Study Design. A cohort study of nonoperatively treated patients with lumbar spinal stenosis.
Objective. To assess the effectiveness of aggressive nonsurgical treatment for lumbar spinal stenosis.
Background Data. While surgical treatment of lumbar spinal stenosis has been widely accepted, the natural history of this condition is poorly documented. Moreover, the effect of other available therapies is unclear.
Methods. Forty-nine patients meeting radiographic and clinical criteria for spinal stenosis underwent nonsurgical intervention consisting of therapeutic exercises, analgesics, and epidural steroid injections. Patients were followed for an average of 33 months. Outcome was assessed using a recently developed patient questionnaire for assessment of patients with lumbar spinal stenosis. Survival analysis was used to assess the probability of surgical intervention over the follow-up period.
Results. At 3 years following treatment, 9 of the 49 patients had undergone surgical intervention. Of the remaining 40 unoperated patients, it is reported that two suffered significant motor deterioration, one of whom still reported overall symptoms as mild improvement, and the other as definite worsening. Five of the 40 unoperated patients reported feeling overall symptoms as probably or definitely worse, 12 reported no change, 11 reported only mild improvement, and 12 reported sustained improvement. Twelve of the 40 unoperated patients also had none or only mild pain.
Conclusions. The authors conclude that aggressive nonoperative treatment for spinal stenosis remains a reasonable option.
Degenerative lumbar spinal stenosis is a common cause of lower back and lower extremity pain. With the advent of more sophisticated noninvasive radiographic technology, spinal stenosis is diagnosed more frequently. 10 In the U.S. there has been a reported increase in the number of surgical procedures performed for the diagnosis of lumbar stenosis. 15 Presumably its nonsurgical treatments are also more frequently prescribed. Reported success rates of surgical outcomes vary. 2-5,8,9,13,14 Often surgical intervention is undertaken with the advice that nonoperative therapies seldom result in sustained improvement. 8,15 Little is known about the efficacy of nonoperative therapy and which factors are associated with better outcome.
Most previous nonoperative investigations do not adopt a specific nonoperative treatment plan. In 1992, Johnsson published a study entitled The Natural Course of Lumbar Spinal Stenosis, and reported 70% of patients were unchanged and 15% improved after 49 months. 6 He concluded observation seems to be an alternative to surgery, and immediate operation should be advised only if neurologic symptoms develop, or if pain is intolerable. Further confounding results, until recently, outcome measures in both surgical and nonsurgical studies for spinal stenosis were various and not validated. Stucki et al has published an outcome measure adopted in two long-term surgical outcome studies demonstrated to be valid, internally consistent and highly responsive. 12
Nonoperative treatment for spinal stenosis varies but includes bed rest, NSAIDs, analgesics, and oral corticosteroids. Physical therapy is initiated when radiculopathy is less severe. Progressive exercise may help to increase lumbopelvic muscular stabilization and maintain better posterior pelvic tilt. It may also improve cardiovascular conditioning and other factors that enhance soft tissue function. Epidural steroid injection is used frequently to control more severe symptoms. The proposed pharmacologic basis for epidural steroids includes suppression of chemical inflammatory mediators, capillary dilation, ectopic nerve root discharge, and blocking nociceptive nerve fibers.
The purpose of this investigation was to assess the outcome of patients undergoing aggressive nonoperative treatments (therapeutic exercise, analgesics, and epidural steroid injections) in terms of survivorship (transfer back to surgery), back and leg pain severity and frequency, walking function, and satisfaction.