Lumbar Spinal Stenosis
Some degree of spinal stenosis is noted on MRI or CT scans of the spine in one in four people over the age of 65. The majority of these people do not and never will have any symptoms. Unfortunately, some people are less fortunate, and symptoms do develop over time. We do not understand why some people with spinal stenosis develop symptoms while others do not.
Spinal stenosis can produces two types of symptoms, pain and nerve symptoms.
A common type of pain produced by lumbar spinal stenosis occurs in one or both legs after a period of standing or walking, and is quickly relieved by squatting, bending forward at the waist or sitting. This pain is called neurogenic claudication and is thought to result from reduction in the size of the spinal canal that occurs with standing or walking as described above. Neurogenic claudication often develops slowly, at first only occurring with walking long distances. For some people even walking or standing for a minute is painful. For other people however, neurogenic claudication comes and goes over time or even disappears. Explanation for this is lacking.
It must be noted that back pain is a common complaint as we age and equally common in people with and without spinal stenosis. Therefore, it is difficult to attribute back pain without leg pain to lumbar spinal stenosis. However, some people with spinal stenosis have back and buttock pain that occurs only after standing or walking for a period of time. This pattern of back pain is uncommon in people without lumbar spinal stenosis and can occur alone or along with neurogenic claudication.
Nerve symptoms caused by lumbar spinal stenosis can include feelings of heaviness or weakness in the legs, numbness of the legs and a feeling of unsteadiness. These symptoms also typically occur or worsen after standing or walking for a period of time and disappear or improve with sitting. These symptoms are thought to reflect temporary disruption in function of the lumbar nerve roots that are being compressed by the spinal stenosis. In some people, these symptoms are so serious that their legs will give out and they will fall if they do not quickly sit or bend forward when symptoms start.
Treatments for Lumbar Spinal Stenosis
Many people with neurogenic claudication from lumbar spinal stenosis try a variety of non-surgical treatments.
The use of simple over the counter medications such as acetaminophen (Tylenol), of anti-inflammatory medications such as ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn) may reduce pain in some, though most people do not find these medications helpful. Some people report improved symptoms after taking gabapentin (Neurontin) or pregabalin (Lyrica), but these powerful medications often cause drowsiness or problems with thinking. Powerful pain medications are not helpful for neurogenic claudication and should be avoided.
Some, but not all people experience a temporary reduction of symptoms following spinal injection of steroids and local anesthetics in the vicinity of the lumbar spinal stenosis. Some patients can use these injections to manage their symptoms for blocks of time over many years. Spinal injections are of low risk, but complications can occur. Spinal injections should only be used several times per year.
Physical therapy is a common treatment for spinal stenosis, and usually focuses on exercise. Most people report that exercise is well tolerated and helpful for improving their flexibility and strength. Only some note that regular exercise improves their ability to walk.
Chiropractic treatments and acupuncture are relatively safe treatment that some people find helpful, but most note that improvement only lasts for a short period of time.
With the lack of powerful non-surgical treatments, it is not surprising that the most people with neurogenic claudication choose to simply adapt their lives to their walking limitations. Many find that they can shop for groceries if they lean on the shopping cart, can walk in a park or the mall if they sit on a bench when needed, and can even play golf by riding in a golf cart. Some people report that leaning slightly forward on a cane is helpful, and some of the more elderly find that leaning on a rolling walking or rollator allows them to walk well enough to accomplish essential daily activities.
To date, the most effective treatment for neurogenic claudication is decompression surgery that attempts to increase the space in the spinal canal by delicately removing the arthritic bone and degenerative tissues. The amount of surgery that is needed is dependent on the extent and locations of the spinal stenosis along with degree to which arthritis has caused the vertebrae to shift or move. Even though the majority of people benefit from surgery, it is not always successful and does have risks and complications. Usually, people who decide to have surgery have carefully considered the risks of surgery and weighed them against the potential benefits of improved walking abilities.
Leg numbness, weakness and other neurological symptoms caused by lumbar spinal stenosis are not treatable with medications or other non-surgical treatments. When symptoms are minor, some people choose to simply live with them, though it is recommended that they see a doctor regularly to monitor their neurological function. However, most people choose to have surgery when neurological symptoms develop, in order to prevent further nerve damage.