From the Guidelines
The best management for lumbar stenosis with associated increasing weakness is prompt surgical decompression, as it offers the best chance to prevent permanent nerve damage and restore function. When neurological deficits are progressing, surgery should not be delayed. The procedure typically involves a laminectomy to remove portions of the vertebral bone and ligaments that are compressing the spinal nerves. For patients with concurrent instability, fusion may also be necessary. According to a recent umbrella review of level 1 evidence published in the BMJ in 2021 1, lumbar spine decompression for spinal canal stenosis has been shown to be effective, although the quality of the evidence is low.
Some key points to consider in the management of lumbar stenosis with increasing weakness include:
- The importance of not delaying surgery when neurological deficits are progressing, as this can lead to permanent nerve damage and disability.
- The use of conservative measures, such as oral steroids (e.g., dexamethasone 4-6mg every 6 hours for 24-48 hours) and NSAIDs (e.g., naproxen 500mg twice daily), which can be used temporarily prior to surgery, but should not substitute for definitive surgical treatment.
- The need for post-surgery rehabilitation to optimize functional recovery and prevent recurrence.
- The comparison of surgical procedures, including decompression, spinal fusion, and interspinous process device implantation, which have shown similar effects in terms of pain intensity, physical function, and quality of life, although interspinous process device implantation may be associated with higher reoperation rates 1.
Overall, the goal of management is to prevent further neurological deterioration, restore function, and improve quality of life, with prompt surgical decompression being the most effective treatment option for lumbar stenosis with associated increasing weakness.
From the Research
Management of Lumbar Stenosis
The management of lumbar stenosis with associated increasing weakness can be approached through both non-surgical and surgical methods.
- Non-surgical management options include:
- Drugs: such as nonsteroidal anti-inflammatory drugs (NSAIDs) 2
- Physiotherapy: to improve mobility and reduce pain 3, 2, 4
- Spinal injections: with or without corticosteroids, although long-term benefits have not been demonstrated 2, 4
- Lifestyle modification: such as reducing periods of standing or walking 2, 5
- Multidisciplinary rehabilitation: to address the overall well-being of the patient 3
- Surgical management options include:
- Decompressive laminectomy: which has been shown to improve symptoms in patients with symptomatic and radiographic degenerative lumbar spinal stenosis 2
- Lumbar fusion: which may be considered for patients with concomitant spondylolisthesis, although the precise indications remain unclear 2
- Minimally invasive surgery: which has been found to result in excellent outcomes in the treatment of lumbar spinal stenosis 6, 4
Considerations for Management
When considering management options for lumbar stenosis with associated increasing weakness, it is essential to note that:
- The diagnosis can generally be made based on a clinical history and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI) 2, 5
- The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency 3
- Surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions 3