Are there any external treatments for stenosis?

External Treatment Options for Stenosis

The type of stenosis and its location determine whether external (non-invasive) treatment is appropriate, with vascular stenosis requiring different approaches than spinal stenosis.

Vascular Stenosis (Carotid, Vertebral, Intracranial)

Medical Management as Primary External Treatment

Optimal medical therapy is the foundation for all patients with vascular stenosis and represents the primary "external" (non-surgical) approach. 1

• Antiplatelet therapy is recommended for all patients with symptomatic vascular stenosis 1
• Statin therapy should be initiated regardless of stenosis severity 1
• Risk factor modification including blood pressure control (<140/90 mmHg) and cholesterol management (total cholesterol <200 mg/dL) may be reasonable for intracranial stenosis 1

When External Treatment Alone Is Insufficient

For carotid stenosis <50%, there is no indication for any intervention beyond medical management 1. However, for more severe stenosis:

• Carotid stenosis 50-69%: Medical therapy alone may be insufficient; CEA is recommended depending on patient factors 1
• Carotid stenosis 70-99%: Surgical intervention (CEA or CAS) is recommended as medical therapy alone has proven inadequate 1

Important caveat: The term "external" treatment for vascular stenosis does not include endovascular procedures (angioplasty, stenting), which are invasive catheter-based interventions, not truly external therapies. 1, 2

Vertebrobasilar and Intracranial Stenosis

• Optimal medical therapy (antithrombotics, statins, risk factor control) is the primary recommendation 1
• Endovascular treatment may be considered only when symptoms persist despite medical therapy, but remains investigational for intracranial disease 1
• EC/IC bypass surgery is not recommended for symptomatic carotid occlusion or intracranial stenosis 1

Lumbar Spinal Stenosis

Non-Surgical External Treatments Are First-Line

For lumbar spinal stenosis causing neurogenic claudication, multimodal non-surgical care should be the initial approach. 3

Recommended External Therapies:

• Patient education and lifestyle modifications combined with home exercise programs 3
• Manual therapy and rehabilitation with behavioral change techniques 3
• Physical therapy focusing on exercises that promote lumbar flexion (which relieves symptoms) 4, 5
• Activity modification: reducing standing/walking periods that provoke symptoms 5

Pharmacological External Options:

• NSAIDs for pain control are commonly used in clinical practice 5
• Serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants may be considered on a trial basis 3

Important pitfall: Epidural steroid injections, while minimally invasive, have not demonstrated long-term benefits for lumbar spinal stenosis 5

Medications to Avoid:

The following should not be used for lumbar spinal stenosis: 3

• Pregabalin and gabapentin
• Muscle relaxants
• Opioids
• Calcitonin
• Methylcobalamin

Natural History Without Surgery

• Approximately one-third of patients improve with conservative management over 3 years 5
• About 50% remain stable without worsening 5
• Only 10-20% deteriorate and may require surgical intervention 5

Median Arcuate Ligament Syndrome (Special Case)

For this specific type of external compression causing celiac artery stenosis:

• Supportive measures (counseling, analgesia, dietary modifications) showed improvement in only one-third of patients compared to 93% with operative management 1
• External compression requires surgical release of the median arcuate ligament for definitive treatment 1
• Endovascular stenting alone without surgical release is generally ineffective due to persistent external compression 1

Clinical Algorithm for Decision-Making

1. Identify stenosis type and location through appropriate imaging (CT, MRI, ultrasound)
2. For vascular stenosis: Initiate optimal medical therapy immediately 1
   • If stenosis <50%: Continue medical management only 1
   • If stenosis ≥50-70% with symptoms: Consider revascularization 1
3. For spinal stenosis: Begin multimodal conservative care 3, 5
   • Continue for 3-6 months minimum before considering surgery
   • Surgery reserved for progressive intolerable symptoms or neurological deterioration 6
4. Monitor response at regular intervals with objective measures of pain, function, and quality of life

Critical distinction: True "external" treatment means non-invasive medical management. Endovascular procedures, while less invasive than open surgery, are still interventional procedures requiring catheter insertion and are not external treatments. 1, 2