Update on Latest Evidence in the Treatment of Spinal Stenosis
Lumbar spinal stenosis (LSS) is a common condition among older adults. The US Agency for Healthcare Research and Quality (AHRQ) estimates that up to 14 per cent of adults with low back pain have severe enough LSS to need surgery.
Many others in this age group suffer from painful symptoms who never see a doctor or who don't want surgery. Finding the best treatment for this condition is the goal of the Spinal Stenosis Work Group of the North American Spine Society (NASS).
This review article is an attempt to provide a summary of the best evidence-based clinical guidelines for the treatment of chronic LSS. These guidelines will help physicians and patients decide the best approach for the patient.
The committee followed 12 specific steps in reviewing the literature on LSS and assessing levels of evidence before making recommendations. Each of these steps was described in this report. When evidence wasn't available, expert opinion was included. Guidelines were not adopted unless there was agreement among the group members.
Eighteen questions were posed during the review of studies published before April 2006. Each of these questions was presented and the findings summarized. Some of the questions included:
What is degenerative lumbar spinal stenosis?
What is the natural history for this condition?
What is the best way to diagnose LSS?
How should this problem be treated?
How should results of treatment be measured?
The group found that about one-third to one-half of all patients with mild to moderate LSS had a favorable prognosis. Severe neurologic decline is rare in this group. Not much is known about what happens to people with severe LSS. MRI is the best imaging test to diagnose LSS. Previously recommended use of electrodiagnostic studies is no longer recommended.
It's still unclear if treatment versus no treatment makes any difference in the long run. This was true for medications, steroid injections, and manipulation. Some treatments such as physical therapy, corsets, and bracing seem to have good short-term effects and help manage pain over the long term. For many areas of study, there simply wasn't enough evidence to support or refute treatment choices.
The work of the NASS Spinal Stenosis group is helpful to all physicians. It reduces the need for everyone to keep up with every study all the time. Clinical guidelines streamline patient care and point to the need for future research. The complete guidelines are available at the NASS web site (www.spine.org). The hope is to keep the core clinical guidelines updated as new research is made available.
William C. Watters, III, MD, et al. Degenerative Lumbar Spinal Stenosis: An Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. In The Spine Journal. March/April 2008. Vol. 8. No. 2. Pp. 305-310.