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Lumbar Spinal Stenosis

What is lumbar spinal stenosis?

  • Lumbar spinal stenosis is a narrowing of the spinal canal in the lower part of your back. Stenosis, which means narrowing, can cause pressure on your spinal cord or the nerves that go from your spinal cord to your muscles.

How common is lumbar spinal stenosis?

  • Relatively rare in the general population, but increases with age.
  • 1.7%–2.2% in the 40-49 years old population.
  • 10.3%–11.2% in the 70-79 years old population (6).

Should I worry?

  • In most cases, no.
  • The condition comes on slowly and is managed with exercises, physiotherapy and medication.
  • More advanced cases significantly affecting walking, or not responding to the above, may require further investigations and, in rare cases, a spinal operation.

Who is most likely to suffer from lumbar spinal stenosis?

  • Increases with age, more common over 50.
  • Someone who is overweight.
  • Increased risk when you have a family history of osteoarthritis.

What are the common symptoms?

  • Back and/or leg pain with standing or walking.
  • Leg altered sensation/numbness.
  • Leg weakness.
  • Decreased walking distance.
  • Feelings of heaviness in the legs.

What can I do?

  • Regular exercise such as cycling, strength training for legs and back.
  • Maintain a healthy weight.
  • Medications if appropriate.
  • Pace activities such as walking.

How long will it take to recover?

  • There is no cure for the condition but correct management can significantly reduce your symptoms and allow you to lead a normal life.
  • Studies suggest that over the course of 5 years, in patients managed without surgery approximately 70% will remain the same, 15% can improve, and 15% get slightly worse (7).
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1. Introduction

Spinal stenosis means narrowing of the central nerve tunnel in the spine, the “spinal canal”. Sometimes narrowing will occur to the side of this, where the nerve exits the spinal canal.

Spinal stenosis most often affects the lower (lumbar) spine, but it can also occur in the cervical spine (neck) and rarely in the thoracic spine (mid-back). This process mostly happens due to changes in the spine that occur with advancing age (“arthritic changes”) (6). In rarer cases, it can be congenital (meaning a person’s natural anatomy from birth).

This narrowing may not cause any symptoms. However, it may progress to cause some compression of the spinal nerves. Spinal stenosis can cause back pain and/or leg pain. Spinal stenosis can often be treated by simple measures such as keeping as active as you can, losing weight if you are overweight and appropriate medications. In more advanced cases where conservative methods have not managed the condition, surgery may be required (1, 3).

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2. Signs & Symptoms

3. Causes

As part of the normal ageing process, as with every other area of the body, structural changes occur in the spine which is sometimes called “arthritic changes”. These in themselves do not cause pain. However, sometimes they can advance to cause partial compression (stenosis) of the nerve tunnels within the spine and give symptoms into the back and/or leg, which can be termed “neurogenic claudication” (6).

This compression can occur due to the intervertebral discs (shock absorbers between the vertebrae), bony growths/spurs or enlarged ligaments, but often it is a combination.

Some people’s natural anatomy may be that they have more of a congenital (from birth) narrowing/stenosis, which may cause symptoms earlier on in life, or predispose them to an increased likelihood of developing stenotic symptoms.

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4. Risk Factors

This is not an exhaustive list. These factors could increase the likelihood of someone developing lumbar spinal stenosis. It does not mean everyone with these risk factors will develop symptoms.

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5. Prevalence

The prevalence of stenosis itself is difficult to quantify; this is in part because it is typically caused by spinal changes that are a natural part of the ageing process and these do not cause pain in everybody. One study suggests 19%-40% of people between the ages of 60-69 will have stenosis on an MRI (magnetic resonance imaging) scan, however, this does not mean they will necessarily have symptoms (3).

Another study has suggested 1.7%–2.2% in the 40–49 years old population will have symptomatic lumbar stenosis, and this increases to 10.3%–11.2% in the 70–79 years old population (6). It is the highest cause of spinal surgery for people over 60 (4).

6. Assessment & Diagnosis

A diagnosis is typically made by clinical examination and a thorough history is taken by your physiotherapist, based on your presentation and symptoms.
In advanced cases of stenosis which are not responding to self-management and physiotherapy, a magnetic resonance imaging (MRI) scan can confirm the diagnosis and be used to help plan the necessary interventions. A magnetic resonance imaging (MRI) without clinical examination is not useful on its own (1).

7. Self-Management

As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help you recover from your lumbar spinal stenosis symptoms. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.

Maintain your activity levels and fitness as much as you can. Try to gradually increase your walking distance. This may require regular breaks to sit and ease the symptoms but avoiding walking is not beneficial. Cycling tends to be a good exercise option for patients with stenosis.

Pain relief, over the counter, if appropriate, or liaise with pharmacist/GP services (1, 2).

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8. Rehabilitation

Recent evidence supports the use of specific exercise programmes in managing spinal stenosis, and that people involved in these have improved quality of life compared to those not partaking (5). Further exercises to improve back and leg strength can be beneficial (see below) and evidence supports this (5). Your physiotherapist can work with you to devise a programme that suits your needs/goals and help you manage your symptoms.

Below are three rehabilitation programmes created by our specialist physiotherapists to help your back pain. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.

9. Lumbar Spinal Stenosis Rehabilitation Plans

Early Plan

Our early programme focuses on some basic movement-based exercises to try and improve the ability for the back to move well. Pain should not exceed 3/10 on your self-perceived pain scale whilst completing this exercise programme.

Early Plan  - Rating

Intermediate Plan

At this stage, we look at integrating into more strength and stability-focused exercises. This is with the aim of increasing the strength around the abdomen, lower back and hips. Pain should not exceed 3/10 on your self-perceived pain scale whilst completing this exercise programme.

Intermediate Plan  - Rating

Advanced Plan

In our advanced programme, we aim to progress the strength of the back and legs to try and remove the pressure from the spine where possible and increase your ability to do day-to-day tasks. Pain should not exceed 3/10 on your self-perceived pain scale whilst completing this exercise programme.

Advanced Plan  - Rating
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10. Return to Sport/Normal Life

As stated above, normal life and hobbies should be maintained where possible. Pacing activities may be required – meaning doing little and often/taking breaks to enable you to do this. Walking aids/poles may be useful to help with long distance walking. Following your rehabilitation exercises will allow the best opportunity to continue with the things you enjoy.

11. Other Treatment Options

If symptoms are not manageable despite self-management/rehabilitation, or they deteriorate with time, then one option is spinal surgery. The most common operation is called a decompression, meaning the structure(s) irritating the nerve are removed. Spinal fusion may also be considered which involves joining two vertebrae together. The success of surgery for spinal stenosis is variable but generally, results are good (6).

12. Links for Further Reading

References

  1. NHS Tyneside – Spinal Stenosis – https://www.tims.nhs.uk/wp-content/uploads/2020/06/1.8-TIMS-Spinal-Stenosis.pdf (1).
  2.  NICE guidelines. (2016). – low back pain and sciatica in over 16’s https://www.nice.org.uk/guidance/ng59/chapter/Recommendations.
  3. Kalichman et al. (2009). Spinal stenosis prevalence and association with symptoms: The Framingham Study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775665/.
  4. Wu & Cruz. (2020). Lumbar Spinal Stenosis https://www.ncbi.nlm.nih.gov/books/NBK531493/.
  5.  Kumar et al. (2017). Effect of Integrated Exercise Protocol in Lumbar Spinal Stenosis as Compare with Conventional Physiotherapy- A Randomized Control Trial. https://www.researchgate.net/publication/322638554_Effect_of_Integrated_Exercise_Protocol_in_Lumbar_Spinal_Stenosis_as_Compare_with_Conventional_Physiotherapy-_A_Randomized_Control_Trial.
  6. Wu et al .(2017). Lumbar spinal stenosis: an update on the epidemiology, diagnosis and treatment. https://amj.amegroups.com/article/view/3837/4553.
  7.  NHS Torbay and South Devon – Self help for spinal stenosis – https://www.torbayandsouthdevon.nhs.uk/uploads/25631.pdf.
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