Lumbar Spinal Stenosis (LSS)
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) in compression of the neurovascular structures of the spine. (1)
Lumbar Spinal Stenosis significantly impacts our healthcare 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 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 symptoms of Lumbar Spinal Stenosis can vary depending on the severity of the condition and may include: (3,9)
Pain or discomfort in the lower back, buttocks, or legs.
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 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 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).
Red Flag: Loss of bladder or bowel control; this is a red flag. See your medical practitioner immediately.
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
Spondylosis is the term used to describe osteoarthritis of the spine. Arthritis in the spine can cause intervertebral disc and facet joint degeneration, as well as the development of bone spurs, also known as osteophytes. As arthritis worsens, the spinal canal gradually narrows, which can result in the compression of both the spinal cord and nerve roots that exit from the foramina of the spine. This, in turn, leads to a loss of function and pain.
Tip: The good news is that by strengthening the muscles that stabilize the spine, you can dramatically decrease the process of osteoarthritis (osteophyte and bone spur formation) , and help to avoid the progression of LSS.
Spinal Disc Damage
Spinal discs can lose height, become stiff, and lose flexibility due to Degenerative Disc Disease (DDD), injury, and aging. In our twenties, the centre of spinal discs is jelly-like. It contains a high amount of fluid, enabling them to function as effective shock absorbers, distributing spinal forces and preventing harm. Regrettably, by the time most individuals reach the age of sixty, these same discs have become as rigid as a well-done steak, making them a source 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, thereby increasing hydration. This hydration increases disc height and promotes better shock absorption capacity.
Ligament Thickening
Ligaments in good condition have elasticity, meaning they can stretch when subjected to pressure and regain their original shape when the force is released. However, when ligaments are unhealthy, they tend to bunch up and lose their ability to recover their original shape. This can significantly contribute to Lumbar Spinal Stenosis.
Tip: The health of the spinal ligaments is closely linked to several factors, including the patient's present physical condition, level of physical activity, dietary habits, and smoking status. It's worth noting that Lumbar Spinal Stenosis patients should avoid smoking, as it is considered one of the most harmful activities for them.
Inflammation
Swelling, caused by inflammation, is a significant contributor to Lumbar Spinal Stenosis. Swelling restricts the smooth movement of neurological structures and alters the texture of ligaments, muscles, and fascia. Inflammation thickens ligaments, making them stiffer and less elastic, which raises the risk of developing Lumbar Spinal Stenosis.
Congenital Factors
Some people are born with a narrower spinal canal, which can increase the risk of developing spinal stenosis later in life.
Diagnosing Lumbar Spinal Stenosis
Diagnosing Lumbar Spinal Stenosis typically involves a combination of a physical examination, medical history, and imaging tests. During the physical exam, your healthcare provider will likely ask about your symptoms and perform a neurological exam to assess your leg reflexes, strength, and sensation.
Your healthcare provider may also order imaging tests such as X-rays, magnetic resonance imaging (MRI), or computed tomography (CT) scans to get a detailed look at the structures of your spine and confirm the diagnosis of Lumbar Spinal Stenosis.
In some cases, your healthcare provider may also order a nerve conduction study or electromyography (EMG) to evaluate the function of your nerves and muscles.
Key Diagnosis Questions:
The International Delphi study stated 7 historical diagnostic questions that can be used to help identify Lumbar Spinal Stenosis. (5,9)
Does the patient experience leg or buttock pain when walking?
Does the patient flex forward to relieve symptoms?
Does the patient experience decreased pain when using a shopping cart or bicycle?
Does the patient have motor or sensory disturbances while walking?
Are the ‘pulses’ in the foot present and symmetric?
Does the patient have lower extremity weakness?
Does the patient have low back pain?
Differential Diagnosis of Lumbar Spinal Stenosis
When diagnosing a patient with Lumbar Spinal Stenosis, we also must consider other conditions that may mimic Lumbar Spinal Stenosis. For example, Osteoarthritis, Herniated Disc, Trochanteric Bursitis, Peripheral Neuropathy, or Vascular Claudication. (6,9)
Hip Osteoarthritis (OA)
There is a 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.
Osteoarthritis can cause cartilage breakdown in the spine's joints, leading to bone spurs and narrowing of the spinal canal. You must consider that both conditions could occur simultaneously.
Herniated Disc
A herniated disc occurs when the soft inner material of a spinal disc pushes through the outer layer and presses on a nerve. This can cause pain and numbness in the back and legs.
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.
Peripheral Neuropathy
This condition involves damage to the peripheral nerves, which can cause pain, numbness, and weakness in the legs and feet.
Vascular Claudication
Vascular claudication is a leg pain that occurs due to decreased blood flow. Similar to Lumbar Spinal Stenosis, vascular claudication (caused by Peripheral Arterial Disease - PAD) causes 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 common orthopedic and neurological examination procedures we use to diagnose spinal Lumbar Spinal Stenosis.
Low Back Examination - Effective Orthopaedic Testing - This video covers some common causes of low back pain and how to diagnose them using orthopedic examination procedures.
Hip Examination - Orthopaedic Testing This video goes through inspection and observation, palpation, Active and Passive Ranges of motion, and orthopedic examination of the Hip region.
Lower Limb Neuro Examination - The lower limb neurological examination is part of the overall neurological examination process. It assesses the motor and sensory neurons that supply the lower limbs.
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is valuable 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 review some common procedures we perform in daily clinical practice.
Treatment of Lumbar Spinal Stenosis
As previously mentioned, Lumbar Spinal Stenosis is a frequent cause of spinal surgery in patients over 65. However, just because surgery is prevalent, it doesn't imply that it should be the initial approach to addressing this condition or that surgery will inevitably be required.
Strong evidence suggests that manual therapy, coupled with exercise, should be the first course of action before considering surgery. Furthermore, even if surgery becomes necessary, traditional therapy (manual therapy + exercise) can significantly achieve better outcomes, both before and after surgery.
Some common manual therapy techniques used for Lumbar Spinal Stenosis include:
Spinal mobilization involves slow, rhythmic movements of the spine to improve joint mobility and decrease pain.
Soft tissue therapy involves applying pressure and manipulating soft tissues, such as muscles and ligaments, to decrease tension and improve blood flow.
Stretching: Your provider may guide you through specific stretches to improve flexibility and reduce symptoms.
Myofascial Release: This technique involves applying pressure to specific regions in the body to release tension and decrease pain.
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 avoid surgery completely. (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 pharmaceutical intervention makes sense. But only so they can sleep, perform their prescribed exercises, and receive 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 to the lumbar region, as one functional unit that needs optimum mobility for load distribution. When your upper back and neck are mobile, flexible, and strong, then when you act, the force exerted is shared throughout the entire spine.
That is why we recommend that patients focus on both the symptomatic area (lumbar spine) and 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 for an example of lumbar spinal joint mobilization.
Joint Mobilization - Lumbar Spine
Many aspects 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 in adjacent and distant joints.
Soft Tissue Therapy
The following videos are examples of common MSR procedures 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 must be addressed is the deep paraspinal muscles. The Deep Para-Spinals (transversospinalis) muscles often atrophy in chronic low back pain cases.
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.