Treatment Options for Mild to Moderate Spinal Canal Stenosis
For patients with mild to moderate spinal canal stenosis, conservative treatment should be the initial approach, as the natural history often includes long periods of stability or even improvement, with surgical intervention reserved for those who fail conservative management or show progressive neurological deficits.1, 2
Clinical Presentation and Natural History
- Cervical spinal stenosis typically presents with low-back pain, weakness, radiculopathy, claudication, and occasionally bowel or bladder dysfunction 2
- The natural history of mild to moderate spinal stenosis is mixed, with many patients experiencing slow, stepwise decline, but long periods of quiescence are not uncommon 1
- In patients younger than 75 years with mild cervical spondylotic myelopathy (mJOA scale score > 12), nonoperative management is associated with a stable clinical course over a 36-month period 1
- Clinical gains from nonoperative treatment are often maintained over 3 years in approximately 70% of patients 1
Diagnostic Evaluation
- MRI (preferred) or CT is recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions 1
- Plain radiography cannot visualize discs or accurately evaluate the degree of spinal stenosis 1
- Asymptomatic radiographic stenosis does not require intervention 2
- Cord signal changes on T2-weighted MRI images are a sign of myelopathy and may indicate need for more aggressive treatment 2
Conservative Treatment Options
First-Line Approaches
- Patient education about the generally favorable prognosis and self-care options 1
- Advice to remain active, which is more effective than bed rest for patients with acute or subacute back pain 1
- Multimodal nonpharmacological therapies including:
Additional Conservative Measures
- Traditional acupuncture on a trial basis (though evidence quality is very low) 3
- Delordosing physiotherapy and epidural injections may be considered in the initial management 4
- A trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants may be considered 3
Treatments Not Recommended
- Evidence does not support the use of:
- NSAIDs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants 3
- Pregabalin, gabapentin 3
- Epidural steroid injections (high-quality evidence against their effectiveness) 3
- Strong evidence indicates that steroid epidural injections are not effective 5
- Moderate evidence indicates that calcitonin is not effective 5
Indications for Surgical Management
- Surgical intervention is indicated for:
- Patients with progressive neurological deficits 2
- Patients with cord signal change or syringomyelia 2
- Those with severe and/or long-lasting symptoms 2
- Failure of conservative treatment after 3-6 months in patients with severe symptoms 4
- Clinically relevant motor deficits or symptoms of cauda equina syndrome (absolute indications) 4
Surgical Approaches
- Decompression with fusion provides better long-term outcomes for pain relief, functional improvement, and quality of life 2
- Approximately 97% of patients have some recovery of symptoms after appropriate surgical intervention 2, 6
- For patients with stenosis and degenerative spondylolisthesis, decompression with fusion is recommended over decompression alone 1
- Laminectomy alone is associated with higher risk of reoperation due to restenosis, adjacent-level stenosis, and postoperative spinal deformity 2
Cautions and Considerations
- Long periods of severe stenosis can lead to demyelination of white matter and potentially irreversible neurological deficits 1, 6
- Conservative treatment has been shown to be less successful in elderly patients with severe stenosis 7
- There is insufficient high-quality evidence comparing surgery to conservative care, with only one high-quality study showing surgery to be more effective 5
- Surgical risks must be weighed against potential benefits, considering the patient's overall health status 6