From the Guidelines
The treatment plan for lumbar spinal stenosis with disc disease should prioritize conservative management, including physical therapy and pain management with NSAIDs, before considering surgical options. This approach is supported by the American College of Physicians and the American Pain Society's joint clinical practice guideline, which recommends providing patients with evidence-based information on low back pain, advising them to remain active, and informing them about effective self-care options 1.
Conservative Management
Conservative management should include:
- Physical therapy focusing on core strengthening and lumbar flexibility exercises, performed 2-3 times weekly for 6-8 weeks
- Pain management with NSAIDs such as ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily with food) for 2-3 weeks, then as needed
- Activity modification to avoid prolonged standing, heavy lifting, and activities that worsen symptoms
- Consideration of epidural steroid injections containing methylprednisolone or triamcinolone for temporary relief of radicular symptoms
Surgical Options
Surgical options, such as laminectomy or minimally invasive procedures, should be considered if conservative measures fail after 3-6 months or neurological deficits worsen. The decision to proceed with surgery should be based on the clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, surgical risks, and costs, and will generally require specialist input 1.
Diagnostic Imaging
Magnetic resonance imaging (MRI) or CT scans are recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions, as they can accurately evaluate the degree of spinal stenosis and visualize discs 1. However, clinicians should be aware that findings on MRI or CT are often nonspecific and should be interpreted in the context of clinical symptoms and severity.
Patient Education
Patients should be informed about the generally favorable prognosis of acute low back pain, the importance of remaining active, and the effectiveness of self-care options, as well as the potential risks and benefits of surgical interventions 1. A stepwise approach, prioritizing conservative management and reserving surgical options for those who do not respond to conservative treatment, is the most effective way to manage lumbar spinal stenosis with disc disease and improve patient outcomes.
From the Research
Treatment Options for Lumbar Spinal Stenosis with Disc Disease
- Nonoperative treatment includes: + Activity modification, such as reducing periods of standing or walking 2 + Oral medications to diminish pain, such as nonsteroidal anti-inflammatory drugs (NSAIDs) 2, 3 + Physical therapy 2, 4, 3
- Surgical options: + Decompressive laminectomy, which has been shown to improve symptoms in carefully selected patients 2 + Lumbar fusion, which may be considered for patients with concomitant spondylolisthesis, but is associated with greater risk of complications 2 + Epidural steroid injections, which may provide short-term relief, but have not been shown to have long-term benefits 2, 4
Effectiveness of Treatment Options
- A systematic review found insufficient evidence to recommend any specific type of non-surgical treatment 5
- A randomized controlled trial found that epidural steroid injections and physical therapy both improved pain and functional parameters in patients with lumbar spinal stenosis, but there was no significant difference between the two treatment groups 4
- A prospective longitudinal quality of life spine registry found that comprehensive medical management did not result in sustained improvement in pain, disability, or quality of life for patients with surgically eligible degenerative lumbar spondylolisthesis, stenosis, or disc herniation 6
Considerations for Treatment
- The diagnosis of lumbar spinal stenosis can be made based on a clinical history and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI) 2, 3
- Surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions 5
- The precise indications for concomitant lumbar fusion in persons with lumbar spinal stenosis and spondylolisthesis remain unclear 2