Lumbar Spinal Stenosis (LSS)

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What is Lumbar Spinal Stenosis?


Lumbar Spinal Stenosis is one of the most common reasons for spinal surgery in patients over 65. Lumbar Spinal Stenosis is caused by a gradual narrowing of the central spinal canal, the lateral recess, or IVF (intervertebral foramen – a passage between the spinal canal and the periphery) resulting in compression of the neurovascular structures of the spine. (1)


Lumbar Spinal Stenosis has a significant impact on our health care system as it is a leading cause of disability in an aging population. Lumbar Spinal Stenosis causes more functional limitations than congestive heart failure, COPD (Chronic obstructive pulmonary disease), or even Lupus. (2,9)


The good news is that Lumbar Spinal Stenosis often responds to a combination of exercise and manual therapy. Surgery is necessary for some patients, but not for many others. In addition, spinal stenosis is a slow progressing condition. This means that in most situations you have time to improve your health and deal with this condition.


 

Symptoms of Lumbar Spinal Stenosis (LLS)


The following are some of the common symptoms of Lumbar Spinal Stenosis: (3,9)

  • Low back pain.

  • Weakness or cramping in the legs (unilateral or bilateral). This is most often caused by neurogenic claudication. (Neurogenic means arising in the nervous system. Claudication refers to leg pain, heaviness, or weakness when walking).

  • Difficulty standing up straight or difficulty with prolonged standing.

  • Back pain that decreases when bending forward (ordinary back pain often feels worse when bending forward in a flexed position). Clinicians refer to this symptom as a shopping cart sign.

  • Decreased balance.

  • Back pain that is reduced by sitting (ordinary back pain usually increases with sitting).

  • Back pain or leg pain that increases with standing (ordinary back pain often feels better on standing).

  • Increased strength in the legs with sitting or lying down (regular back pain does not cause an increase or decrease in leg strength in the legs with a change of position).


 

Causes of Lumbar Spinal Stenosis (LSS)


Osteoarthritis, damage to spinal discs, thickening of ligaments and inflammation are key causative factors in Lumbar Spinal Stenosis. (4)


Osteoarthritis

Osteoarthritis of the spine is known as spondylosis. Arthritis in the spine leads to intervertebral disc degeneration, facet joint degeneration, and the formation of bone spurs (osteophytes). As arthritis worsens, there is often a progressive narrowing of the spinal canal. This narrowing can cause compression of both the spinal cord and the nerve roots that exit from the foramina of the spine. This intern leads loss of function and pain.


Tip: The good news is that by strengthening the muscles that stabilize the spine, you can dramatically can decrease the process of osteoarthritis (osteophyte and bone spur formation) , and help to avoid the progression of LSS.


Spinal Disc Damage

Degenerative Disc Disease (DDD), injury, and simple aging can cause spinal discs to lose height, and become very stiff and rigid. In our twenties, our spinal discs have a jelly-like centre with a high level of fluid content. Because of this, the discs of a twenty (or thirty) year-old act as great shock absorbers, distributing spinal forces and preventing injury. Unfortunately, by the time most people reach sixty years of age, these same discs now have the consistency of a well-done steak (rigid non-pliable), and become another cause of neurovascular compression.


Tip: Lack of disc hydration is a major issue. Fortunately, exercise is a great way to increase hydration of spinal discs. When we exercise, we increase the blood supply to our spinal discs and thereby increase hydration. This hydration increases disc height and promotes better shock absorption capacity.


Ligament Thickening

Healthy ligaments are elastic in nature, they lengthen under pressure, and then return to their original shape when the tension is removed. Unhealthy ligaments bunch up and do not return to their original shape. This can be a major cause of Lumbar Spinal Stenosis.


Tip: Remember that the health of the spinal ligaments is directly related to the patient’s current physical health, how much exercise they get, their diet, and whether or not they are a smoker. (Smoking is of one the worst activities you can do if you have Lumbar Spinal Stenosis).


Inflammation

Inflammation causes swelling, and swelling is directly related to Lumbar Spinal Stenosis. Swelling not only inhibits the gliding of neurological structures, but it also changes the consistency of ligaments, muscles, and fascia. Inflammation thickens ligaments makes them more rigid, harder, and reduces their elasticity. All of which increases the likelihood of developing Lumbar Spinal Stenosis.




 

Diagnosing Lumbar Spinal Stenosis


Often a diagnosis of Lumbar Spinal Stenosis is based on clinical findings, and may not need imaging procedures. The International Delphi study stated 7 historical diagnostic questions that can be used to help identify Lumbar Spinal Stenosis. (5,9)

  1. Does the patient experience leg or buttock pain when walking?

  2. Does the patient flex forward to relieve symptoms?

  3. Does the patient experience a decrease in pain when using a shopping cart or bicycle?

  4. Does the patient have motor or sensory disturbances while walking?

  5. Are the ‘pulses’ in the foot present and symmetric?

  6. Does the patient have lower extremity weakness?

  7. Does the patient have low back pain?


Differential Diagnosis of Lumbar Spinal Stenosis

When diagnosing a patient that may have Lumbar Spinal Stenosis, we also must consider other conditions that may mimic Lumbar Spinal Stenosis. For example, Osteoarthritis, Trochanteric Bursitis, or Vascular Claudication. (6,9)


Hip Osteoarthritis (OA)

There is considerable cross-over in symptoms between Lumbar Spinal Stenosis and Hip OA. Hip OA also presents with gluteal, groin, lateral hip and leg pain when weight bearing. You must consider that both conditions could be occurring simultaneously.


Trochanteric Bursitis

With trochanteric bursitis, the patient often experiences lateral leg pain, which is increased by lying on the affected side. This is not the case with Lumbar Spinal Stenosis and is one way to differentiate between the conditions.


Vascular Claudication

Vascular claudication is a pain in the legs that occurs due to decrease blood flow. Similar to Lumbar Spinal Stenosis, vascular claudication (caused by Peripheral Arterial Disease - PAD) cause increased pain with walking that is also relieved by rest. The difference is that the pain of vascular claudication is not relieved with forward flexion (shopping cart sign) or cycling as it is with Lumbar Spinal Stenosis. With Lumbar Spinal Stenosis a change in position (forward flexion) will cause a decrease in symptoms; with PAD, all activity will have to be stopped to relieve symptoms.


 

Physical Examination

The following videos contain some of the common orthopaedic and neurological examination procedures we use in diagnosing spinal Stenosis.


Low Back Examination - Effective Orthopaedic Testing - This video covers some of the common causes of low back pain and how to diagnose them using orthopaedic examination procedures. This video will be available for the public on Nov. 7th/2022.



Hip Examination - Orthopaedic Testing This video goes through inspection and observation, palpation, Active and Passive Ranges of motion, and orthopaedic examination of the Hip region. This video will be available for the public on Feb. 10th/2023.



Lower Limb Neuro Examination - The lower limb neurological examination is part of the over all neurological examination process, and is used to assess the motor and sensory neurons which supply the lower limbs. This video will be available for the public on Nov. 11th/2022.


Peripheral Vascular Examination - Key Points


A peripheral vascular examination is a valuable tool used for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video we go over some of the common procedures we perform in daily clinical practice. This video is available for the public on November 14/2022.


 

Treatment of Lumbar Spinal Stenosis


As I mentioned, Lumbar Spinal Stenosis is one of the most common reasons for spinal surgery in patients over 65. Just because surgery is common does not mean surgery should be your starting point for addressing this condition. Nor does it mean that they will eventually require surgery.


There is good evidence to support the use of manual therapy (combined with exercise) as the first line of treatment before ever considering surgery. Even if surgery is necessary, conventional therapy (manual therapy + exercise) can play a significant role in achieving better results, both pre-and-post-surgery.


Research shows that 33%-50% of patients (with mild to moderate symptoms) who receive conventional therapy show significant functional improvements. By improvement, I am referring to decreased levels of pain, overall improved function in activities of daily living, and an increased ability to walk. This change could be enough of an improvement to completely avoid surgery. (1, 7, 8,9)


It is interesting to note what research DOES NOT recommend. For example, the use of Tylenol, NSAIDs, opioids, neurogenic pain medications, muscle relaxants, and epidural steroidal injections are not recommended for the treatment of Lumbar Spinal Stenosis. Unfortunately, these are some of the most common forms of treatment prescribed for this condition. (9)


If a patient is in acute pain, is not sleeping, or cannot perform exercises due to pain, then the use of pharmaceutical intervention makes sense. But only so that they can sleep, perform their prescribed exercises, and receive their manual therapy. (1, 7, 8,9)


 

Manipulation & Mobilization

Spinal Manipulation or Mobilization can be of great benefit in helping patients who suffer from Lumbar Spinal Stenosis. Think of the spine, from the neck right down to the lumbar region, as one functional unit, which needs optimum mobility for load distribution. When your upper back and neck are mobile, flexible, and strong, then when you perform an action, the force exerted is shared throughout the entire spine.


However, if you have a stiff and rigid upper back and neck, then more of the load is placed on the lower back (lumbar region). This creates stress, with the increased force required to complete repetitive motions by each lumbar vertebra.


That is why we recommend that patients focus on both the symptomatic area (lumbar spine) and also consider any other areas of spinal tension. The following videos provide examples of both manipulation and mobilization procedures. Both types of procedures are extremely effective, and we customize our recommendations and treatments based on the needs of each individual patient. (1) Click on the video about to see an example of lumbar spinal joint mobilization.


Joint Mobilization - Lumbar Spine - There are many aspects that need to be addressed when eliminating low back pain. One of the key aspects is joint mobility. Basically, our capacity to produce an unlimited variety of movements requires good joint integrity. No joint ever works in isolation. An injury in one joint often results in bio-mechanical compensations occurring in both adjacent and distant joints.


 

Soft Tissue Therapy

The following videos are examples of common MSR procedures that we often use with our Stenosis patients. The quality of your soft tissues will directly affect the level of pain experienced and your ability to function.


Lumbar and Thoracic Spine Fascial Release - In many cases the thoracolumbar fascia can be an important key to resolving chronic low back pain. The Thoracolumbar Fascia [TLF] is a large region of connective tissue.


Resolve Chronic Low Back Pain - One of the structures that needs to be addressed are the deep paraspinal muscles. The Deep Para-Spinals (transversospinalis) muscles often atrophy in cases of chronic low back pain.



 

Exercise is Critical


Research shows that individuals who exercise regularly are less likely to suffer from spinal stenosis. When you are hurting, it may seem counterintuitive to exercise while you’re in pain, but it is not.


Think of exercise as a counter-inflammatory strategy. Exercise increases circulatory function, removes waste by-products, brings more oxygen to the site of injury, and greatly reduces pain levels. It is a simple equation. The more inflammation, the more pain is experienced, decrease the inflammation, and experience a corresponding decrease in pain.


In addition to reducing inflammation, exercise makes make ligaments and fascia more pliable, less rigid, and less likely to compress neurological structures. Exercise also decreases swelling, thus reducing the amount of neurovascular compression. (1)


Aerobic Exercise

Aerobic or cardiovascular exercise is all about increasing your aerobic capacity, improving circulatory function, and increasing energy production. Aerobic exercise does this by increasing the density of capillaries in the muscles and by increasing the level of mitochondrial function in the cells. When you have more capillaries, your cells can obtain more nutrients for repair and can get rid of waste by-products more rapidly. Aerobic exercise is all about increasing your capillary health. Aerobic exercise is essential when dealing with Lumbar Spinal Stenosis. It can make the difference between being symptom-free and being in constant pain. (10)


Your Aerobic Zone

It is important when performing an aerobic exercise that you work within your aerobic zone. This is the range within which you want your heart to operate while you are performing your aerobic exercise. Think of your aerobic zone as the base which you must first establish for rehabilitation.

Calculating your aerobic zone - Use the following formula to calculate your aerobic zone: (11)

  • Subtract your age from the number 220. For example, if I am 40 years old, then 220 - 40 = 180.

  • Obtain the low end of your aerobic range by multiplying the result of step 1 by 0.6. In our example: 180 * 0.6 = 108

  • Obtain the high end of your aerobic range by multiplying the result of step 1 by 0.7. In our example: 180 * 0.7 = 126

This is your aerobic heart rate zone. Work within this zone to develop your aerobic capacity. It is the zone which will best speed your recovery from an injury. If you work above this zone you run the risk of injury. If you work below this zone, you will not achieve the maximum benefits provided by your aerobic warm-up.


We recommend our patients take a staggered approach to aerobic exercise.

  • In stage 1, we recommend 5 to 10 minutes of aerobic exercise for 3 to 5 days per week (riding a bike, or swimming).

  • In stage 2, we recommend 15 to 20 minutes of aerobic exercise 4 to 7 days per week (riding a bike, or swimming).

  • In stage 3, we recommend 30 to 60 minutes of aerobic exercise 5 to 7 days per week (riding a bike, or swimming).

TIP: We highly recommend purchasing a heart monitor/watch to monitor aerobic activity. You will progress faster and be better able to monitor potential cardiovascular issues.


Walking

Lumbar spinal stenosis can make walking difficult and painful. For many, walking may not be the best type of exercise if you are suffering from lumbar spinal stenosis. In addition, it is very difficult to get into the aerobic zone with walking; biking and swimming are much better choices.


That does not mean you need to give up on walking! You need to keep walking. Think of walking as a ‘baseline test’, one in which you slowly increase your distance as your pain-free walking capacity increases.


Just be remember that if your legs are feeling really weak you should NOT push yourself to walk further distances. Doing so could lead to further damage and weakness.


Daily Exercise Routine

The following video is an example of some of the common exercises we prescribe to patients suffering from Lumbar Spinal Stenosis. You will notice that several of these exercises focus on hip mobility. Increasing hip mobility through exercise and manual therapy can often make the difference between being pain-free or suffering from extreme pain with each step.


5 Best Exercises For Spinal Stenosis - These are some of the common exercises we prescribe to patients suffering from Lumbar Spinal Stenosis.






 

General Recommendations


In addition to exercise and treatment, use the following pain avoidance strategies to deal with Lumbar Spinal Stenosis. These strategies are based on pain avoidance. With lumbar spinal stenosis, performing an activity that aggravates the condition, may cause the patient to feel the effects of that action for several hours after.


Avoiding Pain-Causing Activities

Patients will often tell me how performing certain actions causes them pain. But, then they keep performing those same actions repeatedly, exacerbating their condition and prolonging their pain. A good example is continually trying to stand up straight, even when it is one of the most painful positions for many people who suffer from LSS.


Patients suffering from Lumbar Spinal Stenosis often show a bent-over, flexed posture. These patients tend to keep trying to straighten up, when they are not ready, and end up being in constant pain. I keep telling my patients that they should NOT force themselves to stand up straight. I tell them to straighten up only when their inflammation and swelling are decreased. This is when the pressure on neurological structures is decreased, and they can then move into an upright position without being in pain. Forcing yourself to stand up straight when suffering from LLS can increase pressure on the spinal cord, which intern can decrease leg strength.


The key to healing from LSS is to avoid any activity that forces you to bend backwards as this position closes down the foramina and creates less space in the spinal channel. For example, reaching overhead for an item in a cupboard could cause pain for several hours.


Tip: You should only reintroduce new activities when you can start performing them without pain.

Use Braces, Canes and Walkers

Braces (elastic corset) can be of great benefit to patients who suffer from Lumbar Spinal Stenosis, especially during a flareup. This is because the brace limits lateral flexion and the frequency of repetitive motion. This limits nerve root irritation a a possible source of radicular pain. Braces can help the patient to remain active while reducing the chance of re-injury. In addition, the brace helps them sleep better by keeping the spine in a neutral position while sleeping.


A lot of patients avoid using walkers (or canes) out of fear of building a dependency, but they really should not. Just because they need it at certain times does not mean you will need it forever. By using a walker when their symptoms are severe (during a flareup) or for a couple of days, they could greatly reduce the level of pain experienced. In addition, using the walker first thing in the morning or at the end of the day could help prevent a fall, and a possible hip or spinal fracture. When you are feeling better/stronger you can get rid of the walker.


Sleeping Positions

The most comfortable sleeping for most people suffering from Lumbar Spinal Stenosis is on their side, in a fetal position (knees curled up toward the abdomen). Another alternative is to use an adjustable bed, or a recliner that allows the head and knees to remain raised.


 

CONCLUSION – LUMBAR SPINAL STENOSIS (LSS)


Lumbar Spinal Stenosis is a leading cause of disability in an aging population. Lumbar Spinal Stenosis causes more functional limitations than congestive heart failure, COPD (Chronic obstructive pulmonary disease), or even Lupus.


The GOOD NEWS is that Lumbar Spinal Stenosis often responds to a combination of exercise and manual therapy. Surgery is necessary for some patients, but not for many others. In fact, research shows that the most important factor in treating spinal stenosis is improving your overall physical health. There was never a better time than right now to deal with this debilitating condition.


 

DR. BRIAN ABELSON DC.

Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.

Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication.


 

Make Your Appointment Today!

Make an appointment with our incredible team at Kinetic Health in NW Calgary, Alberta. Call Kinetic Health at 403-241-3772 to make an appointment today, or just click the MSR logo to right. We look forward to seeing you!



 

References:

  1. André Bussières, Carolina Cancelliere , Carlo Ammendolia Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline. J Pain. 2021 Sep;22(9):1015-1039. doi: 10.1016/j.jpain.2021.03.147. Epub 2021 Apr 12.

  2. Anderson DB, Luca K, Jensen RK et al, A critical appraisal of clinical practice guidelines for the treatment of lumbar spinal stenosis. Spine J. 2021 Mar;21(3):455-464. doi: 10.1016/j.spinee.2020.10.022. Epub 2020 Oct 26.

  3. J J Young, J Hartvigsen, E M Roos, C Ammendolia, A Kongsted, S T Skou, D T Grønne, R K Jensen Symptoms of lumbar spinal stenosis in people with knee or hip osteoarthritis or low back pain: a cross-sectional study of 10,234 participants in primary care Osteoarthritis Cartilage. 2021 Nov;29(11):1515-1520. doi: 10.1016/j.joca.2021.07.012. Epub 2021 Jul 31.

  4. Jon Lurie, Christy Tomkins-Lane Management of lumbar spinal stenosis, BMJ. 2016 Jan 4;352:h6234. doi: 10.1136/bmj.h6234.

  5. Timothy R Deer, Jay S Grider, Jason E Pope et al. The MIST Guidelines: The Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment. Pain Pract. 2019 Mar;19(3):250-274. doi: 10.1111/papr.12744.

  6. Rikke Krüger Jensen 1 2, Biswadjiet S Harhangi 3, Frank Huygen 4, Bart Koes Lumbar spinal stenosis BMJ. 2021 Jun 29;373:n1581. doi: 10.1136/bmj.n1581.

  7. Rikke Rousing, Rikke Krüger Jensen, Søren Fruensgaard, Janni Strøm et al. Danish national clinical guidelines for surgical and nonsurgical treatment of patients with lumbar spinal stenosis Eur Spine J. 2019 Jun;28(6):1386-1396. doi: 10.1007/s00586-019-05987-2. Epub 2019 May 16.

  8. Michael J. Schneider, DC, PhD, Carlo Ammendolia, DC, PhD, Donald R. Murphy, et al. Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis, JAMA Netw Open. 2019 Jan; 2(1): e186828.

  9. Shawn Thistle, Older & Bolder: Chiropractic Care for Healthy Aging. Calgary 2022.

  10. Lundby, C., Jacobs, R.A. (2016). Adaptations of Skeletal Muscle Mitochondria to Exercise Training. Experimental Physiology, 101 (1), 17-22

  11. Exercises for the Jaw to Shoulder – Copyright Canada 2009, by Dr. Brian J. Abelson DC and Kamali T. Abelson B.Sc. 223 pages were published in 2010 by Rowan Tree Books Ltd. ISBN (978-0-97338484-0).




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