches

Physical Activity and Self-Care

• Patients should be advised to remain active rather than resting in bed, as this is more effective for managing pain 1
• Application of heat using heating pads or heated blankets can provide short-term relief 1
• Medium-firm mattresses are preferred over firm mattresses for patients with chronic back pain 1
• Self-care education based on evidence-based guidelines is recommended as an inexpensive and efficient supplement to clinical care 1

Physical Interventions

• Exercise therapy is moderately effective for chronic low back pain, with programs that incorporate individual tailoring, supervision, stretching, and strengthening showing the best outcomes 1
• Spinal manipulation may provide small to moderate short-term benefits for acute low back pain 1
• Massage therapy has shown moderate effectiveness for chronic low back pain 1
• Acupuncture can be considered for chronic low back pain 1

Interventional Procedures

Epidural Injections

• The 2025 BMJ Clinical Practice Guideline strongly recommends against epidural injection of local anesthetic, steroids, or their combination for chronic axial spine pain 1
• The American Society of Interventional Pain Physicians (ASIPP) has contradictory recommendations, supporting fluoroscopically guided epidural injections for spinal stenosis 1
• Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been consistently demonstrated 2

Radiofrequency Ablation

• The 2025 BMJ guideline strongly recommends conventional or cooled lumbar radiofrequency ablation for low back pain 1
• However, the 2021 American College of Occupational and Environmental Medicine guideline recommends against radiofrequency neurotomy for chronic low back pain 1

Surgical Management

• Surgery should be considered for patients with persistent symptoms associated with spinal stenosis who have failed conservative management 1
• Decompressive surgery appears more effective than non-operative therapy in carefully selected patients with symptomatic and radiographic lumbar spinal stenosis 2
• For patients with spinal stenosis and spondylolisthesis, evidence is mixed regarding whether fusion provides additional benefit beyond decompression alone 2
• Only about 10-20% of patients with lumbar spinal stenosis report worsening symptoms over time without surgical intervention 2

Common Pitfalls and Caveats

• Avoid prolonged bed rest as this can lead to deconditioning and potentially worsen symptoms 1
• Be cautious with NSAIDs in older patients and those with cardiovascular, renal, or gastrointestinal risk factors 1
• Routine imaging is not recommended for initial evaluation unless there are red flags suggesting serious underlying conditions 1
• Extended courses of medications should be reserved for patients showing continued benefits without major adverse events 1
• Recognize that findings on MRI (such as bulging discs) may be nonspecific and should be correlated with clinical symptoms 1