A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study

Donald R Murphy, Eric L Hurwitz, Amy A Gregory, Ronald Clary, Donald R Murphy, Eric L Hurwitz, Amy A Gregory, Ronald Clary

Abstract

Background: While it is widely held that non-surgical management should be the first line of approach in patients with lumbar spinal stenosis (LSS), little is known about the efficacy of non-surgical treatments for this condition. Data are needed to determine the most efficacious and safe non-surgical treatment options for patients with LSS. The purpose of this paper is to describe the clinical outcomes of a novel approach to patients with LSS that focuses on distraction manipulation (DM) and neural mobilization (NM).

Methods: This is a prospective consecutive case series with long term follow up (FU) of fifty-seven consecutive patients who were diagnosed with LSS. Two were excluded because of absence of baseline data or failure to remain in treatment to FU. Disability was measured using the Roland Morris Disability Questionnaire (RM) and pain intensity was measured using the Three Level Numerical Rating Scale (NRS). Patients were also asked to rate their perceived percentage improvement.

Results: The mean patient-rated percentage improvement from baseline to the end to treatment was 65.1%. The mean improvement in disability from baseline to the end of treatment was 5.1 points. This was considered to be clinically meaningful. Clinically meaningful improvement in disability from baseline to the end of treatment was seen in 66.7% of patients. The mean improvement in "on average" pain intensity was 1.6 points. This did not reach the threshold for clinical meaningfulness. The mean improvement in "at worst" pain was 3.1 points. This was considered to be clinically meaningful. The mean duration of FU was 16.5 months. The mean patient-rated percentage improvement from baseline to long term FU was 75.6%. The mean improvement in disability was 5.2 points. This was considered to be clinically meaningful. Clinically meaningful improvement in disability was seen in 73.2% of patients. The mean improvement in "on average" pain intensity from baseline to long term FU was 3.0 points. This was considered to be clinically meaningful. The mean improvement in "at worst" pain was 4.2 points. This was considered to be clinically meaningful. Only two patients went on to require surgery. No major complications to treatment were noted.

Conclusion: A treatment approach focusing on DM and NM may be useful in bringing about clinically meaningful improvement in disability in patients with LSS.

Figures

Figure 1
Figure 1
The application of distraction manipulation.

References

    1. Arbit EPS. Lumbar stenosis: A clinical review. Clin Orthop. 2001;384:137–143.
    1. LaBan MMIA. "Young" lumbar spinal stenotic: review of 268 patients younger than 51 years. Am J Phys Med Rehabil. 2003;82:69–71. doi: 10.1097/00002060-200301000-00012.
    1. Jenis LG, An HS. Lumbar foraminal stenosis. Spine. 2000;25:389–394. doi: 10.1097/00007632-200002010-00022.
    1. Matsumoto T, Yoshida M, Yamada H, Kurimoto K, Tamaki T. Lumbar canal stenosis caused by hypertrophy of the posterior longitudinal ligament case report. Spine. 2001;26:e576–e579. doi: 10.1097/00007632-200112150-00028.
    1. Adamova B, Vohanka S, Dusek L. Differential diagnostics in patients with mild lumbar spinal stenosis the contributions and limits of various tests. Eur Spine J. 2003;12:190–196.
    1. Szpalski MGR. Lumbar spinal stenosis in the elderly: an overview. Eur Spine J. 2003;12:S170–S175. doi: 10.1007/s00586-003-0612-1.
    1. Gibson JNAWGGIC. The Cochrane Library. Issue 3. Chichester, UK, John Wiley and Sons, Ltd; 2004. Surgery for degenerative lumbar spondylosis.
    1. Binder DKSMHWPR. Lumbar spinal stenosis. Sem Neurol. 2002;22:157–166. doi: 10.1055/s-2002-36539.
    1. Özaktay ACCJMAIDLJAWJN. Dorsal root sensitivity to interleukin-1 beta, interleukin-6 and tumor necrosis factor in rats. Eur Spine J. 2002;11:467–475. doi: 10.1007/s00586-002-0430-x.
    1. Anzai H, Hamba M, Onda A, Konno S. Kikuchi S. Epidural application of nucleus pulposus enhances nociresponses of rat dorsal horn neurons. Spine. 2002;27:E50–E55. doi: 10.1097/00007632-200202010-00003.
    1. Lipetz JS. Pathophysiology of inflammatory, degenerative and compressive radiculopathies. Phy Med Rehabil Clin N Am. 2002;13:439–449.
    1. Hoyland JA, Freemont AJ, Jayson MIV. Intervertebral foramen venous obstruction: a cause of periradicular fibrosis. Spine. 1989;14:558–568.
    1. Porter RW. Spinal stenosis and neurogenic claudication. Spine. 1996;21:2046–2052. doi: 10.1097/00007632-199609010-00024.
    1. Kobayashi S, Shizu N, Suzuki Y, Asai T, Yoshizawa H. Changes in nerve root motion and intradicular blood flow during and intraoperative straight-leg-raising test. Spine. 2003;28:1427–1434. doi: 10.1097/00007632-200307010-00014.
    1. Schonstrom NLSWJHT. Dynamic changes in the dimensions of the lumbar spinal canal: an experimental study in vitro. J Orthop Res. 1989;7:115–121. doi: 10.1002/jor.1100070116.
    1. Beurskens AJ, de Vet HC, Koke AJ, van der Heijden GJ, Knipschild PG. Measuring the functional status of patients with low back pain assessment of the quality of four disease-specific questionnaires. Spine. 1995; 29:1017–1028.
    1. Deyo RA. Measuring the functional status of patients with low back pain. Arch Phys Med Rehabil. 1988;69:1044–1053.
    1. Cox JM. Low back pain: mechanisms, diagnosis and treatment. 6th. Baltimore, Williams and Wilkens; 1999.
    1. Stern PJ, Cote P, Cassidy JD. A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors. J Manipulative Physiol Ther. 1995;18:335–342.
    1. Gudavalli MR, Cox JM, Cramer GD, Baker JA, Patwardhan AG. Intervertebral disc pressure changes during a chiropractic procedure. BED- Advances in Bioengineering. 1997;36:215–216.
    1. Gudavalli MR. Biomechanics research on flexion-distraction procedure. In: Cox JM, editor. Low Back Pain: Mechanism, Diagnosis and Treatment. 6th. Baltimore, Williams and Wilkens; 1999. pp. 261–272.
    1. Hall TM, Elvey RL. Nerve trunk pain physical diagnosis and treatment. Man Ther. 1999;4:63–73. doi: 10.1054/math.1999.0172.
    1. Butler DS. The Sensitive Nervous System. Adelaide, Australia, Noigroup Publications; 2000.
    1. Lewit K, Liebenson C. Palpation - problems and implications. J Manipulative Physiol Ther. 1993;16:586–590.
    1. McGill S. Low Back Disorders. Evidence-Based Prevention and Rehabilitation. Champaign, IL, Human Kinetics; 2002.
    1. Richardson CJGHPHJ. Therapeutic Exercise For Spinal Segmental Stabilization In Low Back Pain. Scientific Basis and Clinical Approach. Edinburgh, Churchill Livingstone; 1999.
    1. McGill SM. Low back stability: from formal description to issues for performance and rehabilitation. Exerc Sport Sci Rev. 2001;29:26–31. doi: 10.1097/00003677-200101000-00006.
    1. Hurwitz ELMHHPKGFBTRYFAAH. A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low-back pain: Six-month follow-up outcomes from the UCLA Low-Back Pain Study. Spine. 2002;27:2193–2204. doi: 10.1097/00007632-200210150-00002.
    1. Hashemi LWBSCEA. Trends in disability duration and cost of workers’ compensation low back pain claims (1988-1996) J Occup Environ Med. 1998;40:1110–1119. doi: 10.1097/00043764-199812000-00011.
    1. Hsieh CJPRBAAHPMH. Functional outcomes of low back pain: Comparison of four treatment groups in a randomized controlled trial. J Manipulative Physiol Ther. 1992;15:4–9.
    1. Salaffi FSASCACGW. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain. 2004;4:283–291. doi: 10.1016/j.ejpain.2003.09.004.
    1. Johnsson KE, Rosen I, Uden I. The natural course of lumbar spinal stenosis. Clin Orthop. 1992;279:82–86.
    1. Atlas SJDRAKRBCAMPDLLJMSDE. The Maine Lumbar Spine Study. Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine. 1996;21:1787–1795. doi: 10.1097/00007632-199608010-00012.
    1. Atlas SJ, Keller RB, Robso ND, Deyo RA, Singer DE. Surgical and nonsurgical management of lumbar spinal stenosis four-year outcomes from the Maine Lumbar spine study. Spine. 2000;25:556–562. doi: 10.1097/00007632-200003010-00005.
    1. Simotas AC, Dorey FJ, Hansrai KK, Cammisa F. Nonoperative treatment for lumbar spinal stenosis clinical and outcome results and a 3-year survivorship analysis. Spine. 2000;25:197–204. doi: 10.1097/00007632-200001150-00009.
    1. Amundsen TWHNHJMBAMLF. Lumbar spinal stenosis: Conservative or surgical managment? Spine. 2000;25:1424–1436. doi: 10.1097/00007632-200006010-00016.
    1. Pickar JG, McLain RF. Responses of mechanosensitive afferents to manipulation of the lumbar facet in the cat. Spine. 1995; 20:2379–2385.
    1. Leinonen V, Maatta S, Taimela S, Herno A, Kankaanpaa M, Partanen J, Kansanen M, Hanninen O, Airaksinen O. Impaired lumbar movement perception in association with postural stability and motor and somatosensory-evoked potentials in lumbar spinal stenosis. Spine. 2002;27:975–983. doi: 10.1097/00007632-200205010-00019.
    1. Sanders GEROTRMP. Chiropractic adjustive manipulation on subjects with acute low back pain: visual analog pain scores and plasma b-endorphin levels. J Manipulative Physiol Ther. 1990;13:391–395.
    1. Bulbulian R, Burke J, Dishman JD. Spinal reflex excitability changes after lumbar spine passive flexion mobilization. J Manipulative Physiol Ther. 2002;25:526–532. doi: 10.1067/mmt.2002.127073.
    1. Leboeuf-Yde C, Hennius B, Rudberg E, Leufvenmark PTM. Side effects of chiropractic treatment a prospective study. J Manipulative Physiol Ther. 1997;20:511–515.
    1. Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy. Spine. 1997;22:435–441. doi: 10.1097/00007632-199702150-00017.

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