Understanding Lumbar Spinal Stenosis; Lumbar Spinal Stenosis Treatment & Lumbar Spinal Stenosis Exercises

Welcome to the Back Pain Solutions Podcast – Understanding Lumbar Spinal Stenosis; Lumbar Spinal Stenosis Treatment & Lumbar Spinal Stenosis Exercises

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Listen To The Episode Below

Episode Introduction

Lumbar spinal stenosis is defined as a degenerative condition in which there is diminished space available within the spinal canal, or spinal foramen, for the neural and/or vascular elements in the lumbar spine. Narrowing within the spine is most often due to age-related changes that take place over time. This is called “acquired spinal stenosis” and is most common in people over 50 years of age. Acquired forms of LSS can be subclassified as degenerative, spondylolisthesis – that is to say one vertebrae has slipped forward on another; iatrogenic – which is the result of post medical intervention, or examination usually postsurgical; posttraumatic, or it in some cases can be a combination of the above. For example, someone who has a historical spondylolisthesis may have degenerative changes as a result of that specific issue, which in turn leads to spinal stenosis but, like with many conditions, no two cases will be the same. Importantly, lumbar spinal stenosis is associated with substantial functional limitation of walking, disability, and an increased risk of falling. Given the impact on quality of life, as well as the additional risks, effective management is important.

In this episode, we discuss lumbar spinal stenosis and the common presenting symptoms that we find associated with this condition. We identify some of the common patterns related to the problem, such as patients leaning forward to alleviate their symptoms, which helps to identify the problem. In addition, we discuss some of the diagnostic tests used to diagnose the condition as well as the treatment options that will likely be considered to help manage symptoms.

Some of the things you’ll discover…

The average age of patients suffering from lumbar spinal stenosis
Which tissues are commonly the culprit of spinal canal, or foramen, narrowing?
What are the common symptoms associated with lumbar spinal stenosis?
The difference between neurogenic and vascular, claudication and how to differentiate the two
Why bending backwards can often increase the symptoms a patient will experience
Some of the different treatment options available for the management of symptoms associated with stenosis

Episode Highlights

Spinal surgery is often an early treatment approach for patients with lumbar spinal stenosis. However, given the average age of the patient, and the associated risk factors, taking a conservative approach should be the first line approach in the management of this condition. Given the additional health benefits to people in this age category a physical therapy approach would be of benefit, although the research evidence directing specific exercise choice is still limited. Long term outcome to surgery does demonstrate clinical benefit but should always remain a consideration further along the management pathway.

Episode Transcription

Intro 0:00
When we’re young, we move with freedom and confidence with a great resilience to injury. But somewhere along the line we develop poor habits and become more vulnerable to back pain. Back Pain solutions features evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better back health through movement. So join us as we demystify some of the commonly held beliefs about back pain and build your confidence to a stronger back the smart way.

Ben James 0:29
Hello, welcome back to the back pain solutions podcast with me Ben James. And it’s me alone. Today I’m doing a solo show and I’m discussing the topic of lumbar spinal stenosis. We had a query come through from a client over in the US who had recently read about this condition online and associated some of those symptoms some of their symptoms with their own condition. So I thought it would be a good opportunity to do an episode focused on this particular topic. So we’ll discuss Well, what is lumbar stenosis? And what are some of the classic symptoms and of course, discuss some of the treatment options available for those suffering from this condition, or for those people listening that may think they might have this condition, whether that’s from listening to this episode, or from doing their own research, because in the age of Google and other search engines, we’re always finding that people are doing their own research online, which is, in some ways, very good, but also, it can be a bit of a concern for some people as well as they read and, and the fears that they generate as a result. So let’s dive in and discuss first of all, what spinal stenosis is?

Well, spinal stenosis is generally defined as a degenerative condition in which there are diminished spaces available within the spinal canal or spinal foreman for the neural or vascular element elements, or indeed, both in the lumbar spine. And that in itself can lead to different various symptoms, which we’ll discuss. Now, importantly, lumbar spinal stenosis is associated with substantial functional limitation of walking, disability and other increased concerns risks such as falling, for example, and we know that falling can result in hip fracture, that in itself can result in increased risk of mortality, which seems pretty drastic, but you know, really is a concern. And it’s important to recognize this condition, because there’s a lot that can be done to support these patients or patients suffering from this condition symptoms of this condition, so that we can help them to retain their independence, and quality of life ultimately, so let’s be proactive, let’s take a pro vented approach to this condition. And so if you’re suffering, or you think you could be suffering early symptoms, then seek out advice because there are things that we can do. And there’s certainly conservative management that should be considered for patients suffering from this condition. And as clinicians, we should be taking a proactive approach with all our elderly patients, as they could really benefit from support advice to help keep them active. And this condition is one that can benefit from care. So I guess the big question is what what’s causing the narrowing itself? You know, why do we get a narrowing within the spinal canal or in the spinal foreman, and Firstly, I guess we should acknowledge that some people are born with a smaller spinal canal or smaller spinal forum and that is just an anatomical thing. We’re all different. We’re all individuals and some people are born with smaller spaces. It’s as simple as that. So they are more susceptible. And in some cases, where there is the there are those congenital narrowing then it can be diagnosed as congenital stenosis. However, spinal canal narrowing is most often due to age related changes that take place over time as all has already been indicated. And this is essentially called acquired spinal stenosis and is most common in people over the age of 50 years, generally 50-60 years of age, but over there is 50 of the general age population that get this condition and experience symptoms with this condition. And without going into too much detail. In this episode, acquired forms of lumbar spinal stenosis can be further so classified as degenerative spondylolisthesis. So that’s to say one of the vertebra has slipped forward on another, which can occur for a number of reasons. Iatrogenic which is post medical treatment examination, and usually post surgical, in this case, post traumatic is most likely or it can be a combination of the above so it doesn’t have to be one single cause, for example, someone with a historical spondylolisthesis, they might not have even known they’ve got such a condition such a slippage of one vertebra on another. But that in itself could lead to degenerative changes as a result of that specific issue, and that in itself could cause the stenosis. So this degenerative changes that occur as a result of the other condition, result in symptoms of spinal stenosis. So, as I say, it might not be that there are any symptoms experienced of that initial injury or underlying problem. But it’s the degeneration caused by that that leads to spinal stenosis. So it can be a combination of, of things that cause this condition and the symptoms that result. So what is causing, I guess, the narrowing specifically then. So degeneration itself doesn’t just cause a narrowing, there has to be something that occurs as a result of that. And, you know, something ultimately starts getting in the way effectively, and ultimately, it’s anatomy that gets in the way. And if we think about the spine, there are a number of tissues that can get in the way, degeneration can result in the formation of bony spurs, which could reduce canal size ligaments that run throughout the spine can hypertrophy so they get bigger, which can reduce canal size and intervertebral discs can degenerate and protrude backwards, reducing spinal canal size, we can also get fat at height hypertrophy. So the small joints at the back of the spine that that form between two adjacent vertebra, they can increase in size. And often at the level of those facet joints is where we see the narrowing and the problems occurring with spinal stenosis or spinal canal stenosis. And that is often one of the late locations the level of of those four set joints and ultimately, some tissue is getting in the way, which is causing the problem. And resulting in symptoms and people suffering from this condition classically experience some pain and or other symptoms so often during prolonged walking, standing, and also with back extension, so when we’re when we’re leaning backwards, and that’s because when we lean backwards, the ligaments themselves can kind of bunched up for one of a better term. And that in itself, that bunching causes a reduction in the space. And so leaning backwards, is often an aggravating factor. And that’s why we’re often looking as clinicians, those patients that are scooped forward, bending forward and elderly at the same time, because that can be an indicative sign of of this condition, because people are bending forwards to try and alleviate their symptoms. And it’s when we’re walking for longer periods that there’s a neurogenic claudication. So the nerves are becoming compressed. And that’s impacting their ability to function effectively. And that impacts the the muscles in the legs can cause weakness in the legs. And that’s why people often will have to stop start during walking or they certainly notice the symptoms more during prolonged walking. And you might see people kind of rest up or they might find that they rest up and put a bit of pressure lean on a wall or some search and or a park bench, something like that and get a little bit of relief from those symptoms. So people, as I say, classically get pain and other symptoms, neurological symptoms can also occur.

One classic condition, as I’ve alluded to is neurogenic claudication. That’s a cramping feeling and pain in the legs and usually is bilateral. And that’s another important kind of feature and distinguishing feature and again, always got to be as clinicians ruling things in moving things out of it bilateral, elderly patient, then we’re more suspicious of spinal stenosis, whereas unilaterally younger patient, then we might be thinking more ridiculous with ear and nerve root that’s irritated maybe by a lumber, herniated disc, and it’s causing a single nerve root specifically to be aggravated. And in neurogenic claudication. with spinal stenosis, it’s often more widespread weakness in in both legs, rather than specific to a nerve root, which is again, something that as a clinician would be, would be focused on and if you’re an individual suffering symptoms, and you get more of a widespread weakness or discomfort in the legs, then again, you know, this could be more of an indicative factor of spinal stenosis rather than anything else. With with spinal stenosis, and this can in neurogenic claudication. We’ve always got to rule out any vascular claudication. peripheral arterial disease in in patients can lead to similar symptoms, but generally, people with spinal stenosis won’t actually Symptoms at night in bed. Whereas if you suffer from peripheral arterial disease and similar cramping and symptoms in the legs, then often you will get pain or discomfort at night when you’re lying in bed. So again, another factor that’s worth considering as part of this clinical diagnosis and the journey that we go down in history taken an examination to try and elicit or recreate symptoms and rule in and rule out other conditions. So patients can suffer other symptoms. So numbness, tingling is also common in the legs, numbness and tingling usually experienced, as I say, throughout the legs, not specific to one nerve root, as you’d expect from a nerve root irritation, a ridiculous apathy, as we call it. And ridiculous apathy, as I say, been irritation of the one nerve root or a single nerve root generally exited in the spine. Many patients experienced weakness in the legs with spinal stenosis generally, and walking upstairs is often easier than walking downstairs because when you walk upstairs, you’re generally leaning forward. Whereas when you’re walking downstairs, you generally lean in a little bit further backwards. So again, other distinguishing features of this condition which are often elicited as part of the history taken examination, but something just to consider, if you think you might be suffering from this condition, or if you’re experiencing symptoms, such as the so weakness in the legs often a significant finding or a symptom that people relay. Ultimately, diagnosis is made based on patient history and physical examination. And in some cases, medical imaging can be performed to confirm the diagnosis. The first clinical diagnosis of lumbar spinal stenosis is an exclusion of other competing conditions. And the history of medical history of the patient should be questioned.

First of all, really, and examination sorry, further investigation may confirm findings, history and examination. But it’s important to mention that a lot of patients or a lot of individuals that don’t experience symptoms can be shown to have narrowing or signs of spinal stenosis on radiological imagery imagery, so it’s not perfect in terms of its accuracy. So further imaging, as quite often is the case can be supportive of a good diagnosis and examination and good examination and history should I say, but not necessarily perfect as a go to, to make that diagnosis. And I think that’s important to mention. And the therapist will likely check for pain or symptoms, specifically when you hyperextend. So we’re going to try and recreate that those symptoms by getting you to bend backwards, which is often an aggravating factor. And they should, if they’re doing a good job check for normal neurological function. So I’ll test sensation muscle strength, and the reflexes in both the arms and the legs, because we always want to check is is the stenosis actually lumber, and in the lower back, or is it higher up because it can occur in the neck as well. And posture is often a giveaway as a safe because patients will lean forward to help themselves alleviate symptoms, and other things as well, that should be considered our balanced tests likely be performed and other tests such as a bicycle stress test can also be used. So in this test, what we’re doing is getting a patient to pedal honor cycle machine in the upright position. So what we’re trying to do is preserve the neutral spine, keep the spine upright, and time how long it takes before symptoms occur, then what we’ll do is we’ll get the patient to lean forward or bend forward and do the same, the same exercise. And this time, we’ll time it again and see what the difference is. And often the time in the second test is longer because leaning forwards is alleviating those symptoms, generally. So ultimately, examination is important. Those additional tests are important because, like I mentioned evidence demonstrates that radiology X-ray isn’t perfect and in fact it’s around 30% of asymptomatic individuals have evidence of canal narrowing. So clearly, X ray alone or other investigations aren’t on ideal. So, bicycle stress tests and other examinations should be considered as part of this diagnosis of this condition. So some classes Six signs, symptoms and some generally accepted tests and procedures to try and determine identify this condition. And when it comes to treatment, and the first thing to know is that neurological symptoms, If present, which often they can be a rarely progressive. So it’s not a condition where we see a gradual decline generally. And so on that basis, we really should be trying to be conservative in our approach. And that should be the first option to manage this condition. But sadly, a lot of patients diagnosed with lumbar spinal stenosis often receive early surgical treatment. And research demonstrates that this is this is indeed the case. But given the complications that can arise from surgery, and especially in in more elderly patients, it does make sense, in my opinion, to try a conservative approach, first of all, and research demonstrates that physical therapy is associated with reduced likelihood of surgery within within a year, which is positive. So even if surgery is ultimately required, then perhaps we can extend the amount of time and prior to that need. And that’s got to be a good thing in terms of maintaining quality of life and independence because of, of the risks of surgery. And that’s not to say, to kind of scare monger around surgery because it is an option. But let’s let’s consider it as an option further down the pathway or the the journey, shall we say this condition? So in terms of conservative treatment, what what are the options? Well, you know, we mentioned about leaning forward and alleviating symptoms as well flexion based exercise programs therefore, could be considered. So exercises that do involve you kind of bending forward more regularly can help alleviate symptoms. And there are other treatments that that can be done, such as flexion, distraction, so special benches, often you’ll see them in chiropractic clinics, osteopathic clinics, and no doubt in physiotherapy settings as well where the bench kind of moves up and down and you can introduce flexion into into the low back. So that can be also be considered. But certainly flexion based exercise programs and exercise physical therapy based approaches are hugely beneficial, because we can help improve strength and endurance generally. And that’s got to be an overall benefit to a patient whether it truly ultimately alleviates any symptoms and prevents the need for surgery or not. Because if someone needs surgery, and they’ve done exercise prior to it, they’re going to be in much better shape afterwards. So definitely flexion based exercise programs, manual therapy, as I say things like flexion distraction manipulation can help with this condition help to manage this condition, stretching programs as well. And static and dynamic postural exercises, these kinds of things can all be beneficial. But a graded rehabilitation approaches is makes sense in focusing on improving ambulation and shows, improvements in pain scores. So a lot of things that can be considered and other things such as stabilization exercise of the abdominals, and the back muscles. Because if we’re helping to keep that back in better shape, through better posture and better endurance than that can prevent any micro movements in the low back that may be contributing to this condition. So there are a lot of things that can be done conservatively, to manage patients with this condition. Other things such as aerobic exercise, cycling exercises, so that you are introducing aerobic exercise leaning forwards, hugely beneficial for a lot of patients. And there are in fact, as well, some supporting kind of, and I don’t want to call it a brace, but course it type and products that can help to distract that spine a little bit that we’ve also shown to to be beneficial in some cases, but we always try and strengthen muscles and not rely on something like that specifically, but hey, if it’s an option, and needs to be considered, then at least it’s something that that is there as part of this. This treatment plan potentially for you as an individual this condition might just help.

So hopefully that’s given a bit of an idea about what the this condition is and how it can be treated. It’s as I say, it’s a condition where the spinal canal, the central canal, where the spinal cord runs, or the lumber vertical foremen are narrowed and if the narrow is substantial, and it can cause compression, if it causes compression. It can cause symptoms, and those symptoms can be problematic. So typically, as I say they’re aggravated by walking and they’re relieved by rest in classic cases, but interventions are available. relief of symptoms can be experienced with conservative treatment and patient education and support. So non operative treatment can help. But surgery has been shown over longer periods of time to also provide some significant and positive results. So let’s go conservative. First, let’s consider surgery. As a last resort, let’s get patients active. Let’s get patients independent back up on their feet and help them manage this condition because, hey, it can be achieved. And hopefully, if you’re listening in you’re experiencing those symptoms, or you’ve had the diagnosis of this condition, are you concerned you might have this condition then there’s hope that it can be managed effectively, and it has been shown to be successful. So get in touch. If you’ve got any questions, reach out, always happy to answer any questions. And as always, we ask you to head on over to the iTunes website, give us a review, give us a rating it helps to get the message out, share the show with others, and hopefully help more people to improve their back health and get back to the activities that you love. So as always, thanks for listening. And we’ll catch you again soon on the next show.

Transcribed by https://otter.ai