3 The First Five Things Your Central Lumbar Stenosis Patients Should Know
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Dynamic Chiropractic – June 1, 2016, Vol. 34, Issue 11

The First Five Things Your Central Lumbar Stenosis Patients Should Know

By Ronald Fudala, DC, DACAN

Lumbar canal stenosis is becoming more prevalent as the population ages and a common reason patients undergo spine surgery.1-2 An estimated 65 million people will be afflicted over the next decade.3-4 The disorder is a common presentation in chiropractic practice, as shown in the SPORT trial, in which 33 percent of 368 stenosis patients studied had received previous chiropractic care.5

Let's explore five basic items worthy of discussion in order to build a solid foundation for shared decision-making between clinicians and their lumbar central canal stenosis patients. Shared decision-making is a process mentioned more frequently as a model for clinical practice6 and has been defined as "an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences."7

1. Back Pain Is Not Enough

Patients must first know that back pain alone is not symptomatic central canal stenosis. Asymptomatic lumbar canal stenosis can be seen in up to 47 percent of patients presenting with isolated back pain.8 The high rate of MRI abnormalities in completely asymptomatic patients has long been known, as has the fact that many are performed discordant with published guidelines.9-11

Problems arise from the start when imaging findings are overemphasized. Doing so leads to patients with a decreased perception of health, fear-avoidance and catastrophizing behavior, increased risk of chronicity, and a two- to three-fold rate of undergoing unnecessary surgery.12

Symptomatic lumbar central stenosis must involve the legs, usually to a much greater degree than the low back, and be clearly related to posture or activity. The North American Spine Society's (NASS) 2011 guidelines define it as a variable clinical syndrome of gluteal and/or low-extremity pain and fatigue, which may occur with or without back pain. Provocative features should include exercise in upright postures, with relief occurring during forward flexion, sitting or when recumbent.13

A recent study reinforced this, further noting an 80 percent diagnostic certainty when pain / tingling with walking, relief with sitting, bending or leaning on a shopping cart, and normal low-extremity pulses occurred in combination.14 It is not uncommon for nonspecific urinary disturbances and nocturnal leg cramps to be a part of the symptom complex.15-16

2. Symptom Severity and MRI Findings Don't Correlate

Symptomatic patients should understand that the severity of their symptoms, or outcome with any form of treatment, bears little, if any, relationship to what is seen on their MRI. Servanci, et al., found no correlation between the Oswestry Index and degree of stenosis on MRI, further noting a large number of individuals with spinal canal narrowing, yet without symptoms.17 Moojen and Schenk's study of 115 patients with intermittent lumbar claudication showed that the degree of stenosis on MRI neither correlated with the severity of symptoms nor had the ability to predict success with lumbar surgery.18

Results are similar when larger groups are observed. Of 938 patients with MRI-confirmed lumbar stenosis, only 5.3 percent of mild, 9.9 percent of moderate and 17.5 percent of severely stenotic patients were symptomatic.19

Additional substantiation is found in a recent paper in which the authors concluded, "The radiologic severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes, and should not be overemphasized in clinical decision making."20

The relationship between symptoms and imaging becomes more obscure when studies report paradoxical findings, such as higher levels of pain and disability in individuals with moderate and single-level stenosis, as compared to those with severe and/or multi-level stenosis.21-22

For balance, it's important to note that a few papers have described a correlation between imaging and symptoms. However, these found the correlation related more to walking tolerance than pain.23-24

3. There's Usually Good News

The natural history of lumbar stenosis is generally favorable. Patients can be confidently informed that there is no urgent need to consider surgery. The NASS guidelines mentioned above state, "[T]he natural history of patients with clinically mild to moderately symptomatic degenerative lumbar stenosis can be favorable in about one-third to one half of patients," and "rapid or catastrophic neurologic decline is rare." NASS felt the present literature was insufficient to determine the natural history of severe lumbar stenosis.

In the absence of clarity regarding the natural history of severe stenosis, it is interesting to note a study by Pearson, et al., which found individuals with severe symptomatic stenosis (> than 56 on the Oswestry Index) fared far better with conservative care as compared to surgery.25

Other research has found that over a five-year period, 70 percent of patients remain stable, 15 percent improve and only 15 percent deteriorate.26-27 In a smaller cohort of 39 patients with asymptomatic lumbar stenosis, 35 remained asymptomatic over a mean follow-up period of 6.5 years.28

4. Patients Have Care Options

The best type of treatment for lumbar stenosis has not been clearly established. Patients have options and should be informed about them. Most authorities recommend conservative care before considering surgery. A recent review found no clear benefits for surgery compared to nonsurgical treatment, a 10-24 percent complication rate with surgery, and no complications with conservative care.31 The authors concluded, "These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects."

Other studies have shown surgery as a more beneficial option, at least over a four-year observation period.32

Most of the commonly utilized nonsurgical treatments have literature both supporting and refuting the various approaches. To date, systematic reviews have failed to define one form of conservative care as being superior to another.33-34

Studies have shown how commonly patients choose inappropriate clinical pathways.35 The first provider seen is often a determinant of this, especially when personal bias, rather than clinical evidence, is used in decision-making.36 With such potential for bias, patients need clinicians who are not only knowledgeable about the outcomes of a wide variety of conservative measures, but also willing to use these as a guide in treatment recommendations.

(The outcomes and expectations for conservative care of lumbar stenosis, and how to use them, will be discussed in a future article.)

5. A Dose of Reality Is Critical

A patient needs to have realistic expectations about their care. Success rarely implies a complete resolution of symptoms, regardless of what treatment is chosen. This "expectation-actuality" discrepancy was recently explored by Witiw, et al., who found patient expectations frequently exceed outcomes and treatment satisfaction declines as the "expectation-actuality gap" grows.37

A recent study reported that a pain reduction of three or greater on a 10-point scale served as the point at which patients judged their surgery as a success. With this definition, 53 percent of 1,782 lumbar stenosis patients considered their surgery successful.38 A paper reporting on 49 patients undergoing multimodal conservative care, inclusive of flexion-distraction treatment, noted average changes in the ODI from 50.8 to 35.6, VAS back pain from 7-4 and leg pain from 7-5, considering all of these clinically significant improvements.39

A meta-analysis of epidural steroids for lumbar stenosis considered success as a 50 percent or greater reduction in pain, with researchers noting success was obtained in 53 percent of the 1,465 subjects in their analysis. ODI improved by an average of 14.5 percent, and VAS pain scale by 3.8.40

From the above, it is clear that success is rarely complete, and often in the eye of the beholder. Minimally clinically important difference is a term used to describe the lowest threshold of relevant benefit from a given form of treatment. For patients under surgical consideration, it has been reported to be 12.8 percent on the Oswestry Index, and 1.2-1.8, on a 0-10 VAS scale for back-leg pain.41 This also would appear to serve as a reasonable initial target for those patients choosing to undergo chiropractic care.

References

  1. Skolasky RL, Maggard AM, Thorpe RJ, et al. United States hospital admissions for lumbar spinal stenosis;; racial and ethnic differences, 2000 through 2009. Spine, 2013;38:2272--2278.
  2. Aebi M, Gunzburg S, Szpalski S. The Aging Spine. Germany: Springer, 2005.
  3. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med, 2008;358:818--825.
  4. Deyo RA. Treatment of lumbar spinal stenosis: a balancing act. Spine J, 2010;10:625--627.
  5. Cummins J, Lurie JD, Tosteson TD, et al. Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial's (SPORT) three observational cohorts. Spine, 2006;31(7):806-14.
  6. Elwyn G, et al. Shared decision making: a model for clinical practice. J Gen Intern Med, 2012 Oct; 27(10):1361-1367.
  7. Elwyn G, Coulter A, Laitner S, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. BMJ, 2010;341:c5146.
  8. Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, Hunter DJ. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J, 2009 Jul;9(7):545-50.
  9. Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of magnetic resonance imaging. JAMA Intern Med, 2013;173(9).
  10. Boden SD et al. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg (U.S.), 1990;72A:403-408.
  11. Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine, 2003;28:616-20.
  12. Flynn TW, et al. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. JOSPT, 2011;41(11):838-846.
  13. NASS Guidelines: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis, 2011.
  14. Tomkins-Lane C , Melloh M, Lurie J, et al. Consensus on the clinical diagnosis of lumbar spinal stenosis: results of an international delphi study. Spine, 2016 Feb 1. [Epub ahead of print]=
  15. Cong ML, Gong WM, Zhang QG, Sun BW, Liu SH, Li L, Zhang LB, Jia TH. Urodynamic study of bladder function for patients with lumbar spinal stenosis treated by surgical decompression. J Int Med Res, 2010 May-Jun;38(3):1149-55.=
  16. Seiji Ohtori, Masaomi Yamashita, et al. Incidence of nocturnal leg cramps in patients with lumbar spinal stenosis before and after conservative and surgical treatment. Yonsei Med J, 2014 May 1;55(3):779-784
  17. Sirvanci M, Bhatia, M, et al. Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging. Eur Spine J, 2008 May;17(5):679-685
  18. Moojen WA, Schenck CD, et al. Preoperative MR imaging in patients with intermittent neurogenic claudication: relevance for diagnosis and prognosis. Spine, 2015 Nov 30.
  19. Ishimoto Y, Yoshimura N, et al. Associations between radiographic lumbar spinal stenosis and clinical symptoms in the general population: the Wakayama Spine Study. Osteoarthritis and Cartilage, June 2013;21(6).
  20. Weber C, Giannadakis C, et al. Is there an association between radiological severity of lumbar spinal stenosis and disability, pain, or surgical outcome? A multicenter observational study. Spine, 2016 Jan;41(2).
  21. Kuittenen P, et al. Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability. BMC Musculoskeletal Disorders, 2014,15:348.
  22. Sigmundsson FG, Kang XP, Jonsson B, Stromqvist B. Correlation between disability and MRI findings in lumbar spinal stenosis: a prospective study of 109 patients operated on by decompression. Acta Orthop, 2011;82:204-210.
  23. Jonsson B, Annertz M, Sjoberg C, et al. A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part I: clinical features related to radiographic findings. Spine, 1997;22:2932-7.
  24. Barz T, et al. The diagnostic value of a treadmill test in predicting lumbar spinal stenosis. Eur Spine J, 2008 May;17(5):686-690.
  25. Pearson A, et al. Who should have surgery for spinal stenosis?: Treatment effect predictors in SPORT. Spine, 2012 Oct. 1;37(21).
  26. Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Acta Orthop Scand, Suppl 1993;251:67-68.
  27. Schulte TL, Bullmann V, Lerner T, et al. [Lumbar spinal stenosis]. Orthopade, 2006,35(6):675-692.
  28. Tsutsumimoto T , Shimogata M, Yui M, Ohta H, Misawa H. The natural history of asymptomatic lumbar canal stenosis in patients undergoing surgery for cervical myelopathy. J Bone Joint Surg (U.K.), 2012 Mar;94(3):378-84.
  29. Ammendolia C1, Stuber K, de Bruin LK, Furlan AD, Kennedy CA, Rampersaud YR, Steenstra IA, Pennick V. Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review. Spine, 2012 May 1;37(10):E609-16.
  30. Ammendolia C1, Stuber KJ, Rok E, Rampersaud R, Kennedy CA, Pennick V, Steenstra IA, de Bruin LK, Furlan AD. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev, 2013 Aug 30;8.
  31. Zaina F, Tomkins-Lane C, Carragee E, et al. "Surgical Versus Non-Surgical Treatment for Lumbar Spinal Stenosis." Cochrane Library, January 2016.
  32. Weinstein JN, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis: four-year results of the Spine Patient Outcomes Research Trial. Spine, 2010;35(14).
  33. Ammendolia C1, Stuber K, Tomkins-Lane C, Schneider M, Rampersaud YR, Furlan AD, Kennedy CA. What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review. Eur Spine J, 2014 Jun;23(6).
  34. Ammendolia C1, Stuber KJ, Rok E, Rampersaud R, Kennedy CA, Pennick V, Steenstra IA, de Bruin LK, Furlan AD. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev, 2013 Aug 30;8.
  35. Fourney DR, Dettori JR, Hall H, Härtl R, McGrit MJ, Daubs MD. A systematic review of clinical pathways for lower back pain and introduction of the Saskatchewan spine pathway. Spine, 2011;36(21 suppl):S164-S171.
  36. Carey TS, Freburger JK, Holmes GM, et al. A long way to go: practice patterns and evidence in chronic low back pain care. Spine, 2009;34:718-724.
  37. Witiw CD, Mansouri A, Mathieu F, Nassiri F, Badhiwala JH Fessler RG. Exploring the expectation-actuality discrepancy: a systematic review of the impact of preoperative expectations on satisfaction and patient reported outcomes in spinal surgery. Neurosurg Rev, 2016 Apr 7. [Epub ahead of print]
  38. Fekete TF, Haschtmann D, Kleinstück FS, Porchet F, Jeszenszky D, Mannion AF. What level of pain are patients happy to live with after surgery for lumbar degenerative disorders? Spine J, 2016 Apr;16(4 Suppl):S12-8.
  39. Ammendolia C, et al. Clinical outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis: a retrospective study. JMPT, March-April 2015.
  40. Meng H, Fei Q, Wang B, Yang Y, Li D, Li J, Su N. Epidural injections with or without steroids in managing chronic low back pain secondary to lumbar spinal stenosis: a meta-analysis of 13 randomized controlled trials. Drug Des Devel Ther, 2015 Aug 13;9:4657-67
  41. Copay AG, Glassman SD, Subach BR, Berven S, Schuler TC, Carreon LY. Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J, 2008 Nov-Dec;8(6):968-74.

Dr. Ronald Fudala, a 1987 graduate of National University of Health Sciences, developed Cincinnati, Ohio's first full-time consulting and electrodiagnostic testing practice devoted to meeting the needs of the region's chiropractic physicians in 1993. In 2001, he was invited to join the neurosurgical department of a large tertiary care referral practice in Cincinnati to function in a similar capacity. During his 11 years at the neurosurgical practice, he functioned as a triage physician, performed the majority of EMGs / NCVs requested by the surgeons, and developed a structural spine care center for both surgical and postsurgical patients.

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