Current treatment of lumbar stenosis

Lumbar Spinal Stenosis

Conservative Management for the “Simple” Minded Practitioner

By Joe Hlavin PA-C

The Only Way To Heal Is With Ice Cold

Steal

Conservative Management of LSS is Anything and

Everything Other than the Last Slide

And when the patient in your office tells you:

I don’t want surgery, you might look like this…

But Seriously……..

Current Treatment of Lumbar Stenosis

Role of Non-Operative Management

By

Joseph Hlavin PA-C

Goals of this Presentation(BUT Not to bore you)

• Quickly– Review the clinical presentation of LSS– Review causes of LSS

• List the different conservative treatments available

• Propose a debate on when it is reasonable to offer conservative management over surgery

• Offer articles/studies as a guide for who, when and for how long

Overview

1. Hypertrophy of the Yellow Ligament

2. Flattening/bulging disc

3. Facet Hypertrophy

4. Foraminal Stenosis

5. Canal Stenosis

Hallmark Symptoms

• Neurogenic Claudication

• +/- Lower back pain

• +/- hip and/or radicular pain

• Improvement of pain with forward flexion of the lumbar spine:– Shopping cart sign– Easier walking up hill

Neurogenic Claudication

• Not to be confused with Vascular Claudication

– Neurogenic:• Symptoms w/ walking AND standing• Variable walking distance w/o symptoms• Relief w/ sitting & flexion• Lower extremity pulses OK

Neurogenic Claudication

– Vascular Claudication• Symptoms w/ walking BUT NOT standing• NO variability in walking distance prior to

onset of symptoms• NO relief with lumbar flexion• Diminished pulses in feet

Degenerative Lumbar Stenosis

• Age related: (Spondylosis)– Spondylosis – Degeneration

of the facet joints– Degenerative spondylolithesis– Facet arthropathy– Degenerative disc bulge/spur– Hypertrophic ligamentum flavum

Stenosis to a Degree

• Mild

• Moderate

• Severe

Degenerative Lumbar StenosisMild

Lumbar Stenosis - Moderate

Lumbar Stenosis - Severe

Flaniken, DorisFlaniken, DorisM000473610M00047361012/14/193512/14/1935FF

Page: 32 of 39Page: 32 of 39

TE: 86TE: 86TR: 8830TR: 8830FA: 180FA: 180SESEEC: 0EC: 0

St. J oseph Regional Health Center St. J oseph Regional Health CenterLUMBAR SPINE MRI W/O CONTRASTLUMBAR SPINE MRI W/O CONTRAST

t2_tse_rst_tra_msmat2_tse_rst_tra_msma 2/12/2007 15:40:26 2/12/2007 15:40:26

001087049001087049

LOC: - 100.81 LOC: - 100.81THK: 4 SP: 4.4THK: 4 SP: 4.4

HFSHFS

IM: 32 SE: 4IM: 32 SE: 4Compressed 7 :1Compressed 7 :1

W: 708W: 708C: 314C: 314

Z: 1.60Z: 1.60

RR LL

AA

PP cm cm

Flaniken, DorisFlaniken, DorisM000473610M00047361012/14/193512/14/1935FF

Page: 9 of 15Page: 9 of 15

TE: 115TE: 115TR: 3750TR: 3750FA: 170FA: 170SESEEC: 0EC: 0

St. J oseph Regional Health Center St. J oseph Regional Health CenterLUMBAR SPINE MRI W/O CONTRASTLUMBAR SPINE MRI W/O CONTRAST

t2_tse_rst_sagt2_tse_rst_sag 2/12/2007 15:27:21 2/12/2007 15:27:21

001087049001087049

LOC: - 6.87 LOC: - 6.87THK: 4 SP: 4.4THK: 4 SP: 4.4

HFSHFS

IM: 9 SE: 2IM: 9 SE: 2Compressed 7 :1Compressed 7 :1

W: 378W: 378C: 110C: 110

Z: 1.14Z: 1.14

AA PP

HH

FF cm cm

L4-5

Lumbar Stenosis – Other Causes

• Causes of non-arthritic lumbar canal stenosis:– Disc rupture– Tumor– Abscess– Hematoma– Trauma/FX

Spinal Stenosis - Trauma

Lumbar Stenosis – Abscess

Lumbar Stenosis - Tumors

The Conservative Approach• Medications

– NSAIDsAcetaminophenOral corticosteroidsMuscle relaxantsNarcoticsNeurontin / Lyrica

The Conservative Approach• Physical Therapy

ConditioningStretchingStrengtheningModalities   (i.e., heat, ice, ultrasound, electrical stimulation)

• Encourages weight loss; improves aerobic conditioning

• Lumbosacral corset (soft) or Lumbosacral orthosis (rigid)

The Conservative Approach

• Epidural Steroid Injections– including:

• Caudal blocks• Central epidural steroids• Foraminal epidural steroids

Epidural Steroid Inj (ESI)

• Staple of conservative management

• Usually given in a “series” of 3

• But usually limited to 3 injections in a year

• Not a long term solution

• Literature support is limited

The Conservative Approach

• Alternative treatments

– Chiropractor

– DRX-9000 (Traction Device)

Questions?• Who gets surgery, who does not?

• When do we institute conservative treatment?

• How long do we pursue a conservative route?

• What literature is out there to provide guidance?

Who gets what treatment?Flaniken, DorisFlaniken, DorisM000473610M00047361012/14/193512/14/1935FF

Page: 9 of 15Page: 9 of 15

TE: 115TE: 115TR: 3750TR: 3750FA: 170FA: 170SESEEC: 0EC: 0

St. J oseph Regional Health Center St. J oseph Regional Health CenterLUMBAR SPINE MRI W/O CONTRASTLUMBAR SPINE MRI W/O CONTRAST

t2_tse_rst_sagt2_tse_rst_sag 2/12/2007 15:27:21 2/12/2007 15:27:21

001087049001087049

LOC: - 6.87 LOC: - 6.87THK: 4 SP: 4.4THK: 4 SP: 4.4

HFSHFS

IM: 9 SE: 2IM: 9 SE: 2Compressed 7 :1Compressed 7 :1

W: 378W: 378C: 110C: 110

Z: 1.14Z: 1.14

AA PP

HH

FF cm cm

OR

-71 y/o female-Severe claudication-Over weight-Poor cardiac function-Newly diagnosed pulmonary lesion

-64 y/o female-Incapacitating LBP-N. Claudication-Healthy

At what point should conservative treatment be used?

• In a perfect world, all non operative management is tried prior to the first visit to the office

• For certain patients, non surgical means should be exhausted prior to surgical consideration

• Initial focus should be on patient education, pain control, and getting the patient back to ADL

How long do we give non operative treatment?

• Based on each individual patient– Symptoms– Clinical findings

• The “gut” feeling of the practitioner based on experience

Now is the time for the coffee to kick in!!!

BORING RESEARCH DATA ALERT!!

What does the literature say?

• Non operative treatment of LSS w/ 3 year outcome analysis by Simotas et al (2000)

• Maine Lumbar Spine Study by Atlas et al (2005) – perspective observational study

• A randomized controlled trial for surgical vs. non surgical treatment of LSS, Malmivaar et al (2006)

Non operative treatment of LSS w/ 3 year analysis

• 49 patients treated non operatively

• Excluded if < 50 y/o and history of previous lumbar surgery

• Inclusions were severe back, buttock, and leg pain w/ MRI and/or CT evidence of single level central LSS

• Methodic regimen of conservative therapy

Non operative treatment of LSS w/ 3 year analysis

• Conservative regimen (each step based on outcome of previous treatment)– Bed rest– Tapered oral corticosteroids– Epidural steroid (2 – 3 at physician discretion)– NSAIDS for 4 -6 week periods

• Aggressive rehab/PT during above tx

Non operative treatment of LSS w/ 3 year analysis

• Mean F/U 33 months (16 – 55 months)• conclusion:

– Authors suggest that conservative treatment is a viable option for LSS base on:

• 25% significant improvement in symptoms and satisfaction

• Rare neurologic deterioration over time of study

• But you decide for your self

Is 25% acceptable?

Maine Lumbar Spine Study• 1,4,and 8 to 10 year follow ups

• Patients recruited from various orthopedic, neurosurgical, and occupational clinics in Maine

• 148 initial patient population

• 81 patients underwent surgical decompression

• 67 patients treated non surgically

Maine Lumbar Spine Study

• Moderate findings/ moderate symptoms• Surgical patients had the worse baseline

symptoms and function• Conclusions after 1 year:

– Best outcomes in the surgical population were observed in the first 3 months after surgery

– No significant change in symptoms were noted in the non operative population but also no worsening of neurologic function

Maine Lumbar Spine Study

• Conclusions at 4 years:– 119 patients remaining– 70% of surgical patients report improvement in

symptoms vs. 52% of non surgical patients– 63% of surgical patients satisfied with symptoms vs.

42% of non surgical patients– Moderate decline in the satisfaction of the surgical

group– Conversely, the non operative group moderate

improvement in symptoms and stability– ? convergence

Maine Lumbar Spine Study

• Conclusions at 8 to 10 years:– 105 remaining patients at 8 years– 97 remaining at 10 years– 53% of surgical patients improved– 52% of non surgical patients improved– 55% of surgical patients satisfied– 49% of non surgical patients satisfied

Maine Lumbar Spine Study

• Results were tainted by:– 23% of surgical patients required re-operation– 39% of non surgical patients underwent at least on

lumbar surgery

• Ultimately:– There was a similarity between the results of the initial

treatment and the 8/10 F/U– Leg pain relief and functional issues still favored initial

surgical management

A randomized controlled trial for surgical vs. non surgical treatment of LSS

• 94 patients• 50 surgical/ 44 non surgical• Surgical: segmental decompression w/o

facetectomy• Non surgical: under the care of physiatrist

(NSAIDS and physical therapy. No mention of ESI in this report)

• 6 month, 1 year, and 2 year F/Us

A randomized controlled trial for surgical vs. non surgical treatment of LSS

• Included:– Clinical symptoms of LSS– Persistent pain w/o neurological deficit– Spinal canal <10mm on MRI– Duration of symptoms > 6 months– Disease level could be treated either way

A randomized controlled trial for surgical vs. non surgical treatment of LSS

• Extensive exclusion list:– Previous surgery– Severe stenosis w/ progressive neurologic deficit– LSS that was too mild (wouldn’t warrant surgery)– Other spinal disorders/pathology– Diabetic neuropathy– Other disorders of the lower limbs– Psychiatric disorders/alcoholism– Diagnosis of herniated lumbar disc in past 12 mon

A randomized controlled trial for surgical vs. non surgical treatment of LSS

• Of note:– Mean age was 62/63 (ns/s)– Majority of both group were retired– time of symptoms from onset (yrs): 14/16– Most participants in both groups perceived their

health as poor– Exam: neg SLR, low percent of LBP, better w/ lumbar

FF, >50% decreased vib sense, and >30% had loss of AJ reflex

A randomized controlled trial for surgical vs. non surgical treatment of LSS

• Results:– 4 areas calculated:

• Oswestry Disability Index• Leg pain during walking• LBP during walking• Self reported walking distances

• Oswestry Index (disablility) (0 – 100%)– Ref. 0-20% stbl/no tx, 21-40% mod/cons tx– At 24 months: (NS) 29% vs (S) 21%

• Leg pain w/ walking (@ 24 months)– 0 – 10 pain scale– 4.5 (NS) vs. 3 (S)

• LBP w/ walking (@ 24 m, same scale)– ~5 (NS) vs. ~2.5 (S)

A randomized controlled trial for surgical vs. non surgical treatment of LSS

A randomized controlled trial for surgical vs. non surgical treatment of LSS

• Self reported walking distances– At 1 year F/U

• 1.28 miles (NS) vs. 1.38 miles (S)

– At 2 year F/U• 1.26 miles (NS) vs. 1.29 miles (S)

– Not a very significant difference in distance from one group to the other

A randomized controlled trial for surgical vs. non surgical treatment of LSS

• Conclusions:– Surgical patients did better in terms of

disability, leg pain, and LBP– Walking distance was not clinically significant

as noted– There was meaningful recovery in the non

surgical group– Supports surgical decompression after

exhaustion of conservative treatments

My Conclusions

• Simply:– Each patient represents a different set of

circumstances regarding their level and tolerance of pain and disability

– Finding on studies and neurological deficit tend to push surgeons to offer decompression

– BUT patients are motivated more by how they feel and what they are willing to tolerate

My Conclusions

• Moreover:– Studies have proven efficacy of conservative

management for patients with LSS– When to institute non operative therapy and

once started, when to stop are not well outlined for the practitioner

– Individual conservative measures need to be studied better

My Conclusions

• So FINALLY:

– Nothing short of surgical decompression will structurally change the diameter of the stenotic segment

– Although extensive studies have proven the worth of conservative management for LSS, most came up short of providing data that allows the practitioner to make a confident decision

Thank You