The lumbar stenosis is a narrowing of the lumbar spinal canal, causing potential neurologic symptoms due to compression of the spinal cord and/or spinal nerve roots. The lumbar stenosis may cause low back pain as well as pain or abnormal sensations in the legs, thighs, feet or buttocks, or loss of bladder and bowel control. It usually affects elderly (+50) but also younger patients may be affected, male>female.

Causes
The cause of lumbar lumbar stenosis can be divided into congenital or acquired.

1.  Congenital (rare): the spinal canal may be narrow due to congenitally short pedicles, thickened facets and lamina, or excessive scoliosis.These anatomic changes may lead to clinically significant stenosis if additional elements such as herniated intervertebral discs or other space-occupying lesions further narrow the canal and contribute to the compression (below the normal lumbar vertebra).
2. Acquired (most common) such as:

• spinal injuries (car accidents and other major trauma can cause dislocations or fractures of one or more vertebrae)
• degenerative or arthritic changes of the ligaments, facet joints and intervertebral discs (osteophyte, disc herniations or bulge, flavum ligaments hypertrophy, etc).
• tumor (abnormal growths can form inside the spinal cord).
• spondylolisthesis.

Diagnosis

• History. Typically, the earliest complaint is back pain. Several months to years after the back pain was first noticed, the patient may experience leg fatigue, pain, numbness and weakness. The leg pain may be bilateral, involving the buttocks and thighs and spreading distally toward the feet (neurogenic claudication). Symptoms are often worsened by activity and standing (**consider also vascular claudication**) and are relieved by bending forward, lateral bending, sitting or lying down. Patients may complain also of difficulty walking even short distances and do so with a characteristic stooped or anthropoid posture in more advanced cases.
• Physical examination. The back of the patient should be examined, recording the shape, mobility and flexibility. SLR test (Lasègue’s sign) may be negative. The neurologic examination may not reveal significant sensorimotor deficits at rest or in a neutral position. Deep tendon reflexes may be decreased, absent or normal, depending on the chronicity of the caudal root compression. Upper motor neuron signs, such as hyperactive deep tendon reflexes or the presence of pathologic reflexes, such as the Babinski’s sign or Hoffmann’s sign, are typically absent unless there is injury to descending long tracts. With the onset of walking, sensory deficits may appear, and motor weakness or reflex changes may be elicited. Therefore, it is extremely important to perform a thorough neurologic examination before and immediately after symptoms appear following a short period of ambulation. Similarly, changes in the neurologic examination with variations in posture should also be recorded.
• X-ray: is not diagnostic but may demonstrates degenerative changes in the vertebrae or disc spaces, disclose some forms of occult spina bifida or reveal spondylolisthesis (shown below) or scoliosis in some patients.
• MRI: imaging modality of choice to evaluate soft tissue encroachment. The MRI depicts soft tissues, including the cauda equina, spinal cord, ligaments, epidural fat, subarachnoid space and intervertebral discs.(**MRI abnormalities have been documented in 20% of asymptomatic subjects**).

• CT: Computed tomography (CT) scans can create cross-section images of your spine. Your doctor may also order a myelogram. In this procedure, dye is injected into the spine to make the nerves show up more clearly. CT scans with intrathecal contrast injection are able to demonstrate the lumbar subarachnoid space and nerve roots with enhanced sensitivity, but this is an invasive test with potential morbidity.

Treatment
Conservative treatment versus surgical treatment is controversial.

Conservative
Conservative treatment often alleviates symptoms or halts their progression. Patient should be active and follow the agreed management plan. Bed rest and wearing an elastic lumbar binder is not recommended, as may lead to deconditioning of the paraspinal musculature (in the long term).
1. Avoid heavy lifting and excessive trunk extension.
2. NSAIDs for acute flare-ups.
3. Stretch and strength training (ex. trasversus abdominis, ileopsoas stretch etc)
4. Lumbar traction.
5. Osseous manipulation/mobilization (flexion-distraction adjustments preferred).
6. Massage.
7. Electrotherapy (TENS, IFC, US).
8. Acupuncture.
9. Exercise (read the tips).

Surgical.
Surgery is indicated if a well-conducted conservative management fails and is reserved for patients who have intolerable pain, progressive neurological deficit or cauda equina syndrome (weakness of the muscles of the lower extremities innervated by the compressed lumbar roots, urinary retention/incontinence, saddle anesthesia, fecal incontinence).
• Partial laminectomy/arthrectomy or laminarthrectomy
• Interspinous process distraction

Tips
Lying prone or in any position that extends the lumbar spine may exacerbates the symptoms, presumably because of ventral in-folding of the ligamentum flavum in a canal already significantly narrowed by degenerative osseus changes. Urgent hospitalisation if the patients complains of sciatic leg pain and/or severe back pain, with altered sensation over saddle area (genitals, uretha, anus, inner thighs), urine retention or incontinence. Bed rest is no longer recommended as it could lead to deconditioning of the paraspinal musculature. Patients often find activities/exercises for lumbar stenosis that are done in a bending-forward position are more comfortable (stationary bike and swimming are suggested) and jogging, contact sports should be avoided. However the best exercise is one that will become part of one’s daily routine. Pick something that is personally rewarding, fun and enjoyable for the patient. Do not exercise through pain and other symptoms. When a canal size is too narrow for the dural sac size that it contains, stenosis occurs. An identical canal size can therefore be stenotic for one person while not being stenotic for another who happens to have a smaller dural sac size. Lumbar spinal stenosis is therefore a clinical condition and not a radiological finding or diagnosis.

Surgery vs conservative treatments
1. In patients with symptomatic lumbar stenosis, the implantation of a specific type of device or decompressive surgery, with or without fusion, is more effective than continued conservative treatment when the latter has failed for 3 to 6 months. (Kovacs et al., 2011)
2. Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis (Atlas et al., 2005).
3. Patients with lumbar stenosis should receive a trial of the proposed conservative, aggressive treatment before surgery is considered (Theodoridis et al., 2008).
4. The outcome was most favorable for surgical treatment. However, an initial conservative approach seems advisable for many patients because those with an unsatisfactory result can be treated surgically later with a good outcome (Amundsen et al., 2000).

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome