Treatment for Back Pain with MRI-Confirmed Spinal Stenosis
For a patient with back pain and MRI-confirmed spinal stenosis, initiate conservative management with activity modification (reducing standing/walking periods), NSAIDs for pain control, and physical therapy, reserving surgical decompression for those who fail to improve after 6 weeks of optimal conservative treatment and remain surgical candidates. 1, 2
Initial Conservative Management (First-Line Treatment)
Start with activity modification by reducing periods of standing or walking, as lumbar extension provokes symptoms in spinal stenosis while flexion provides relief 2
Prescribe NSAIDs as the primary oral medication to diminish pain 2
Refer to physical therapy as part of the conservative treatment triad 3, 2
Reassure the patient that approximately one-third will improve with conservative management alone over 3 years, while about 50% will remain stable 2
When to Escalate Treatment
Reassess at 6 weeks - if symptoms persist after optimal conservative management and the patient remains a surgical candidate, proceed with surgical evaluation 1
Consider epidural steroid injections cautiously - while they may be attempted, long-term benefits for lumbar spinal stenosis have not been demonstrated 2
Surgical Intervention Criteria
Offer decompressive laminectomy to carefully selected patients with back, buttock, and lower extremity pain who fail conservative management 2
Decompressive surgery improves symptoms more than continued nonoperative therapy in patients with symptomatic radiographic stenosis (7.8-point improvement on Oswestry Disability Index) 2
Avoid routine fusion unless specific indications exist - fusion adds greater risk of complications (blood loss, infection, longer hospital stays, higher costs) without clear additional benefit in most stenosis cases 2
Urgent Red Flags Requiring Immediate Intervention
Perform emergency surgical decompression if cauda equina syndrome develops (bladder/bowel/sexual dysfunction, saddle anesthesia, bilateral lower extremity weakness) 1
Expedite surgery for rapidly worsening motor weakness or multifocal neurologic deficits, as delayed diagnosis worsens outcomes 1
Common Pitfalls to Avoid
Do not rely on epidural steroid injections as a long-term solution - evidence does not support sustained benefit 2
Avoid premature imaging - the MRI has already been done, but recognize that findings often correlate poorly with symptoms in asymptomatic individuals 1
Be cautious with supine positioning during procedures in patients with extension-exacerbated pain, as this may further compress neural tissue 4
Medication Considerations for Neuropathic Component
Consider pregabalin if radicular neuropathic pain is prominent, as it is FDA-approved for neuropathic pain associated with spinal cord injury and may benefit radicular symptoms 5, 3
Dose pregabalin flexibly from 150-600 mg/day based on response and tolerability if neuropathic features predominate 5